MOTHER-CHILD ATTACHMENT DEVELOPMENT IN YOUNG CHILDREN WITH HEARING LOSS: EFFECTS OF EARLY VERSUS LATE DIAGNOSIS OF HEARING LOSS By Hollea Ann McClellan Ryan Dissertation Submitted to the Faculty of the Graduate School of Vanderbilt University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY in Hearing and Speech Sciences August, 2012 Nashville, TN Approved: Anne Marie Tharpe, Ph. D. Daniel H. Ashmead, Ph. D. Mary Jo Ward, Ph. D. Mark Wolery, Ph. D.
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MOTHER-CHILD ATTACHMENT DEVELOPMENT IN YOUNG CHILDREN WITH
HEARING LOSS: EFFECTS OF EARLY VERSUS LATE
DIAGNOSIS OF HEARING LOSS
By
Hollea Ann McClellan Ryan
Dissertation
Submitted to the Faculty of the
Graduate School of Vanderbilt University
in partial fulfillment of the requirements
for the degree of
DOCTOR OF PHILOSOPHY
in
Hearing and Speech Sciences
August, 2012
Nashville, TN
Approved:
Anne Marie Tharpe, Ph. D.
Daniel H. Ashmead, Ph. D.
Mary Jo Ward, Ph. D.
Mark Wolery, Ph. D.
ii
DEDICATION
To my husband Kevin who has supported me unconditionally every step of the way,
and
To my son Evan who provided many wonderful examples of attachment behavior.
iii
ACKNOWLEDGEMENTS
The completion of this research project reflects the direct and indirect
contributions of many wonderful people. Words cannot describe the appreciation that I
feel to all those that have assisted me along this journey. Nonetheless, I wish to
acknowledge those who have provided me support, encouragement, and direction.
First and foremost, my advisor and dissertation director, Anne Marie Tharpe, has
been an example of excellence in mentorship. Her patience, understanding,
encouragement, assistance and leadership are reflective of a person dedicated to the
advancement of our understanding of speech-language-hearing issues. I am additionally
indebted to Daniel Ashmead, Mark Wolery, and Mary Jo Ward for serving on my
committee. The direction and support they provided throughout this project made it a
success.
I would also like to thank Alex Lathe, Liz Harland, and Brittany Alex for their
contribution to this study by serving as observers. Their insight and dedication to this
project was greatly appreciated. Furthermore, the study would not have been possible
without the mother-child dyads who participated. My greatest appreciation goes out to
each family for allowing us to go into their home and complete observations on their
child’s attachment behaviors.
It seems unlikely that any person can go through a doctoral program without
finding support and encouragement from fellow students. I am no exception. My
appreciation goes to the members of the Auditory Development Lab including Heather
Porter, Kathryn Guillot, Dana Kan, Uma Soman, and Lindsey Rentmeester, who were
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always available to discuss ideas, problems, and everyday issues that arise when working
on a dissertation. Marjorie Grantham, Jeremy Federman, Krystal Werfel, and Erin Picou
were fellow students who provided indispensable friendship during my doctoral program
for which I am thankful.
Lastly, I recognize that I would not be where I am today had it not be for the love
and support of my family. Even from a young age, my parents encouraged me to pursue
higher education. I can only hope that I have made them proud. Furthermore, I
appreciate my sister Heather and her husband André for being my cheering squad during
my doctoral program. Most of all, the support and encouragement that my husband Kevin
provided was invaluable. The love and pride I felt from him and our son Evan was so
very, very precious to me.
v
TABLE OF CONTENTS
Page
DEDICATION .................................................................................................................... ii
ACKNOWLEDGEMENTS ............................................................................................... iii
LIST OF TABLES .............................................................................................................. X
LIST OF FIGURES ............................................................................................................ X
