J. Pediatr. Psychol. 1996 Robinson 401 17

8/10/2019 J. Pediatr. Psychol. 1996 Robinson 401 17

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Journal of Pediatric Psycho logy. Vol. 21, No. 3. 1996. pp. 401-417

Quality of Attachment as a Predictor of Maternal

Visitation to Young Hospitalized Children

1

Jane R. Robinson

2

Case Western Reserve University

Jane L. Rankin

Drake University

Dennis Drotar

Case Western Reserve University School of Medicine

Received June I. 1994; accepted October 13. 1995

Tested a com prehensive mod el of factors predicting ma ternal visitation with

hospitalized children. Subjects were 86 mothers who completed the Spielberger

State-Trait Anxiety Inventory, a 12-item attachm ent measure derived from the

Waters and Deane Attachment Q-sort and a demographic questionnaire. Chil-

dren were 10 months to 4 years old (37 female, 49 ma le) and hospitalized for

acute nonsurgical illness. Hierarchical regression analyses indicated that, of the

subset of variables tested (SES, number of

children

at home, gender, age, num-

ber of previous hospitalizations, state

anxiety,

and security of attachm ent), qua li-

ty of attachment was the only significant predictor of maternal visitation rate.

Mothers who reported that their children displayed insecure attachment behav-

'This manuscript is based on the first authors master's thesis which was supervised by the second

author and completed at Drake University. Preparation of this manuscript was supported in part by

National Institute of Mental Health grant 18830. The authors acknowledge Susan Isbill and Susan

Kashubeck for their contributions to this research and to Everett Waters for graciously sharing his

Attachment Q-sort me asure . We also thank the students in the pediatric psychology research training

program at Case Western Reserve University for their endless support and editing, along with the

nursing staff of Iowa Methodist Blank's Children's Hospital for their assistance in the data collec-

tion. Finally, this manuscript is lovingly dedicated to, and in memory of my father Dr. James L.

Robinson who died August I, 1995

2

AII correspondence should be sent to Jane R. Robinson, Department of Psychology, Case Western

Reserve Un iversity. 10900 Euclid Avenue, Cleveland, Ohio 441 06-7 123 .

401

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402 Robinson , Ran kin, and Drotar

iors maintained a significantly lower rate of visitation than mothers who reported

that their children displayed secure attachment behaviors. Results of this study

highlight the importance of understanding parent-child attachment in predicting

maternal visitation when a child is hospitalized.

KEY WORDS:

attachment; separation distress; maternal visitation rate.

As many as 5 million American children undergo medical procedures each year

for treatment or diagnosis (Bush, Melamed, Sheras, & Greenbaum, 1986), with

many requiring hospitalization. Infants and children between the ages of 0-5 are

the overw helm ing majority of these hospital izations (T rad, 1987). It is well

established that the hospitalization of a child is stressful for both the parent and

child alike, as the major factor contributing to the psychological upset of pre-

school children is separation from their parents (Bowlby, 1988; Crowell & Wa-

ters, 1990; Nagera, 1978; Prugh, Staub, Sands, Kirschbaum, & Lenihan, 1953).

Children between the ages of 6 months and 4 years are the age group considered

most vulnerable to the emotional effects of separation and illness (Bowlby, 1969;

Trad, 1987;

Wolff,

1969).

Researchers have sought to determine whether interventions such as unre-

stricted visitation and parental rooming-in may reduce the emotional conse-

quences for hospitalized children. Early studies showed that when parents were

allowed to visit longer hours, children's negative behavioral outcomes (e.g.,

increased separation anxiety, increased sleep anxiety, aggression toward authori-

ty, eating disturbances, temper tantrums, and bed wetting) lessened upon return-

ing home (Douglas, 1975; Freiberg, 1972; Illingworth & Holt, 1955; Lehman,

1975; Prugh etal., 1953).

While hospital visitation policies now frequently allow for unlimited visita-

tion (Alexander, Powell, Williams, White, & Conlon, 1988; Hamlett, Walker,

Evans, & Weise, 1994), not all parents can take advantage of such opportunities

due to responsibilities for other children, work obligations, and level of family

resources. Some children have chronic conditions that require prolonged pedi-

atric hospitalization that severely taxes the ability of parents to sustain visitation

and in some cases affecting the relationship with their children (Hamlett et al.,

1994). For these reasons, identification of factors that sustain or disrupt the

frequency of parental visitation to hospitalized children continu es to be im portant.

