Evaluating Caregiver Sensitivity To Infants: Measures Matter

Download as pdf or txt
Download as pdf or txt
You are on page 1of 42

THE OFFICIAL JOURNAL OF THE

INTERNATIONAL CONGRESS
OF INFANT STUDIES

Infancy, 23(5), 730–747, 2018


© International Congress of Infant Studies (ICIS)
ISSN: 1525-0008 print / 1532-7078 online
DOI: 10.1111/infa.12248

Evaluating Caregiver Sensitivity to Infants:


Measures Matter

Yvonne Bohr
Department of Psychology
LaMarsh Centre for Child and Youth Research
York University

Diane L. Putnick
Eunice Kennedy Shriver National Institute of Child Health and Human Development
National Institutes of Health USA

Yookyung Lee
LaMarsh Centre for Child and Youth Research
York University

Marc H. Bornstein
Eunice Kennedy Shriver National Institute of Child Health and Human Development
National Institutes of Health USA and
Institute for Fiscal Studies London, UK

The significance of caregiver sensitivity for child development has been debated among scholars,
not least due to sensitivity’s inconsistent predictive value over time and across con texts. A lack of
uniformity in the definition of sensitivity contributes to this debate, but shortfalls of intertool
concordance and construct validity in the instruments used to assess sensitivity may also be at
issue. This study examines correspondences among four established standardized measures of
caregiver sensitivity in independent classifications of the same sam ple of mothers of infants. Fifty
European American mother–infant dyads of diverse SES were independently assessed with three
observational caregiver sensitivity measures: the Emotional Availability Scales (EAS; Biringen,
2008, Emotional availability (EA) scales man ual (4th ed.): Part 1. Infancy/early childhood version
(child aged 0–5 years). Colorado State University. Unpublished manuscript), the Parent Child
Interaction—Nursing Child Assess ment Satellite Training Feeding Scale (PCI-NCAFS; Oxford
& Findlay, NCAST

Correspondence should be sent to Yvonne Bohr, Department of Psychology, LaMarsh Centre for Child and Youth
Research, York University, Behavioural Sciences Building, 4700 Keele Street, BSB 117, Toronto ON M3J 1P3,
Canada. E-mail: bohry@yorku.ca. Marc H. Bornstein, Eunice Kennedy Shriver National Institute of Child Health and
Human Development National Institutes of Health USA and Institute for Fiscal Studies London, UK. E-mail:
marc.h.bornstein@gmail.com.
EVALUATING CAREGIVER SENSITIVITY: MEASURES MATTER 731

caregiver/parent-child interaction feeding manual, Seattle, WA: NCAST Programs, University of


Washington, School of Nursing, 2015), and the Maternal Behavior Q-Sort (MBQS; Moran,
Pederson, & Bento, 2009, Maternal Behavior Q-Sort (MBQS)–Overview, available materials and
support. University of Western Ontario. Unpublished). Ratings were juxta posed with
classifications of the same sample based on the original Ainsworth Maternal Sen sitivity Scales
(AMSS; Ainsworth, 1969, Power, 6, 1379). The EAS, NCAFS, and MBQS are related to the
AMSS, but large proportions of variance were unshared. Researchers and clin icians should be
cautious when assuming that popular observational assessment instruments, commonly believed
to measure a generic construct of caregiver sensitivity, are interchange able, as these measures
may evaluate different features of sensitivity to infants.

