Wednesday, February 09, 2005

A Limited-Resources Ecology

There's another depressing article about triplets published in the latest issue of Pediatrics: "Does a Triplet Birth Pose a Special Risk for Infant Development? Assessing Cognitive Development in Relation to Intrauterine Growth and Mother-Infant Interaction Across the First 2 Years." The authors' take-away conclusion? "Without organized assistance [financial and social support], it cannot be expected that the mother will form the unique, sensitive, individualized relationship that is necessary for these high-risk infants."

These types of articles tend to spark indignant protest among triplet parents. The study group was too small; the comparison groups (twins and singletons instead of large families) was skewed; the authors unfairly focused on the drawbacks without mentioning that hallowed sibling bond. I don't tend to have a lot of patience with these responses, partly because I think a less self-serving critique exists. For example: child development theory overwhelmingly emphasizes the importance of the mother. Fathers, other family childcare providers (i.e., grandparents), and non-family childcare providers all might as well be invisible. To the extent that assumptions about maternal-infant interaction in singleton families are flawed, their applicability to triplet families is minimized. Furthermore, child development research relies overwhelmingly on researcher observation of interactions at home and in laboratory settings, and while there's continuous emphasis on "objective coding," I don't even have time to begin outlining the inherent problems in this, the entire field's baseline methodology. Finally, the statistical correlations are often much weaker, and the differences between groups much smaller, than the broad generalizations of the authors would suggest.

And yet....This is a peer-reviewed article; it conforms to the state of the art in the field. We dismiss the authors' conclusions and recommendations (which are, after all, in favor of increased support for triplet parents) at our peril. Do I enjoy hearing that my family situation correlates with negative environments for my children? No. I hate it. I hate it. But how are my children well-served by the ostrich approach, denial and deliberate refusal to engage with the research? I might feel better in the short run, but what if the authors are indeed correct? Isn't it better to be inspired to prove the research wrong through careful attention to the questions raised?

Do any of us have sympathy anymore with adoptive parents who claim that adoption "doesn't matter" for their child? Being born as part of a set, especially a large set, matters--the body of research isn't large, but it's consistent--and we parents of high-order multiples have an obligation to attend to how it does matter. Our children deserve that.

Luckily, I have access through Calder to the full texts of these articles. So here, for your consideration, are a few provocative and uncomfortable excerpts.

First, an excerpt describing the behaviors studied:
Maternal sensitivity was based on 10 items ... acknowledgment of the infant’s interactive signals, elaboration of the child’s vocalizations and movements, warm and positive affect, affectionate tone of voice, fluency of the interaction, consistency and predictability of style, resourcefulness in dealing with the infant’s negative states, appropriate range of affect, and adaptation to the infant’s state and signals. ... Child social involvement was calculated from 5 items at 6 months and from 7 items at 12 and 24 months. These included child initiation of interactive bids, child positive affect, child vocalization, child alertness, and child-led interactions. At 12 and 24 months, 2 additional codes were included, ie, child symbolic-creative play and child competent use of the environment. (Pages 445-446)
The study also measured infant cognitive development, using the Bayley Scales, and maternal competence and satisfaction, measured using the Parental Competence and Satisfaction Scale, "a 17-item instrument assessing the levels of parental anxiety, frustration, motivation, competence, and problem-solving." (Page 446)