Prior studies concerning maternal visitation have focused, almost exclu-

sively, on assessing the influence of maternal anxiety on visitation to the hospi-

talized child. However, the frequency of parental visitation and rooming-in can

be affected by multiple factors that have not been described in a comprehensive

framework, nor empirically tested. Based on dimensions proposed by Prugh et

al.

(1953), J. R. Robinson (1994), and previously cited psychological studies



Hospitalizatkm and Attachment

403

(e.g., Alexander et al., 1988; Berenbaum & Hatcher, 1992; Freiberg, 1972;

Hamlett et al., 1994; D. Robinson, 1968; Skipper, 1966), a comprehensive

model of influences on parental anxiety and parental visitation was developed to

provide a framework for the present investigation (see Figure 1).

This model describes the relationship among several factors that are hy-

pothesized to predict maternal rates of visitation. These include overall level of

family resources

(e.g., socioeconomic status),

family and parental demands

(e.g., number of children at home),

parental moo d slate

(e.g., anxiety),

quality

of parent-ch ild relationship

(e.g., security of attachment),

child characteristics

(e.g., gender, age, previous hospitalizations, nature and severity of illness), and

'Socioecooomic Stuns:

L^VCl

Of

O^DG^QOQ

Tnmpoftarjon/Proximjty to bcopittl

•Number of

hildren

it home

FiniHy Strcsson

Pir eo al perception of tevcrity of

\S\xa

QtmtioD of bospitilizxtioa

Burden of iHaess

ftriiri

Chtnrtr

rittiri

•Gender

•A«e

'Number of previoui hocpiulu alioas

'Nature Severity of m n en

'Security of Atttchment

\

•Anxicty (Stiic)

Depression

Confusion

*R*te of Milcnul VUrtatioo

StifiyPircnl Contmunicitjoo

Sleeping Aoconun

Encouragement of parents to room -in/visil

Pcrcepo oo of psxcntxl role

partW-jpiiinn of f*nu\y when dntd is ill

Fig . I. Con cep tual mod el of factors hypo thesiz ed to predict maternal visitation rates and state

anxiety. * = Variables tested in this model.



404 Robinson, Ran kin, and Drotar

other contextual factors

(e .g ., quality of hospital support provided to parents),

and cultural factors (e .g ., family response to the child 's illness, and patterns of

family participation in the child's care). The role of several of these factors,

(e.g., family resources, maternal anxiety) have received empirical support in

prior research while others (e.g., quality of accommodations and support pro-

vided to parents in the hospital) are supported by clinical observation but have

not been tested empirically, to our knowledge.

It has been suggested that maternal anxiety stems from a variety of sources,

such as anxiety over seeing other ill children in the hospital (Freiberg, 1972),

lack of information concerning the ill child's diagnosis and treatment (Freiberg,

1972; Skipper, 1966), fear of criticism from the hospital staff, and judgments of

the mother's effectiveness as a parent (Prugh, 1983). More recently, Berenbaum

and Hatcher (1992), found higher levels of maternal distress (e.g., anxiety,

depression, and confusion) were associated with younger parental age, increased

family stressors, prior experience with hospitalization, and maternal appraisal of

her child's illness as severe.

Several studies have suggested that the level of maternal anxiety affects the

frequency of maternal visitation. Early research (e.g., Prugh et al., 1953;

D. Robinson, 1968) reported that as a mother's own fear of hospitalization

increased, time spent visiting her ill child decreased. In a study of non-rooming-

in and rooming-in mothers of hospitalized children, Alexander et al. (1988)

found elevated anxiety levels in non-rooming-in mothers that correlated pos-

itively with the number of children at home, and negatively with maternal educa-

tion level, occupation, and social status. Comparisons between groups demon-

strated that non-rooming-in mothers had higher state anxiety, lower

socioeconomic status (SES), fewer rooming-in experiences with their hospi-

talized children, and more children at home than did rooming-in mothers.