Sensitivity to infants ranks among the most central yet somewhat equivocal constructs in the
field of parenting. Noticing an infant’s signals, “interpreting them accurately and...responding
to them appropriately” (Ainsworth, Blehar, Waters, & Wall, 1978; p. 40) have long been
considered cornerstones of the type of good parenting that leads to a child’s secure attachment
and optimal physical and mental health (Bigelow et al., 2010; van den Boom, 1997; Bornstein,
2015; Bowlby, 1969; Bretherton, 2013; McEl wain & Booth-LaForce, 2006; World Health
Organization, 2004). Yet many questions persist about the strength of associations between
sensitivity and child development generally (Atkinson et al., 2000; Bigelow et al., 2010; De
Wolff & van IJzendoorn, 1997; Goldsmith & Alansky, 1987; Paavola, Kemppinen,
Kumpulainen, Moilanen, & Ebeling, 2006; Page, Wilhelm, Gamble, & Card, 2010; Pillhofer
et al., 2015; Tamis LeMonda, Briggs, McClowry, & Snow, 2009) and the predictive value of
sensitivity in diverse contexts (Ispa et al., 2004; Jin, Jacobvitz, Hazen, & Jung, 2012).
The putative significance of sensitivity is based on studies that have linked it to important
psychosocial, cognitive, and physiological developmental outcomes (Baker mans-Kranenburg,
van IJzendoorn, & Juffer, 2003; Bernier, Carlson, & Whipple, 2010; Feldman, Eidelman, &
Rotenberg, 2004; Hirsh-Pasek & Burchinal, 2006; Lemelin, Tar abulsy, & Provost, 2006;
Mesman, van IJzendoorn, & Bakermans-Kranenburg, 2012). Research has further uncovered
associations of caregiver sensitivity with specific aspects of child language and intellectual and
academic development (Feldman et al., 2004; Hirsh-Pasek & Burchinal, 2006; Lemelin et al.,
2006; Nozadi et al., 2013; Paa vola et al., 2006; Roger Mills-Koonce et al., 2015; Vallotton,
Mastergeorge, Foster, Decker, & Ayoub, 2017), associations that may not be quite so robust or
unique as those reported for other aspects of child development (Page et al., 2010).
Not surprisingly, caregiver sensitivity has been most consistently linked to child social and
emotional development, largely because of sensitivity’s established ties to the quality of
caregiver–infant attachment, which in turn generally predicts positive mental health outcomes
(Bigelow et al., 2010; Bretherton, 2013; McElwain & Booth-LaForce, 2006; Moran, Pederson,
& Tarabulsy, 2011; Stams, Juffer, & van IJzendoorn, 2002). Stams et al. (2002), for example,
asserted that higher quality maternal sensitive responding in infancy (birth to 3 years),
measured with the Ainsworth Maternal Sensitivity Scales (AMSS; 1974), uniquely predicted
better social development at age 7 (r = .22, p < .01). However, even the sensitivity–mental
health association has been challenged by studies that have failed to confirm the universal
superiority of sensitivity over other variables (e.g., availability of play materials, parental
supervision, orderly household, and verbal stimulation) when forecasting social and affective
developmental pathways (Diener, Nie var, & Wright, 2003; Longo, McPherran Lombardi, &
Dearing, 2017; Page et al., 2010).
732 BOHR ET AL .
It is also fair to say that “caregiver sensitivity” remains poorly defined. Still over
whelmingly referred to as maternal sensitivity, caregiver sensitivity is habitually used
interchangeably with maternal responsiveness, caregiver–infant interaction quality, or
mother–infant congruence and lacks grounding in universally accepted, clearly delin eated,
and specific behaviors (Bigelow et al., 2010; Meins, Fernyhough, Fradley, & Tuckey, 2001;
Posada et al., 2016; Shin, Park, Ryu, & Seomun, 2008). Scholars largely agree that sensitivity
should be considered a statement about the interaction between caregiver and infant, a highly
complex phenomenon, and important aspect of parent ing (van den Boom, 1997), but its
operationalization is far from standardized. Several theorists have sought to analyze and
synthesize confusing data pertaining to sensitivity. De Wolff and van IJzendoorn (1997) and
Meins et al. (2001), for example, have offered cohesive and accessible definitions of the
construct. However, insights gener ated by studies that critically examine the sensitivity
paradigm, and query its consis tency across contexts and populations, do not always reach
clinical researchers and practitioners in a timely manner. Such delays in knowledge
mobilization are problem atic given the universal importance that assessment of sensitivity
assumes in research and clinical settings, where it is typically used to classify and to make
decisions about quality of caregiving, parental psychopathology, and parenting capacity.
Caregiver sensitivity and its ramifications have been examined in countless studies using a
growing array of standardized measures (Tryphonopoulos, Letourneau, & DiTommaso, 2016).
Importantly however, little is known about the validity and inter changeability of instruments
that are purported to measure sensitivity. In other words, do we really know what we are
assessing?
Sensitivity is typically assessed through one of two approaches: recording specific
behaviors by observing caregivers and children during structured or naturalistic inter actions,
yielding “microanalytic” codes, or more holistic, global assessments that result in
“macroanalytic” descriptions (Bornstein, Hahn, Suwalsky, & Haynes, 2011). Devel
opmentalists have long debated the unique contributions provided by each approach (Bornstein
et al., 2011; Cairns & Green, 1979; Clarke-Stewart & Hevey, 1981; Mac coby & Martin, 1983;
Rothabum & Crockenberg, 1995; Waters, 1978), showing that single-behavior-event-related
versus holistic assessments yield complementary but dis tinct data about parent–child
relationships. Microanalytic coding captures situation specific events and may vary from
context to context for the same parent–child dyad, whereas macroanalytic assessments
highlight more stable, global, enduring interaction styles that are not as those dependent on
contextual variability (Bornstein et al., 2011; Maccoby & Martin, 1983; Rothabum &
Crockenberg, 1995). Perhaps, global analyses more fully capture the essence of established
relationships and core characteristics (ver sus discrete behaviors) of the two members of the
interacting dyad. Moment-to moment event recording provides detailed information about
highly specific caregiver and/or child behaviors and deconstructs dyadic events, allowing for
the examination of relationships (Isabella, Belsky, & von Eye, 1989). Microlevel coding is
considered more straightforward or objective, less open to interpretation, and thus easier to
learn and become reliable on. Macrolevel coding is preferred by some researchers and
clinicians because “macro-level constructs tend to be more conceptually attractive and ...less
labor-intensive...and ... might more accurately abstract a global picture of detailed and
complicated data” (Bornstein et al., 2011, p. 87).
In this study, we examine the concordance of four commonly used standardized mea sures
of caregiver sensitivity in classifying the same sample of mothers of infants. The
EVALUATING CAREGIVER SENSITIVITY: MEASURES MATTER 733