Chapter
I. INTRODUCTION……………………………………………………………….
II. REVIEW OF THE LITERATURE……………………………………………
Attachment Theory……………………………………………………… Attachment Classification……………………………………………… Parent Behavior…………………………………………………………… Tools to Evaluate Attachment……………………………………………… Factors Influencing Attachment…………………………………………… Influences of Newborn Hearing Screenings…………………………… Attachment Research in Children with Hearing Loss……………………… III. METHODS………………………………………………………………
Participants……………………………………………………… Measures…………………………………………………………….. Procedures…………………………………………………………….. IV. RESULTS AND DISCUSSION Group Equivalency………………………………………………………… Group Data Analysis…………………………………………………… Early versus Late Analysis………………………………………………… Qualitative Findings……………………………………………………… V. SUMMARY AND CONCLUSIONS……………………………………………
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Appendix A. Depiction of sorting method…………………………………………………… B. ………………………………………………………………………… C. ……………………………………………………………………….. D. ………………………… REFERNCES……………………………………………………………………
Marvin (1979) found that deaf preschoolers with hearing parents could develop secure
attachments. However, there was a strong link between communication skills and
classification. Specifically, those preschoolers with good communication skills
(determined by the Alphern-Boll Developmental Profile and coded observations) were
securely attached while those with poor communication skills were insecurely attached.
As noted previously, Lederberg and Mobley (1990) found that young children with
hearing loss who had hearing parents were as likely to have secure attachment as their
hearing counterparts. But, for the insecure groups, there was a greater percentage of
ambivalent classification for children with hearing loss than for those with normal
hearing. However, they concluded that children with hearing loss do not have to have
normal language development for secure attachment to occur. Still, it might be possible
that the parents of the children with secure attachment were more effective at picking up
on communicative cues by the child whereas parents of children with insecure
attachments are not as perceptive.
In addition to communication skills, parental attitude toward deafness has been
found to influence attachment development in children with hearing loss. A study
conducted in the mid-1990s examined the relationship of secure attachment and attitudes
toward deafness by mothers and fathers of children whose deafness was identified prior
17
to 18 months of age (Hadadian, 1995). As a whole, deaf children were as likely to
develop secure attachment to the mother as to the father. However, individual dyad
differences were found, indicating that within a family, a child is just as likely to
establish a secure relationship with one parent and an insecure attachment with the other
as they are to establish the same attachment pattern to both parents. This finding was
mediated by parental attitude toward deafness. Specifically, if a parent indicated a
negative attitude toward deafness, there was an increased likelihood that the child would
develop an insecure attachment with that parent (Hadadian, 1995).
Collectively, these findings suggest that deafness, in and of itself, is not a
contributing factor to an increased rate of insecure attachment classification. However,
there remains concern that poor communication in parent-child dyads and/or parental
attitudes toward the deafness contribute to insecure attachment. It is known that, on
average, children with insecure attachment have poorer language skills than their
counterparts with secure attachment (van IJzendoorn, et al., 1995). Additionally, children
with parents who were more sensitive to their needs and interactions were more likely to
be classified as secure (van IJzendoorn, et al., 2007). Therefore, it seems reasonable that
if parents of deaf children are sensitive to the children’s communicative attempts then
secure attachment can be developed. Thus, it might be that the effectiveness of
communication, by both the parents and the children with hearing loss, plays an
important role in attachment development.
In conclusion, attachment development in children with hearing loss has received
limited attention. However, as the age of identification of hearing loss in children
decreases, an early diagnosis might impact attachment development. Although the
18
existing literature suggests that children with hearing loss, as a group, are just as likely to
have secure attachments as their normal-hearing peers, experts in the field of hearing loss
indicate that the current Criterion Sort (Waters, 1995) of the AQS might not provide an
accurate assessment of attachment behavior of children with hearing loss. Therefore, the
current study proposes to address the following questions:
1. Are children with hearing loss who use spoken language in this study as
securely attached as children without hearing loss of similar ages as based on
extant literature?
2. Is attachment classification of deaf children affected by an early versus later
diagnosis of hearing loss?
19
CHAPTER III
METHODS
Participants
Twenty-one young children, ranging in age from 2 to 6 years, with moderate-to-
profound permanent, bilateral hearing loss and their mothers enrolled in this study.
Children were recruited from six metropolitan areas in the southeast U.S. in accordance
to Vanderbilt University Institutional Review Board (IRB) approved procedures. These
mother-child dyads were subcategorized into one of two groups distinguished by the age
of the child at confirmation/diagnosis of the hearing loss (i.e., early-diagnosed, late-
diagnosed). Diagnosis of the hearing loss had to occur by seven months of age for a child
to be placed in the early- diagnosed group. Children with hearing loss diagnosed after age
seven months were placed into the late-diagnosed group. Nine children were classified as
early-diagnosed and twelve children were classified as late-diagnosed. All children had at
least a moderate-to-profound bilateral hearing loss at the time of diagnosis1.