While these studies have enhanced our understanding of the factors that

influence maternal visitation, several methodological problems limit the conclu-

sions that can be drawn from them. For example, Alexander et al. (1988) col-

lected data from rooming-in mothers 2 months to 2 years after data on the non-

rooming-in mothers. For this reason, differences in anxiety levels could reflect

dissimilar environmental and/or societal stressors that were present at the differ-

ent periods. Moreover, the measure of rooming-in or not rooming-in used by

Alexander et al. (1988) forced subjects into descriptive categories. A continuous

measure of the extent of maternaJ visitation might afford a more complete de-

scription and greater statistical sensitivity.

Prior studies that assessed maternal anxiety (Alexander, White, & Powell,

1986;

Alexander et al., 1988; Berenbaum & Hatcher, 1992; D. Robinson, 1968)

have included sm all sam ples (20—30 subjects per group ), thus reducing statistical

power. Children in these previous studies were hospitalized for a variety of

reasons, some general ( e.g ., bronchitis, pneum onia), and others for more serious



Hosp italization and Attachment 405

illnesses such as head trauma and cardiac surgery, which may have a very

different impact. It has been shown that more serious illnesses induce higher

levels of maternal anxiety (Berenbaum & Hatcher, 1992). The age of the hospi-

talized children in these studies also varied from infancy (D. Robinson, 1968)

through 12 years of age (Alexander et al. , 1986, 1988; Berenbaum & H atcher,

1992; Prugh et al., 1953; D. Robinson, 1968; Skipper, 1966). Such wide vari-

ability in the ages of these children makes it difficult to clarify the specific factors

that contribute to maternal anxiety in particular age groups.

This study was designed to address som e of the methodological problems of

past research by including the following procedures: (a) The percentage of time

spent with the child was the primary measure of parental visitation (rather than a

general measure of parental rooming-in); (b) to eliminate variability in measure-

ment that could result from higher anxiety during the first 24 hours, matemai

anxiety was assessed after the first 24 hours of hospitalization and no later than

the third day; (c) diagnosis of the child was limited by including specific condi-

tions typical of childhood illnesses requiring acute hospitalization but not sur-

gery; (d) the number of subjects was much larger than in prior research, thus

affording greater statistical power to detect potential influences; and (e) the age

of the hospitalized child included only children age 10 months to 4 years.

This study tested the utility of a subset of variables from a comprehensive

model, described in Figure 1, in predicting matemai visitation. A novel factor in

the model, not tested in previous research, is attachment. Attachment theorists

and researchers have strongly implicated matemai sensitivity to infant cues in the

development of a secure infant-mother attachment relationship (Ainsworth,

Blehar, Waters, & Wall, 1978; Bowlby, 1969). Therefore, it was hypothesized

that higher levels of mothers' sensitivity when their children were hospitalized

would be displayed through more frequent visitation by mothers of securely

attached infants. However, some insecure patterns of attachment are charac-

terized by behaviors in which the child shows signs of detachment when dis-

tressed (Ainsworth et al., 1978). In such situations, these mothers might interpret

their children's behavior as signaling that they were not needed, thus giving rise

to less visitation. Therefore, we hypothesized that mothers with children classi-

fied as insecurely attached would exhibit less sensitive behaviors towards their ill

children as shown by less frequent visitation.

We also sought to extend previous findings by testing whether higher rates

of matemaJ visitation would be predicted by greater family resources (higher

SES), lower family demands (fewer children at home), child characteristics

(female, younger children, and fewer previous hospitalizations of the child), and

lower maternal state anxiety. Past studies have suggested that family resources,

family demands, hospital support (e.g., systematic staff-parent communication),

child characteristics, and nature and severity of the child's illness predict ele-

ments of parental mood state, particularly state anxiety (Alexander et al., 1986,



406 Robinson, Rankin, and Drotar

1988;

Berenbaum & Hatcher, 1992; D. Robinson, 1968; Skipper & Leonard,

1968). Therefore, it was hypothesized that lower levels of maternal state anxiety

would be predicted by greater family resources (higher SES), fewer family

demands (fewer children at home), and the child characteristics of being female

and of preschool age, and having a greater number of previous hospitalizations.