There were several pages of graphs and regression analysis, and finally the authors concluded:
Triplets as a group showed lower cognitive skills, compared with singletons and twins matched for gestational age and fetal growth parameters, at 6, 12, and 24 months of age, which suggests that the triplet situation itself constitutes a separate risk condition for infants’ cognitive growth, independent of the effects of other known medical risks to infant development. ...
Infant cognitive development is based on 2 central factors, ie, the infant’s disposition and neurologic intactness and the mother’s sensitive support of emerging skills and timely introduction of new and appropriate stimulation. The development of maternal sensitivity requires the mother’s full investment in the well-being, communicative signals, and growing capacities of an individual child. Mothers of triplets were found previously to report higher levels of parenting stress and lower investment in the formation of a unique emotional relationship with each child, and the present findings underscore the role of lower maternal competence in the parenting role as an important factor in the slower cognitive development of triplets. The data demonstrate that, when mothers need to attend to the specific interaction rhythms and growth needs of 3 infants simultaneously, the level of sensitive parenting to each child is significantly reduced. These findings were persistent at 6, 12, and 24 months of age, across the period when infants move from initial manipulation of objects in their environment to interactions that involve symbols, words, gestures, social participation, and initiation. We observed that the decrease in maternal sensitivity among mothers raising triplets was not a transient phenomenon but rather a stable maternal interactive style. This maternal trait was related to the mothers’ decreased sense of self-efficacy and was predictive of the infants’ cognitive outcomes at the toddler stage, beyond the infants’ medical risk and multiple-birth status, which points to the strength of the association between maternal parenting style and infant developmental outcomes.
Similar to the mother’s reduced sensitivity, the infant’s social involvement during mother-child interaction was lower in the triplet group. The present findings, consistent with previous reports and theoretical formulations, indicate that the degree of infant social participation, including child alertness, communicative initiation, vocalization, competent use of toys, and creative-symbolic output, is closely linked to the mother’s sensitive handling of the interactive flow and the timely presentation of new stimuli. The findings demonstrated that infant social skills predicted cognitive outcomes, beyond neurologic intactness and maternal behavior, which highlights the associations between child curiosity, social competence, and creative dyadic play and the ultimate cognitive development of the infant. (Pages 449-450)
And finally, here are some of the hypothesis and theoretical constructs the authors relied upon, and were testing, as they performed their research:
Authors of triplet studies have underscored the potential negative impact of a triplet birth on the development of cognitive skills, as a result of the mother’s limited capacity to provide adequate attention and stimulation to each child. ... Parents admit to a situation they have long desired but have difficulty managing competently once the infants are born. Because triplet pregnancies are associated with increased medical complications for mothers, life at home begins with maternal physical and emotional exhaustion. Interviews with parents indicate not only that parenting of triplets is more difficult than parenting of twins but also that the 1 additional child makes the difference between a manageable parenting situation and an unmanageable situation. Mothers of triplets reporthigh levels of stress, anxiety, social isolation, and fatigue and a significant decline in the marital relationship. Most importantly, mothers of triplets complain of having no energy to develop a unique bond with each child and of emotional detachment from the children.
Because cognitive development in infancy is based in part on the mother’s provision of sensitive, age-appropriate parenting and adequate stimulation of the infant’s growing cognitive skills, the enormous parenting stress and lower sense of competence caused by the triplet situation is likely to interfere with the infants’ cognitive development. Moreover, the effects of the mother’s lower sensitivity on the infant’s cognitive development are likely to be more pronounced during the second year, a period when infants become more mobile and verbal but are still highly dependent on the mother to make sense of their environment, especially because their access to care-giving adults outside the family setting is still limited. Therefore, it may be postulated that, within the limited-resources ecology created by the triplet situation, triplet infants are likely to receive lower levels of maternal sensitivity. (Page 444)
Any thoughts?

Edited to add emphasis on the key assertions.


Anonymous said...

Okay, I made a nice, politically correct reply at TC. But here's more of what I *really* think:


Actually, I have some other thoughts as well, but since I don't want to alienate any triplet moms who may read them, I'll just share them with you privately, Jody.


Anonymous said...

Depressing, yes. For everyone! (I'm not sure if it's cool to post on specifically triplet related articles here since I have singletons, albeit closely spaced.) But for heaven's sake couldn't you substitute working moms, impoverished moms, depressed moms, divorced moms and many other less-than-ideal situations for triplet moms and come up with much the same result? Are there EVER enough resources available to parents to raise our children to some ideal of developmental perfection? And is there no mitigating factor in that at least most triplets are brought into this world with great intentionality and love? I do agree that the controls in this study should have been a large family, not twin/ singletion moms. I know of no second, third, etc. children who got quite the same level of interaction that the first baby did. Mom's just too tired by that point. Off to read the whole article now and bang my head against the wall with that "Parental Competance and Satisfaction Scale."
Thanks for another thought-provoking post Jody.

SheilaC said...

Sigh. Articles like this are so depressing. And yet, thank you for sharing.

As parents of triplets we do the best we can at the time, like any other parents. And we seek help from friends, family, and health care professionals to ensure our children receive appropriate loving care, and to ensure they are growing and developing as they should. If delays are reported, we follow through with Early Childhood Intervention and other therapies to help our children reach their full potential.

Now that my 3 are almost 5 years old and are registered for kindergarten, I'm beginning to believe that they might truly be OK in spite of scary stats and articles like this one, and others about the long-term consequences of very low birth weight. But some part of me will always be anxious, and feel guilty, for the circumstances of our children's conception, birth and early childhood development.

The annoying thing about articles like this is that no solution is offered - once you conceive triplets you are stuck with the situation. It would be helpful if there were recommended steps parents could take to mitigate this unfortunate set of circumstances.

Please keep on sharing the information you find. I also appreciated your summary and reflections on the Selective Reduction issue in December.

SheilaC (from the Triplet Connection).