With the exception of language delay, none of the children had any other
significant disability per parental reports. No parents reported having childhood hearing
loss and all parents primarily used spoken language with their child. Demographic data
obtained on all participants can be seen in Table 1.
1 One child, S11, had hearing thresholds in the mild-to-moderate hearing loss range with a diagnosis of auditory neuropathy/auditory dyssynchrony. This child ultimately received a cochlear implant.
20
Table 1 Demographic Details
Characteristics
Diagnosis
Early (n = 9) Late (n = 12) Sex
Male
4
2
Female
5
10
Age of Observation
Mean (in months) 49.0
57.4
Range (in months) 27 - 79
30 – 83
Age of Diagnosis
Mean (in months) 2.5
19.01
Range (in months) .25 - 6
8 – 30
Amplification
Cochlear Implant 5
6
Hearing Aid 4
4
CI/HA combo 0
2
Newborn Hearing Screen
Completed 8
12
Passed
0
9
Failed
8
3
Mother's Education
HS diploma/GED 2
3
Some college/AA 5
3
4-yr college degree 1
6
Advanced degree 1
0
Mother's Age
Mean (years) 34
33
Range (years) 24-44
22-42
Note: CI/HA combo = cochlear implant/hearing aid combo; GED = General Educational Development; AA = Associate of Arts degree
21
Measures
The primary tool used for this study was the third edition of the Attachment Q-
Sort (AQS; Waters, 1987). The AQS is comprised of 90 behavioral descriptions that
were listed on individual cards for sorting purposes and reflect different types of child
behavior. These behaviors represent such concepts as security, anger, self-efficacy,
communication skills and response to physical contact. The use of the AQS in both
infants (Bakermans-Kranenburg, van IJzendoorn, Bokhorst, & Schuengel, 2004; van
Bakel & Riksen-Walraven, 2004) and older children (i.e., preschoolers - 6 year olds) is
well established (Park, 1992; Symons, et al., 1998).
Secondary measurements included the Amplification in Daily Life Questionnaire,
a non-validated, experimenter-administered tool that has both open-ended questions and
15 items that are scored via a five-point Likert scale (Moeller, Hoover, Peterson, &
Stelmachowicz, 2009). Amplification usage could be considered a possible contributing
factor to attachment development; that is, the amount of amplification usage could have
direct and indirect relationships to language performance or to the child’s responsiveness
towards the parent’s attempt at communication and/or interactions. Thus, total daily
amplification usage information for all children was collected. Additionally, mothers
were asked to complete a study-created demographic survey to collect general
information about the family and the child (e.g., parent education level, cause of hearing
loss, number of siblings, etc.).
The Communication and Symbolic Behavior Scales Developmental Profile
(CSBS DP; Wetherby & Prizant, 2002) was used to assess communication ability of the
participants. The CSBS DP is a norm-referenced tool that evaluates communicative
22
competence in children 2-6 years of (chronological) age but who might have a low
functional communication age (i.e., 6-24 months). The CSBS DP was used in addition to
collecting language performance scores. The language performance scores (i.e., standard
scores) came from recent standardized test(s) completed by the children’s therapists.
Parents were asked to provide their child’s language scores and return to the primary
investigator via a self-addressed, pre-paid envelope along with a copy of a recent
audiogram, unless records could be obtained through Vanderbilt’s medical records.
Procedures
Home observation.
An observer AQS procedure which has been shown to be a valid method to assess
attachment, as opposed to a maternal AQS procedure, was used (van IJzendoorn,
Vereijken, Bakermans-Kranenburg, & Riksen-Walraven, 2004). Home observations were
scheduled to be completed by the primary investigator alone or with a second observer.
An additional observer was present, when possible, to assess the reliability of the AQS
sort description. Three female graduate students were trained to complete the
observations as secondary observers. Prior to experimental observations, the primary
(H.R.) and secondary observers familiarized themselves with the Q-set items and read
educational and instructional materials (Prior & Glaser, 2006; Waters, 1987, n.d.). Each
graduate student observer completed observations and Q-sorts on three normal hearing
children, in the target age range, for training and validation of inter-rater consistency.
The principal investigator, Observer 1, accompanied each of the secondary observers on
23
their home visits and completed a sort for the same observation. Following training, all
observers had a correlation coefficient of at least a .70 inter-rater reliability with Observer
1.