METHOD

Subjects

Participants were recruited from a pediatric unit of Iowa Methodist Blank's

Children's Hospital. To increase the homogeneity of the sample, all mothers

selected for the study had to have a hospitalized child who met three criteria.

First, because the focus was on young children who are most vulnerable to the

effects of separation, the hospitalized child had to be between the ages of 10

months and 4 years. The 10-month cutoff was used because of the lack of validity

for the attachment measure below that age (Waters & Deane, 1985). Second, the

cause of hospitalization had to be respiratory distress, gastrointestinal illness,

rule-out sepsis (ROS), respiratory syncytial virus (RSV), or a combination of the

above. These diagnoses were the most frequent nonsurgical causes of hospital-

ization, as determined by hospital data. Moreover, treatment of these conditions

requires acute hospitalization, thus allowing parents and children little time for

advanced preparation (e.g., to plan changes in their schedule). Mothers of chil-

dren who required surgery, were terminally ill, or in critical condition were

excluded from the sample. Surgical procedures are usually scheduled in advance,

allowing parents to plan for schedule changes. Terminally ill children and their

parents are a unique subgroup who often have multiple hospitalizations associ-

ated with chronic conditions. Third, children with obvious indications of serious

developmental delay (e.g., Down syndrome) or physical handicap (e.g., spina

bifida) were excluded because such conditions could have affected the child's

attachment behaviors.

One mother declined participation in the study while 144 parents agreed.

However, 44 of those people either failed to return the questionnaire or were

discharged before they had an opportunity to complete it. (Due to their small

number and potential gender effects, the 9 fathers were dropped from the analy-

sis. Six additional subjects were omitted due to missing data.) The remaining 86

participants included the biological mother and her child between the ages of 10

months and 4 years (A/ = 22.8 months, SD = 10.5) who was hospitalized for

acute nonsurgical illness. Nearly all (85%) had children hospitalized for either

respiratory distress (51%) or gastro/dehydration-related illness (34%) with an

average hospital stay at the time of questioning to be 2.4 days. Most mothers



Hospitalization and Attachment 407

(74%) were married with an average age of 28 years. Teenage mothers

(n

= 5)

made up only 6% of the sample. In addition, all three SES groups were found to

be representative of national norms (Hollingshead, 1965). Sample characteristics

are shown in Table I.

Procedure

The first author checked the nurses' diagnosis board between 9 and 11 a.m.

Monday through Sunday. If a child was identified as having one of the specified

diagnoses, the researcher contacted the nurse in charge of the child's care,

verified the diagnosis, and ascertained that there were no complications or devel-

opmental delays. Parents were approached by the first author and asked to

volunteer for the study after the first 24 hours of their child's hospitalization and

no later than the third day. The child's attachment figure was identified by a brief

Table I.

Sample Characteristics

Variable

MotheiV education (years)

Age of mother (years)

Age of Hospitalized Child (months)

Days of hospitalization at the time of questioning

Gender of child

Male

Female

Diagnosis

Respiratory

Gastro/dehydration

Rule-out sepsis

Respiratory syncytial virus

Combination of the above diagnosis

Mantal status

Mamed

Single never married

Divorced/currently single

Race

European American

African American

Asian American

Hispanic American

Other

Family socioeconomic status

Upper (major business/professionals)

Middle (semiskilled workers)

Lower (unskilled labor)

M

13.0

27.6

22.3

2.4

SD

2.0

5.8

10.6

0.88

Range

9- 17

16-42

10-48

1-5

%

57

43

51

34

9

5

1

74

19

7

79

13

5

2

1

36

34

26

Hollingshead four-factor index (1965).



408 Robinson , Ran kin, and Drotar

interview (i.e., the person who takes care of the child the majority of the time

and is relied upon by the child during times of stress). This person was asked to

respond to the questionnaire. All participants were given an informed consent

sheet describing the general purposes and procedures of the study, including

assurances of confidentiality and the right to withdraw without penalty. They

were asked to seal their questionnaire in an envelope upon completion, and

return it to the first author or the charge nurse.