focus of the current study is not to differentiate the relative merits of micro- versus macro
analytic assessments of caregiver sensitivity; however, while none of the measures of sensi
tivity studied here use microlevel coding per se, the four instruments used here are situated on
a continuum from prototypically holistic to clearly specific-behavior-event-related.
We examined the Emotional Availability Scales (EAS; Biringen, Robinson, & Emde, 1998;
Biringen, 2008), the Parent Child Interaction—Nursing Child Assessment Satellite Training
Feeding Scale (NCAFS; Barnard, 1978; Oxford & Findlay, 2015), and the Maternal Behavior
Q-Sort (MBQS; Moran, Pederson, & Bento, 2009) and juxtaposed their respective ratings with
classifications of the same sample based on the original AMSS (Ainsworth, 1969). We chose
these measures as among the most well known and accessible in research and clinical
practices, as documented in reviews of commonly used observational assessment tools for
evaluating the quality of caregiver–infant interaction (see Massouda, Davis, & Logsdon, 2011;
Tryphonopoulos et al., 2016). We also con ducted a PsycInfo search using the search terms
“maternal sensitivity,” “parental sensi tivity,” and “caregiver sensitivity” and randomly
selected 200 relevant articles: 148 (74%) studies used at least one of the four measures we
compare here (21.5% used the EAS, 9.0% the NCAST/NCAFS, 27.5% the MBQS, and 49%
the AMSS). The instruments included here all require formal training, a rigorous certification
process, and evidence of reliability from researchers and/or clinicians who wish to use these
measures in their work. All are used internationally in addition to the USA and Canada.
The AMSS (Ainsworth, 1969) constitute a long-standing and widely accepted proto typical
naturalistic observation measure. AMSS provided the foundation for research in
mother–infant sensitivity and its link to attachment style. Ainsworth pioneered the con struct
of maternal sensitivity and is often referenced when defining maternal sensitivity in the
attachment literature (e.g., EAS and MBQS). Rated maternal behavior with the AMSS when
their infants were 9–12 months of age is strongly related to attachment security in the strange
situation (concurrent validity; r = .78; Ainsworth, Bell, & Stayton, 1971; Ainsworth et al.,
1978; Pederson, Bailey, Tarabulsy, Bento, & Moran, 2014). These observations led Ainsworth
and her colleagues to conclude that maternal sensitivity plays a central role in attachment
theory. Results from meta-analytic reviews of maternal sensi tivity and attachment security
support Ainsworth’s maternal sensitivity hypothesis, but with smaller effect sizes (r = .24–.32;
Goldsmith & Alansky, 1987; De Wolff & van IJzen doorn, 1997). A reason for this notable
difference in effect sizes could be that the dura tions of observation periods in replication
studies were much shorter than the observation periods in the original study (Pederson et al.,
2014).
The EAS (Biringen et al., 1998; Biringen, 2008) are also a well-known measure of
caregiver sensitivity that is widely used in research. The maternal sensitivity dimension of
emotional availability is inspired by Ainsworth’s sensitivity conceptualization but is broader
than the original maternal sensitivity concept (Mesman & Emmen, 2013). The EAS differ
from attachment theory-based maternal sensitivity assessments in that the EAS integrate
attachment theory and an emotional availability perspective (Emde, 1980; Mesman & Emmen,
2013; Tryphonopoulos et al., 2016). The EAS emphasize the emo tional features of
mother–infant interactions, including the mother’s emotional signaling and understanding of
her infant’s signaling, in its conceptualization of sensitivity.
The Parent Child Interaction—NCAFS (Barnard, 1978; Oxford & Findlay, 2015), a
commonly used maternal sensitivity measure, is one of the most valid and user-friendly
measures of mother–infant interactions (Byrne & Keefe, 2003; Tryphonopoulos et al., 2016).
This assessment tool was developed to measure the quality of mother–infant
734 BOHR ET AL .