One home visit was made to each mother-child dyad. The average home visit
lasted 3.0 hours (range 2.5 - 4.0 hours). Per van IJzendoorn and colleagues (2004),
studies with at least 3-hour observations had AQS results that were more valid than those
with less observation time. Despite efforts to have two observers for all home visits, 13
observations were completed by two observers with the remaining eight observations
being completed by only Observer 1, the primary investigator.
When scheduling the observation, mothers were informed that optimal
observation conditions would be with the mother and child alone in the home. However,
no families were excluded if additional family members were present for the observation.
In most circumstances, when other families members where present in the home, they
remained in areas separate from where the observation was being conducted. The few
exceptions usually occurred when (younger) siblings were kept close by the mother for
monitoring.
Upon arriving at the home, parents were encouraged to “go about their daily
routine”. Mothers were informed that activities might be suggested during the
observation to facilitate or ensure a variety of behaviors occurred. Such activities
included baking together, reading a book, or playing a game. Additionally, some small
toys designed to initiate activities were brought by the observers (e.g., bubbles, puzzles,
books, stuffed toys) to introduce to the dyad during periods of slow or ‘unproductive’
interactions when, and if, necessary. When determined appropriate by the investigator, or
24
when interest in the ‘toy bag’ was initiated by the child, these toys were introduced one at
a time. Presentation of these toys to the child not only initiated another activity for the
child, but also allowed for different ‘behavioral items’ listed in the AQS to be evaluated
by the introduction of new toys. This primarily unstructured observation is consistent
with Waters and Deane’s (1985) procedure.
The observers attempted to minimize their presence, but interacted appropriately
(as would a social visitor to the family home) if the child initiated conversation or play
with the observer(s). Additionally, the observers attempted to have a relaxed interaction
with the mother. That is, they become acquainted and accepted offerings (e.g., snacks or
drinks) but encouraged the mother to ‘go about her daily activities’. During the
observations, if and when appropriate, the observers initiated certain interactions with the
child that helped in observing certain attachment behaviors. For example, an observer
might have asked the child to show her a toy with which the child was playing or to give
her a good-bye hug. Such a request allowed the observers to determine how the child
responded to requests by visitors, their willingness to show or share toys or personal
belongings with a visitor, or if they willingly allowed physical contact from a visitor.
Brief and direct questions were asked of the mother for clarification or for assistance in
classifying behaviors that were inconsistent or unobserved. For example, the observers
might have asked if a certain behavior was “typical” or just there because a visitor was
present. Mothers also were asked to describe a typical routine, such as bed-time, or a
child’s reaction to certain potentially stressful situations such as the child being left by
the mother with another family member or babysitter.
25
Q-sort.
Observer 1 completed all 21 home observations and was accompanied by
secondary observers on 13 home visits. After each of the observations, the observers
sorted the AQS cards based on their observations and detailed notes taken during the
visits. For each observation, the 90 AQS cards were initially divided into three piles,
reflecting “most characteristic of the child”, “least characteristic of child”, and “neither
characteristic or uncharacteristic of the child”. This sorting is based on the observation of
the child during the three-hour visit in relation to how the child interacted with his/her
mother, with the observers, and how he/she played independently. During this initial sort,
an exact breakdown (i.e., 30 cards in each pile) is not necessary and is done in a quick
manner. After the initial sort into three piles, the observer further sorts the three piles
into nine piles, with the “least characteristic” pile (pile #1) at the far left, the “neither
characteristic or uncharacteristic” pile in the middle (pile #5), and the “most
characteristic” pile (pile # 9) at the far right (see Appendix A for a visual depiction of the
sorted piles). The number of cards in each pile was in quasi-normal order with fewer
cards in the extreme piles and the most in the middle pile. That is, the respective piles
have the following number of cards in them: 4, 6, 10, 15, 20, 15, 10, 6, and 4.The average
time taken to complete the first sort was 48 minutes.
Careful thought during the final phase of sorting is encouraged to ensure that each
characteristic is properly placed (Waters, n.d.). That is, when sorting, the observer placed
items to the extremes that most (or least) represented the child to provide a description of
the child’s behavior. How one sorts the items should reflect the sorter’s response to
26
specific questions about the child’s behavior, such as, “Is this the behavior that would let
me pick this child out of a crowd?” (Waters, n.d.). If a behavioral item was not observed,
or not age appropriate, then that item was placed in the middle pile. All sorts were
completed within six hours of the observation with the exception of one sort that was
completed within 12 hours because of travel requirements.