Measures of Predictor Variables

Fam ily Resources, Fam ily and Parental Dem ands, Child Ch aracteristics

A demographic questionnaire requested information about the parent's age,

gender, relationship status, ethnicity, and SES. The Hollingshead Four-Factor

Index of Social Status (1965), which considers education, occupation, sex, and

marital status was used to compute SES. Participants were also asked questions

about staying overnight with their ill child, the number of children at home, and

if their child had been hospitalized in the past.

Parent-Child Relationship

The child's security of attachment was assessed with a modification of

Waters and Dearie's (1985) Attachment Behavior Q-sort. The Q-sort was devel-

oped to facilitate a more naturalistic assessment of the attachment relationship

and is a behaviorally specific measure that permits valid assessment of security

of attachment outside of the laboratory (Pederson et al., 1990; Waters & Deane,

1985).

The Q-sort provides a continuous metric that consists of 90 behavioral

descriptions that are sorted into nine piles according to similarity with the infant's

behavior. Items most characteristic of the child are placed at one end of the

distribution (Piles 9, 8, and 7) and those most unlike the child are placed at the

opposite end. Vaughn and Waters (1990) found that Strange Situation reunion

behaviors were significant predictors of home-based attachment security as mea-

sured by the Q-sort. Data on instrument development and construct validity are

available in several reports (Vaughn & Waters, 1990; Waters & Deane, 1985).

Use of the Waters and Deane (1985) instrument, which measures sociability

and dependenc y in addition to security of attachm ent, was not feasible for a study

of hospitalized children because it required too much time of the mother. For this

reason, 12 items identified by Vaughn and Waters (1990) as discriminating

between secure and insecure attachment were selected from Waters' (1991) re-

vised Attachment Q-set.

The items selected were reworded to ask parents directly about their child




instead of the original wording which was designed for outside observers. Par-

ents were asked to rate their children on a 9-point Likert scale with anchors and

behavioral descriptors that corresponded precisely to the Attachment Q-sort. The

12-item scale for assessing child attachment behaviors (Cron bach's a = .52)

included questions such as, If given a choice, my child would rather play with

toys than adults and If I move very far, my child follows along and continues

his/he r play in the area I have moved to . Parents were instructed to respond to

the items by reporting their child's typical behavior prior to their illness and

hospitalization.

A total attachment score was calculated by summing the 12 individual

Likert item s, with greater scores indicating m aternal reports of more secure child

behaviors. These Likert scale items were based on the 12 Q-sort items that

statistically discriminated (/-test values) between secure and insecure attachment

groups based on observations of infants and mothers in the Ainsworth Strange

Situation (Vaughn & Waters, 1990). The individual means for each statistically

significant item were reported for both groups. For our purposes, the dividing

point between secure and insecure attachment was determined by summing the

means of the 12 items for the two attachment groups as reported by Vaughn and

Waters (1990), and using these numbers as a guideline for selecting our cutoff

score of 72.

Maternal Psychological State: Anxiety Measure

The State-Trait Anxiety Inventory (STAI) Form Y (Spielberger, Gorsuch, &

Lushenc, 1983) assesses two forms of anxiety and can be completed in approx-

imately 10 min utes, does not exceed a 6th-grade reading level, and h as relatively

high (.80 and .90) internal consistency reliability for both the A-Trait and A-State

forms.

Construct validity for both A-State and A-Trait forms has been demon-

strated in multiple ways and the two tests have been shown to have construct

validity with other tests of anxiety (Anastasi, 1986).

Dependent Measure

Rate of Visitation

Participants were asked to indicate the number of hours (day and evening)

they had spent at the hospital since their child was admitted. In the calculation of

overall visitation rates, those mothers who spent the night were credited with

8 hours for each night they stayed. Maternal rate of visitation was calculated by

summing the number of reported hours of visitation, including hours spent over-

night, and dividing by the total number of hours the child was hospitalized at the




time of questioning. For those mothers who did not stay the night, there was an

open-ended question in which they were asked to describe why they had made

that choice.