interaction and how it influences later child cognitive development (Sumner & Spietz, 1994).
A high total caregiver score suggests a high degree of maternal sensitivity. The NCAFS has
also been used to predict positive child development, behavior, and attachment quality. The
NCAFS demonstrates predictive validity with the Bayley Scales of Infant Development (r =
.72), the Preschool Behavior Questionnaire (r = .79), and the Home Observation for
Measurement of the Environment (HOME; r = .76; Badr, Bookheimer, Purdy, & Deeb, 2009).
The 3-month NCAFS score was a significant, although weak, predictor of security of
attachment in the Ainsworth’s strange situation at 1 year (r = .19; Britton, Britton, &
Gronwaldt, 2006).
The MBQS (Moran et al., 2009; Pederson et al., 1990) is a maternal sensitivity focused,
naturalistic observational assessment tool that is also used often in the mother–infant
relationship and attachment literatures. Theoretically, the MBQS is rooted in Ainsworth’s
maternal behavior descriptions and her Maternal Sensitivity Scales, which describe a mother’s
sensitivity as well as acceptance, accessibility, and cooperation, providing a conceptual
framework for measuring maternal sensitivity. A high MBQS global maternal sensitivity score
suggests a high degree of maternal sensi tivity. There are multiple versions of MBQS; for this
study, the Mini MBQS-VR was used because it is more suitable for coding filmed interactions,
compared to earlier ver sions of the MBQS (Tarabulsy et al., 2009). According to Tarabulsy et
al. (2009), the Mini MBQS-VR is moderately associated with the original MBQS-90 (r = .35)
and with the Q-Sort index of attachment security (r = .34). A systematic review by Mesman
and Emmen (2013) reported that the MBQS maternal sensitivity score is related to maternal
attachment state of mind (Bailey, Moran, Pederson, & Bento, 2007; Lind hiem, Bernard, &
Dozier, 2011; Whipple, Bernier, & Mageau, 2011), associated with infant attachment security
(Atkinson et al., 2000), and sensitive to improvements in parenting quality postintervention
(Moss et al., 2011).
In summary, sensitivity is commonly considered a strong predictor of healthy infant and
child development and is thus a critical element of caregiving in research and clini cal circles
alike, but the construct is beset by a number of inconsistencies and unan swered questions. We
propose that to address the incongruities that characterize sensitivity, it is necessary first to ask
whether the tools that have been used to assess sensitivity across diverse studies—studies that
are routinely pooled in meta-analyses to yield the empirical basis for theory and practice—all
tap into a reliable, recognizable core concept and could thus be considered (relatively)
interchangeable.

METHODS

Participants
The sample consisted of 50 European American mother–infant dyads (50% mothers–
daughters). Mothers were recruited via mailing lists of births in the Washington, DC
metropolitan area, including suburbs of Virginia, Maryland, and West Virginia, with a letter
describing the study and an invitation to contact the researchers if mothers were interested in
learning more about the study and/or participating. Infants averaged 5.38 months (SD = .23) at
the observation and 3,467.45 g (SD = 444.66) at birth. 98.0% of the infants were term;
nonterm infants were healthy and not outliers on any sensitivity measure and were therefore
retained in the sample. Mothers averaged 27.48 years of age (SD = 6.92) and varied in
educational achievement (18% had not completed high school,
EVALUATING CAREGIVER SENSITIVITY: MEASURES MATTER 735

16% completed high school, 20% partially completed college, 26% completed college or
university, and 20% completed university graduate programs); families varied in socioe
conomic status (SES; Hollingshead, 1975; M = 48.39, SD = 13.93) across a range from 19 to
66. The sample is socioeconomically diverse, but ethnically homogenous, to enable the
examination of cross-measure reliability eschewing ethnicity as a confounding vari able
(Bornstein, Jager, & Putnick, 2013; Jager, Putnick, & Bornstein, 2017).
This study was conducted according to guidelines laid down in the Declaration of Helsinki,
with written informed consent obtained from a parent or guardian for each child before any
assessment or data collection. All procedures involving human sub jects in this study were
approved by the Institutional Review Board at the Eunice Ken nedy Shriver National Institute
of Child Health and Human Development.