Once the sort was completed, each AQS item was assigned a value based on the
pile into which it was sorted. The pile to the far left (i.e., pile #1) was assigned a value of
one. Likewise, the second pile from the left (i.e., pile #2) was assigned a two, and so on.
Thus, the far right pile, or the “most characteristic” pile (i.e., pile #9) was assigned a
value of 9. All items within a given pile receive the assigned value. As such, four items
have a value of “1”, six items have the value of “2”, 10 items have the value of “3”, and
so on.
After completion of the first sort by both observers, a review of item scores was
conducted. Any item resulting in a difference in value equal to or greater than three was
considered to be in ‘discrepancy’ between the two observers and was discussed. Using a
difference of three or greater is consistent with other AQS studies (Posada, 2006). The
average number of item discrepancies across all observer pairs during a single sort was
15 out of 90.
Following the first sort and a discussion between the two observers, a second sort
was completed by each observer. Observers were encouraged to take into consideration
comments made during the discussion session. However, observers were not to change
an item placement unless they felt confident in the change. That is, the primary
investigator did not want the student observers to be influenced or to feel obligated to
27
change their rating of an item simply to agree with Observer 1. Inter-rater reliability was
calculated by correlating the q-sort produced by Observer 1 with the q-sort produced by a
second observer. Overall inter-rater reliability after the second sort was .74 (range: .63 -
.84) and was consistent with other studies (Bost, Vaughn, Washington, Cielinski, &
31. Child wants to be the center of mother’s attention. If mom is busy or talking to someone, he interrupts.
2.5 5.0 -2.5 -1.1
33. Child sometimes signals mother (or gives the impression) that he wants to be put down, and then fusses or wants to be picked right back up.
1.3 4.7 -3.4 -6.1
34. When child is upset about mother leaving him, he sits right where he is and cries. Doesn’t go after her.
1.2 4.9 -3.7 -15.6
38. Child is demanding and impatient with mother. Fusses and persists unless she does what he wants right away.
1.2 4.3 -3.1 -1.3
41. When mother says to follow her, child does so. 8.5 5.6 2.9 2.1
57
42. Child recognizes when mother is upset. Becomes quiet or upset himself. Tries to comfort her, Asks what is wrong, etc.
8.2 5.7 2.5 2.9
53. Child puts his arms around mother or puts his hand on her shoulder when she picks him up. 8.5 5.4 3.1 2.7
60. If mother reassures him by saying “It’s OK” or “It won’t hurt you”, child will approach or play with things that initially made him cautious or afraid.
8.5 4.9 3.6 4.0
61. Plays roughly with mother. Bumps, scratches, or bites during active play. (Doesn’t necessarily mean to hurt mom).
1.8 4.5 -2.7 -1.5
69. Rarely asks mother for help. 2.3 5.4 -3.1 -2.4
70. Child quickly greets his mother with a big smile when she enters the room. (Shows her a toy, gestures, or says “Hi, Mommy”).
8.0 5.1 2.9 1.4
71. If held in mother’s arms, child stops crying and quickly recovers after being frightened or upset. 8.8 5.7 3.1 3.1
74. When mother doesn’t do what child wants right away, child behaves as if mom were not going to do it at all. (Fusses, gets angry, walks off to other activities, etc.)
1.5 4.3 -2.8 -1.4
77. When mother asks child to do something, he readily understands what she wants. (May or may not obey).
7.7 5.4 2.3 1.6
80. Child uses mother’s facial expressions as good source of information when something looks risky or threatening.
8.5 4.9 3.6 4.5
58
81. Child cries as a way of getting mother to what he wants. 1.8 5.0 -3.2 -2.0
88. When something upsets the child, he stays where he is and cries. 1.2 4.9 -3.7 -4.0
90. If mother moves very far, child follows along and continues his play in the area she has moved to. (Doesn’t have to be called or carried along; doesn’t stop play or get upset.)
8.3 4.6 3.7 3.1
59
Appendix C
Items with a difference score equal to or less than |.05|.