RESULTS

Rate of Visitation

Mothers in this study responded to the questionnaires after their child's first

24 hours of hospitalization and no later than the third day. On average, children

were hospitalized 2.4 days

(SD

= 0.9) at the time of que stioning. D uring the first

day of their child's hospitalization, mothers visited an average of 16 hours

(SD

=

7). A total of 78 mothers reported visitation hours for the first and second day of

their child's hospitalization, indicating they visited an average of 15.5 hours

(SD

= 9) during the second day. The majority of mothers (87%) roomed-in. When

asked whey they did not stay the night, more than half (55%) of the 11 non-

rooming-in mothers reported they were needed at home by other children. At the

time of questioning, average overall rates of visitation indicated that mothers had

spent 65% (SD = 27) of their child's hospitalization with their ill child.

Prediction of State Anxiety

Pearson product-moment correlations were calculated to test the hypothesis,

depicted in Figure I, that higher SES, fewer children at home, female children,

older children, and greater numbers of previous hospitalizations, would correlate

with lower levels of state anxiety. No statistically significant relationships were

detected between state anxiety and any of these variables. In fact, not even

marked associations were found among the variables. Results are presented in

Table II.

Predictors of Visitation Rate

Hierarchical multiple regression analysis was used to test the hypothesized

model (see Figure 1) that state anxiety, SES, number of children at home, age

and gender of child, number of previous hospitalizations, and attachment, would

predict rate of maternal visitation. Security of attachment was entered last to test

the strength of its relationship to maternal visitation after accounting for the

association of all other variables. As shown in Table III, these results indicate

that security of attachm ent was the only significant predictor variable of maternal

visitation rate. Mothers who described more secure attachment behaviors in



Hospitalization and Attachmen t 411

Table II. Correlation Matnx for Maternal State Anxiety and Rate of Maternal Visitation, Family

Resources, Family and Parental Demands, Child Characteristics, and Parent-Child Relationship

1. AN X

2.

SE S

3. DIA

4.

AG E

5.

GE N

6. HOS

7.

VIS

8. CHO

9. ATT

2

- . 0 1

—

3

- . 0 9

.01

—

4

- . 1 8

- . 1 3

- . 0 3

—

5

.22

- . 1 0

- . 0 0

- . 2 0

—

6

.11

.21

- . 2 0

.19

- . 0 5

—

7

- 19

- . 2 3

.03

- . 1 4

- . 1 5

- 25

—

8

05

25

.08

- 02

.05

.03

- 07

—

9

- . 0 6

- . 1 2

05

- . 0 9

- 0 6

- 07

33 *

00

—

ANX = maternal state anxiety; SES = socioeconomic status; DIA = diagnosis; AGE = age of

child; GEN = gender, HOS = no. of previous hospilalizalions; VIS = rate of maternal visitation;

CHO = no. of children at home, ATT = security of attachment

h

p <

.01 .

their children demonstrated higher overall rates of visitation,

R

2

change = .08,

F(l,

78) = 2.61 ,

p <

.01 .

In the regression analysis, security of attachment was a continuou s measure.

To better relate these findings to past research on attachme nt, which has utilized a

dichotomous classification of children as secure versus anxious/avoidant, chil-

dren were classified as secure or insecure. Maternal visitation rates were then

compared between the two groups. Based on an attachment cutoff score of 72,

sixty mothers rated their children (70%) as scoring the secure attachment range

(M =

80,

SD =

7), and 26 mothers rated their children (30%) in the insecure

attachment range (M = 63 , SD = 8). This distribution was similar to that

reported by Ainsworth et al. (1978).

Table III. Hierarchical Multiple Regression Analyses: Maternal Rate of Visitation

Step variable

1. State anxiety

2.

Family characteristics

No of children at home

SES score

3. Child characteristics

No. of previous hospitalmuons

Gender of child

Age of child

4.

Attachment

R

2

.03

06

13

2 1

3

1

1

2

F

.1

.5

.7

.6 1

1, 84

3 ,82

6, 79

7, 78

B

- . 1 0

05

.1 3

- . 1 8

- . 1 1

- . 0 7

.28

Adjusted

Ri

.0 3

.02

.05

.1 3

Ad j .

R

2

-change

03

.07

. 08

p < .01



412

Robinson, Rankin, and Drotar

80

Insecure

Fig. 2. Visitation rate as predicted by quality of attachment.

Consistent with the findings from the regression analysis, mothers who

reported their children displayed insecure attachment behaviors maintained a

significantly lower rate of visitation overall (Af = 56%,

SD =

27) than parents

who reported that their children displayed secure attachment behaviors

(M =

69%, SD = 26, t = 4.12, p < . 05). (See Figure 2.)