Procedures
In the 2 weeks prior to each home visit, mothers completed a demographic question naire
asking for background information about the infant, mother, and family. Each mother–infant
dyad was visited in the home by a single observer to film a 1-h video of naturalistic mother
and infant behavior. The caregivers decided how to spend that hour. Before filming began,
mothers reviewed and signed informed consent forms. A female filmer stated that she was
interested in the infant’s usual activities and asked the mothers to carry on as they normally
would. The filmer refrained from making eye contact with or interacting with the mother and
the infant.

Coding
Mother–infant interactions were coded from video recordings. All coders were research
reliable as per requirements by the instruments’ authors. Coders were specific to the
instruments except for MBQS and AMSS which were coded by the same group of three
coders as per MBQS coding guidelines. MBQS coding guidelines indicate that MBQS and
AMSS should be coded in tandem. For the EAS, 10 researchers coded the interactions because
several other samples amounting to hundreds of interactions were coded at the same time. For
the NCAFS, two coders coded the interactions. All EAS and NCAFS coders were trained to
reliability by an author of the scales and main tained reliability with one another through
double-coding. All coders were blind to hypotheses and purposes of the study and to
additional information about the dyads. All scales were coded independently, without mutual
consultation or guidance. In addi tion to instrument-specific research reliability, coders also
obtained high intercoder reli ability with other independent coders, assessed using average
absolute agreement intraclass correlation coefficients (ICC) in a two-way random effects
model (McGraw & Wong, 1996; Shrout & Fleiss, 1979). ICC among independent coders is
provided below for each of the measures. Details for each measure follow.

Measures
Ainsworth Maternal Sensitivity Scales (Ainsworth, 1969)
The AMSS consist of four scales. The sensitivity to the baby’s signals scale assesses the
caregiver’s capacity to be aware of the infant’s signals, to interpret, and to respond
736 BOHR ET AL .

appropriately and promptly. Scores range from 1 (highly insensitive) to 9 (highly sensi tive).
The cooperation with baby’s ongoing behavior scale assesses the caregiver’s degree and
frequency of physical cooperation (and lack of interference) with the infant’s activity. Scores
range from 1 (highly interfering) to 9 (conspicuously coopera tive). The physical and
psychological availability scale assesses the caregiver’s accessi bility in terms of
responsiveness to the infant. Scores range from 1 (highly inaccessible, ignoring, or neglecting)
to 9 (highly accessible). The acceptance of the baby’s needs scale assesses the caregiver’s
balance of positive and negative feelings about the infant. Scores range from 1 (highly
rejecting) to 9 (highly accepting). The first 20 min of the interactions were coded with the
AMSS. The ICCs, computed on 20% of the coded caregiver–infant interactions, were .93 for
sensitivity, .92 for cooperation, .94 for avail ability, and .93 for acceptance. The four
Ainsworth’s subscales were highly correlated and were therefore averaged to create a total
scale, a = .95, which were used in the analyses.

Emotional Availability Scales (3rd edition; Biringen et al., 1998)


The EAS capture six dimensions of caregiver –child interaction divided into parent EAS
(four scales) and child EAS (two scales which were not used in this study). The sensitivity
scale assesses the caregiver’s responsiveness to the infant’s communications, affect, regulation,
and creativity in play from 1 (highly insensitive) to 9 (highly sensi tive); the structuring scale
assesses the caregiver’s ability to appropriately facilitate, scaffold, or organize the infant’s
play, exploration, or routine by providing rules with out compromising the infant’s autonomy
from 1 (nonoptimal) to 5 (optimal); the nonin trusiveness scale assesses the caregiver’s ability
to support the infant’s play, exploration, or routine by appropriately initiating interactions,
without interrupting by being overly directive, overstimulating, overprotective, or interfering
from 1 (intrusive) to 5 (nonintrusive); the nonhostility scale assesses the caregiver’s ability to
interact with the infant by being patient, pleasant, and harmonious and not rejecting, abrasive,
impatient, or antagonistic from 1 (markedly hostile) to 5 (nonhostile). All EAS were coded in
½ points. All four EAS of interest were coded to provide scores for each 15- min interval of
the filmed interaction and for the total hour of the interaction. The correlations between
comparable ratings for the first 15 min and the full hour ranged from .70 for nonhostility to .88
for sensitivity. Hence, we chose to use the scores for the first 15 min so that they would be
comparable to the 10- to 20-min segments coded for other scales. The ICCs, computed on
22% of the coded caregiver–infant interac tions, were .84 for sensitivity, .68 for structuring,
.70 for nonintrusiveness, and .73 for nonhostility. The ICCs for structuring, nonintrusiveness,
and nonhostility were a result of low variance in the reliability sample; agreements within 1
point were 91, 100, and 82%, respectively. The four EAS were highly correlated and were
therefore standard ized and averaged to create a total scale, a = .83.