Behavioral Item Waters' Criterion
Sort
Deaf Composite
Sort
Criterion & Composite
Score Differences
3. When he is upset or injured, child will accept comforting from adults other than mother.
4.8 4.6 0.2
9. Child is lighthearted and playful most of the time. 6.5 6.0 0.5
12. Child quickly gets used to people or things that initially made him shy or frightened him.
6.0 5.8 0.2
24. When mother speaks firmly, or raises her voice at him, child becomes upset, sorry, or ashamed about displeasing her.
4.5 4.5 0.0
27. Child laughs when mother teases him. 6.3 6.3 0.0
29. At times, child attends so deeply to something that he doesn’t seem to hear when people speak to him.
4.3 4.6 -0.3
30. Child easily becomes angry with toys. 2.3 2.7 -0.4
37. Child is very active. Always moving around. Prefers active games to quiet ones.
4.8 5.3 -0.5
39. Child is often serious and businesslike when playing away from mother or alone with his toys.
4.7 5.0 -0.3
43. Child stays closer to mother or returns to her more often than the simple tasks of keeping tracks of her requires.
4.7 5.1 -0.4
60
45. Child enjoys dancing or singing along with music. 5.2 5.6 -0.4
46. Child walks and runs around without bumping, dropping, or stumbling.
5.7 5.2 0.5
51. Child enjoys climbing all over visitor when he plays with them. 4.7 4.8 -0.1
52. Child has trouble handling small objects or putting small things together.
3.8 3.6 0.2
56. Child becomes shy loses interest when an activity looks like it might be difficult.
2.7 2.7 0.0
58. Child largely ignores adults who visit the home. Finds his own activities more interesting.
3.2 3.1 0.1
62. When child is in a happy mood, he is likely to stay that way all day. 5.5 5.1 0.4
66. Child easily grows fond of adults who visit his home and are friendly to him.
7.0 7.0 0.0
73. Child has a cuddly toy or security blanket that he carries around, takes it to bed, or holds when upset.
5.2 5.0 0.2
84. Child makes at least some effort to be clean and tidy around the house.
5.0 5.2 -0.2
85. Child is strongly attracted to new activities and new toys. 7.5 7.0 0.5
87. If mother laughs at or approves of something the child has done, he repeats again and again.
5.8 5.8 0.0
89. Child’s facial expressions are strong and clear when he is playing with something.
6.5 6.0 0.5
61
Appendix D
Item modes with a difference equal to or greater than |2.5| between early- and late-diagnosed groups.
Item/Description Waters' Criterion
Sort
Mode for
Early
Mode for
Late
Difference Between Modes
14. When child finds something new to play with, he carries it to mother or shows it to her from across the room.
7.8 7.0 2.5 -4.5
15. Child is willing to talk to new people, show them toys, or show them what he can do, if mother asks him to.
7.7 5.5 8.0 2.5
21. Child keeps track of mother’s location when he plays around the house. 8.8 8.0 4.5 -3.5
24. When mother speaks firmly, or raises her voice at him, child becomes upset, sorry, or ashamed about displeasing her.
4.5 3.5 6.0 2.5
31. Child wants to be the center of mother’s attention. If mom is busy or talking to someone, he interrupts.
2.5 7.0 2.0 -5.0
35. Child is independent with mother. Prefers to play on his own; leaves mother easily when he wants to play.
4.3 1.0 7.5 6.5
39. Child is often serious and businesslike when playing away from mother or alone with his toys.
4.7 4.0 6.5 2.5
40. Child examines new objects or toys in great detail. Tries to use them in different ways or to take them apart.
6.5 3.5 7.0 3.5
41. When mother says to follow her, child does so. 8.5 6.5 4.0 -2.5
62
44. Child asks for and enjoys having mother hold, hug, and cuddle him. 7.7 6.0 3.5 -2.5
58. Child largely ignores adults who visit the home. Finds his own activities more interesting.
3.2 5.0 1.0 -4.0
59. When child finishes with an activity or toy, he generally finds something else to do without returning to mother between activities.
3.8 3.0 7.0 4.0
61. Plays roughly with mother. Bumps, scratches, or bites during active play. (Doesn’t necessarily mean to hurt mom).
1.8 7.0 4.0 -3.0
65. Child is easily upset when mother makes him change from one activity to another.
1.8 6.0 3.0 -3.0
69. Rarely asks mother for help. 2.3 3.5 6.0 2.5
72. If visitors laugh at or approve of something the child does, he repeats it again and again.
4.5 7.0 4.0 -3.0
63
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