DISCUSSION

The major finding of the present study was that mothers with lower rates of

visitation to their hospitalized children also rated their children as displaying

insecure patterns of attachment. These findings are consistent with observations

made as early as 1953 when Prugh et al. noted that parents who visited their ill

children less frequently (below 30%) also displayed unsatisfactory relationships

with their children. However, to our knowledge, this is the first study that has

empirically demonstrated that security of attachment, which may reflect qualities

of the parent-child relationship (Ainsworth et al., 1978) predicts differences in

frequency of maternal visitation rates.

There are several possible explanations for these findings. Our results sug-

gest that attachment patterns that exist prior to hospitalization may influence

frequency of maternal visitation during hospitalization. It is relatively well docu-

mented that parent—child relationships characterized by insecu re attachm ent may

reflect insensitive maternal responses to a range of infant distress cues



Hospitalization and Attachm ent 413

(Ainsworth et al. , 1978; Belsky, Ro vine, & Taylor, 1984). Th us, lower rates of

maternal visitation may reflect preexisting patterns of less than optimal mother-

child relationships (e.g., lower maternal sensitivity to the child's needs). On the

other hand, it is also possible that lower maternal visitation rates may reflect

maternal reactions to their infants' behaviors that are characteristic of insecure

attachments, especially avoidant attachments. Some mothers may have inter-

preted their infants' avoidant or

aloof

behavior as a sign that their children did

not need them or that their child was content to be left among strangers (e.g.,

nursing staff). The present study cannot distinguish between these two alterna-

tive explanations, either or both of which may have contributed to the relation-

ship between attachment and maternal visitation.

This research does not support the hypothesized comprehensive predictive

model, which postulated that maternal anxiety would be affected by SES, num-

ber of children at home, gender and age of the child, and the number of previous

hospitalizations (Alexander et al., 1986, 1988; Berenbaum & Hatcher, 1992;

Pmgh et al ., 1953) and failed to corroborate previous findings (Alexander et al .,

1988; Freiberg, 1972; Prugh et al., 1953; D. Robinson, 1968) that state anxiety

in mothers of hospitalized children would predict hospital visitation. Differences

in methods, including the timing of anxiety measures and selection of partici-

pants could account for the lack of agreement with past research. For example,

all of the parents in this study were approached after the first 24 hours of

hospitalization, when anxiety levels are likely to be lower than at the time of

admission, and all had young children who were hospitalized for acute nonsurgi-

cal,

time-limited procedures.

The lack of support for the proposed comprehensive model may also reflect

special characteristics of this particular setting that rendered the model less

sensitive to individual variations in maternal anxiety and visitation patterns. For

example, on this pediatric unit the nursing staff encouraged parents to room-in

with their children, provided free breakfast, and made private showers available

for parents only. Of the 86 mothers surveyed, 75 did room-in with their ill

children. Moreover, the children in our sample were hospitalized for acute ill-

nesses that required short-term hospitalization. Tests of the proposed comprehen-

sive model in a hospital setting that provides lower levels of support for parental

visitation, and where parental visitation patterns are more variable, or with

children who are hospitalized for more serious illnesses and extensive periods of

t ime, may reveal the influence of family supports and resources that were not

found in this study.

It is also possible that the hypothesized model, which was an initial attempt

to integrate a wide range of variables in our framework, needs further develop-

ment. One means of developing the model, especially in cases of children with

long-term or chronic illnesses, would be to assess, in greater detail, how family

resources (e.g., family income) and parental demands (e.g., needs of other




children at home) are stressed by the burden of

chronically ill child. Additional

family stress, especially in lower SES groups where resources are already ten-

uous, may contribute to a reduction in visitation and possibly contribute to poor

psychological outcomes for the ill child. Douglas (1975), in a longitudinal study,

and Quinton and Rutter (1976) found that children who were hospitalized multi-

ple times in early childhood displayed later behavioral disturbance, especially

children from lower SES family backgrounds. Therefore, an interesting, and

largely unexplained question is how family resources and SES contribute to

maternal visitation when a child is frequently hospitalized or admitted for exten-

sive hospitalization. Other measures of maternal psychological states (e.g., con-

fusion, anger, depression) associated with distress may also predict visitation

rates. Maternal distress induced by the hospitalization of a child and com-

pounded by younger maternal age, increased severity of the child's illness, and

greater experience with hospitalization (Berenbaum & Hatcher, 1992) may cause

mothers to avoid the hospital environment, therefore decreasing their emotional

discomfort, but reducing visitation rates.