NCAFS Feeding Scale (Barnard, 1978; Oxford & Findlay, 2015)


The NCAFS includes 76 binary (yes/no) items that are descriptive of the caregiver– infant
dyadic relationship and organized into six subscales. Four subscales focus on caregiver
behavior (Barnard, 1978). The sensitivity to cues scale assesses the caregiver’s ability to
recognize and respond to the infant’s cues (range = 1–16). The response to
EVALUATING CAREGIVER SENSITIVITY: MEASURES MATTER 737

distress scale assesses the caregiver’s ability to soothe or quiet a distressed child (range =
1–11). The social–emotional growth fostering scale assesses the caregiver’s affect and ability
to communicate a positive feeling tone (range = 1–14). The cognitive growth fostering scale
assesses the caregiver’s ability to make learning experiences available to the infant (range =
1–9). Two additional scales describe the infant’s contri bution to the interaction; they were not
considered in this study. Four caregiver NCAFS’s subscales were coded on 10-min feeding
episodes in the interactions for each dyad. Feeding episodes occurred spontaneously in all the
naturalistic observations. Seventy-six percent of the feeding episodes occurred in the first 20
min of the interac tion and therefore overlapped with the segments for the other coding
systems. Over half of the sample was breast- or bottle-fed (66%), 18% were fed solid food,
14% were fed a combination of bottle and solid food, and 2% were fed with a dropper. When
controlling for maternal age, the feeding method was unrelated to NCAFS scores, F(3, 45) =
1.85, p = .152. The ICCs, computed on 24% of the coded caregiver–infant inter actions, were
.74 for sensitivity to cues, .75 for response to distress, .60 for cognitive growth fostering, and
.77 for caregiver total scales. The four caregiver subscales were summed to provide a total
caregiver score, a = .76.
Mini MBQS-VR (Moran et al., 2009; Tarabulsy et al., 2009)
The Mini MBQS-VR is a shorter form of the original 90-item MBQS card set, con sisting
of 25 items (Tarabulsy et al., 2009). The Mini MBQS-VR focuses on specific sensitive
caregiver behaviors in relation to the infant, including “monitors baby’s activ ities during
visit,” “speaks to baby directly,” and “praises baby.” The items are sorted into five groups, with
five items per group. Items are designated as most like (+2), like (+1), neutral (0), unlike ( 1),
or most unlike ( 2) the behaviors observed in the care giver. The total score obtained for a
given caregiver is then correlated with the devel opers’ criterion sort for the prototypically
sensitive caregiver, generating a global sensitivity score. Scores vary from 1.0 (least like the
prototypically sensitive caregiver) to 1.0 (most like the prototypically sensitive caregiver). The
global sensitivity score can be obtained through an unforced or a forced-choice sort. The
difference between an unforced and a forced sort is that for an unforced sort, the coder is
permitted to assign the quality of maternal behavior to the groups, without being restricted by
the maxi mum number of items that are allowed per group. By contrast, when obtaining a
forced sort, the coder is restricted by the maximum number of items that are allowed per
group. As the unforced and forced scores were correlated, r(48) = .97, p < .001, we used the
forced-choice sort in these analyses. The first 20 min of the interactions were coded with Mini
MBQS-VR to ensure that the MBQS would be able to capture at least 10 min of direct
caregiver–infant interaction, which is required for arriving at a global sensitivity score
(Tarabulsy et al., 2009). The ICC, computed on 22% of the coded caregiver–infant
interactions, was .98.

Analytic plan
Prior to the formal analysis, univariate distributions of the total scores for the AMSS, EAS,
NCAFS, and MBQS, and their subscales were examined for normality, outliers, and influential
cases (e.g., single cases that change the interpretation of the results), and standard
transformations were applied to resolve problems of non-normality
738 BOHR ET AL .

(Tabachnick & Fidell, 2012). Transformed variables were used in all analyses, but for ease of
interpretation, descriptive statistics are presented in the variables’ original met rics. EAS’s
nonintrusiveness and nonhostility were skewed (ps < .05), and no transfor mation would
normalize them; they were therefore analyzed with nonparametric statistics. The skewed
distributions of the EAS’s nonintrusiveness and nonhostility scales are not surprising; these
two scales were designed to capture specific types of negative behaviors that are uncommon in
low-risk samples.
To assess relations between the AMSS, EAS, NCAFS, and MBQS, zero-order cor relations
were computed between the scales and between their subscales. Partial corre lations were then
computed, controlling for covariates, to assess whether relations among scales were inflated
by sociodemographic factors. Further, bivariate correlation comparisons, using Fisher’s r-to-z
transformation, were computed to evaluate whether reported correlation coefficients differed
significantly from one another.
Four sociodemographic variables were considered as covariates: infant birth weight and
age, and maternal age in years and education at the time of the home visit. Infant birth weight
and age were considered as covariates because infant maturity is associ ated with maternal
sensitivity (Muller-Nix et al., 2004). Maternal age was considered as a covariate due to
existing empirical evidence that adult mothers demonstrate higher sensitivity than adolescent
mothers (Lounds, Borkowski, Whitman, Maxwell, & Weed, 2005; Secco & Moffatt, 2003).
Additionally, lower maternal education is related to lower caregiver sensitivity
(Tamis-LeMonda et al., 2009). As maternal age and educa tion were highly correlated, r(48) =
.74, p < .001, we assessed unique relations of each with the total scales, finding that maternal
age but not maternal education had unique relations to all scales. Hence, only maternal age
was controlled in analyses. Infant birth weight and age were unrelated to AMSS, EAS, and
MBQS, but dyads with older infants scored lower on the NCAFS, rs (48) = .31 to .45, ps =
.029–.001.

Statistical power
A post hoc power analysis was computed prior to the data analysis to determine whether the
sample size provided sufficient power to detect a medium-sized effect in a correlational design
(Faul, Erdfelder, Lang, & Buchner, 2007). Given that we expected positive correlations among
scales, we computed one-tailed tests. Power to detect a correlation of .30 was .81 with a = .10
(i.e., one-tailed correlations) and N = 50, indi cating adequate power to detect medium and
large correlations.

RESULTS

Descriptive statistics of the AMSS, EAS, NCAFS, and MBQS total scores and sub scales are
presented in Table 1. These statistics indicate that there was adequate vari ance in all scores.

Correlations among total scales


Table 2 displays correlations among the total scores for the AMSS, EAS, NCAFS, and MBQS
(below the diagonal). Correlations with the NCAFS were medium-sized, and correlations
among other scores were large in size. Despite the strength of these
EVALUATING CAREGIVER SENSITIVITY: MEASURES MATTER 739

TABLE 1
Descriptive Statistics of the Maternal Sensitivity Scores and Subscales

M SD Range

AMSS total 4.29 2.33 1.0 to 8.5 Sensitivity 3.82 2.35 1.0 to 8.0 Cooperation 4.14 2.47 1.0 to 9.0 Availability 4.58
2.45 1.0 to 9.0 Acceptance 4.60 2.74 1.0 to 9.0
EAS total .00 .81 2.39 to 1.01 Sensitivity 5.68 1.64 2.0 to 8.5 Structuring 3.89 .94 1.5 to 5.0 Nonintrusiveness 4.71
.52 3.0 to 5.0 Nonhostility 4.56 .75 1.5 to 5.0
NCAFS total 39.66 5.62 24.0 to 48.0 Sensitivity to cues 13.60 1.95 8.0 to 16.0 Responsiveness to distress 9.88 1.35
6.0 to 11.0 Emotional growth fostering 10.78 2.00 6.0 to 14.0 Cognitive growth fostering 5.40 1.98 1.0 to 9.0
MBQS scale .22 .60 .90 to .80

Note. AMSS = Ainsworth Maternal Sensitivity Scales; EAS = Emotional Availability Scales; MBQS = Maternal
Behavior Q-Sort; NCAFS = Nursing Child Assessment Satellite Training Feeding Scale.