On the other hand, it is possible that the model may be valid, but that some

of the specific variables used to operationalize the concepts are not sufficiently

sensitive. For example, we did not directly examine the relationship of the

families' proximity to the hospital to visitation ra tes. However, it should be noted

that greater than 80 % of all pediatric patients adm itted to this hospital live within

a 10- to 30-minute radius of the hospital. Nor did we directly measure maternal

opportunities for visitation. Although the number of children at home is an

indirect assessment of visitation opportunities, a more precise and extensive

evaluation (e.g., parental work schedules) would clarify this variable and its

impact on visitation. Furthermore, certain other variables, such as staff-parent

communication and perception of the parental role, were not assessed in this

study. Another difficulty is posed by the fact that 30% of the parents w ho w ere

eligible for the study did not elect to participate. Unfortunately, it was not

possible to obtain information concerning the nonparticipants. It is difficult to

determine what impact this may have had on the present findings.

The results of this study need to be interpreted cautiously in light of the fact

that a brief measure of attachment was used that needs further validation and

refinement, especially in light of the low internal consistency demonstrated in

this initial sa mple. F uture refinement of the instrument could include the ad dition

of more items and measures of construct validity obtained by having mothers

complete the entire Attachment Q-sort prior to and/or several weeks after the

hospitalization of their child. N everth eless, it should be noted that this brief L ikert-

scale measure, which is quite feasible to use in a hospital setting, was the only

variable that demonstrated predictive utility in a test of the proposed model. Con-

sequently, this finding provides preliminary construct validity for this measure.

Future studies are needed to explore additional factors that predict parental



Hosp ilalization and Attachment 415

visitation in other populations such as children with chronic pediatric conditions,

especially those who need to be hospitalized for a long period over multiple

occasions. Populations in which predictive models of parental visitation should

be tested include technology-dependent children (Hamlett et al., 1994), children

who are admitted to pediatric rehabilitation hospitals for extended periods of

time, whose hospital stays are typically extended, whose conditions are typically

complex and chronic (Singer & Drotar, 1989), and children who have recurrent

hospitalizations.

The present findings have potential clinical implications. The finding that

mothers of insecurely attached children visit less indicates that such children

have less access to their major attachment figures at a time of significant stress.

In some instances this could serve to jeopardize an already stressed or problemat-

ic parent-child relationship, possibly creating additional apprehension on the

part of the child, and perhaps even progressively less visitation from parents.

Consequently, efforts should be made to identify parents who rarely visit their

children and encourage and support them to do so. When mothers display low

rates of visitation, risk factors associated with insecure attachment should be

considered as explanations (i .e., poor knowledge of caretaking skills (Egeland

& Farber, 1984) and maternal insensitivity (Ainsworth et al., 1978)), along with

environmental resource problems. Moreover, hospital staff may need to consider

special implications of patterns of attachment for the psychological development

of children who are technology-dependent, or require long-term and repeated

hosp italizations, as in the course of a chronic illness (Hamlett et al., 1994). In

such cases, preexisting patterns of insecure attachment could contribute to lower

rates of parental visitation, which in turn could reduce opportunities for parent-

child interactions in ways that eventually threaten the child's psychological de-

velopment. At present, very little is understood about the role of attachment in

the psychological outcomes of these special populations.

Finally, as greater numbers of hospitals allow unlimited visitation, pediatric

psychologists are afforded the opportunity to identify factors that influence ma-

ternal visitation and to determine how maternal visitation patterns influence other

clinically relevant outcomes such as length of stay. The present study identified

only one variable that significantly predicted maternal visitation, quality of at-

tachment. The identification of factors that predict maternal visitation provides

information that could be used to help hospital staff to better assist those mothers

who find it difficult to visit their ill children.

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