relations, 10–91% of the variance between scales was unshared (above the diagonal in Table
2). Perhaps because they were coded by the same coders on the same video seg ments, the
correlation between the AMSS and MBQS scores was very large and larger than the
correlations of the AMSS and MBQS with other scores (see Table 2 notes for z-scores
comparing the correlations). Furthermore, the EAS total score was more highly correlated
with the AMSS score than the NCAFS score. When maternal age was controlled, relations of
the NCAFS total score with other scores attenuated to nonsignificance. Relations between the
AMSS, EAS, and MBQS remained large and statistically significant.
Correlations among subscales
Table 3 presents zero-order correlations and partial correlations controlling for mater nal age
(and infant age for NCAFS correlations) for the subscales of each instrument. Zero-order
correlations among the sensitivity subscales (shaded cells in Table 3) for the AMSS, EAS,
NCAFS (sensitivity to cues), and MBQS were medium to large (rs = .39 .91). Two of the four
NCAFS’s subscales, emotional and cognitive growth fostering, were largely unrelated to the
subscales of other measures. NCAFS respon siveness to distress was also largely unrelated to
the EAS’s subscales. Partial correla tions, controlling for maternal age, reduced the magnitude
of relations slightly, but most remained medium to large in size.

DISCUSSION

Ainsworth’s seminal AMSS, once the “gold standard” for measuring caregiver sensitiv ity, has
given way to an array of more accessible, teachable, and less time-consuming
740 BOHR ET AL .

TABLE 2
Correlations Between Total Sensitivity Scores and Their Unshared Variances in Percentage 1 2 34

1. AMSS total – 56 83 10 2. EAS total .66***,a,b/.59*** – 91 70 3. NCAFS total .41**,c/.14 .30*,a/.04 – 85 4. MBQS
.95***,b,c,d,e/.93*** .55***,d/.46*** .39**,e/.12 –

Note. Pearson’s zero-order one-tailed correlations are below the diagonal before the slash and partial cor relations
controlling for maternal age (and infant age for correlations with the NCAFS total scale) follow the slash. The
percentages of unshared variance based on zero-order correlations are above the diagonal. Zero-order correlations
with the same superscript were significantly different from one another.
AMSS = Ainsworth Maternal Sensitivity Scales; EAS = Emotional Availability Scales; MBQS = Maternal Behavior
Q-Sort; NCAFS = Nursing Child Assessment Satellite Training Feeding Scale. az = 2.84, p = .005. bz = 5.90, p <
.001. cz = 7.54, p < .001. dz = 8.09, p < .001. ez = 7.84, p < .001. *p ≤ .05. **p ≤ .01. ***p ≤ .001.

tools that were all designed to capture the quality of “sensitivity” in caregiver–infant
interaction as originally conceived by Ainsworth. Our data suggest that the most popu lar
observational assessment tools for caregiver sensitivity today, administered by reli able coders,
may not be transposable in assessing the quality of dyadic relationships. The three assessment
tools examined here do indeed conceptually relate to sensitivity as originally conceived by
Ainsworth (AMSS), as shown by several medium-to-high associations between measures.
However, what is surprising is that large fractions of the variance between these scales are
unshared (see Table 2). The current results support De Wolff and van IJzendoorn’s (1997)
concerns about a large unexplained variance in the observational sensitivity measures they
studied in the context of their meta-analysis that examined the relation between sensitivity and
attachment. It is thus important to acknowledge that these popular tools are not similar enough
to be used interchangeably in either research or clinical practice.
Our findings offer a partial explanation for inconsistent reports on relations between
sensitivity and developmental outcomes in children (Paavola et al., 2006; Pillhofer et al.,
2015). The data raise broad questions about the examination of caregiver sensi tivity in
research and practice, the repercussions for its predictive value in child devel opment, and, not
least, the value of using sensitivity assessment results in the design of parenting interventions
(Nozadi et al., 2013; Vallotton et al., 2017; Vandell, Belsky, Burchinal, Steinberg, &
Vandergrift, 2010). Given the common assumption that avail able caregiver sensitivity
measures all capture a common construct, child development researchers typically may prefer
to use measures that require less administration time, less training, and simpler reliability
procedures, for example the NCAFS (Tryphono poulos et al., 2016). In addition,
developmental scientists with limited budgets may gravitate to brief behavior-based event
coding systems that appear to be inherently more objective as well as being more economical
to administer (e.g., tools such as the NCAFS). In this study however, of the three instruments
examined, the NCAFS proved to have the weakest association with the AMSS, calling into
question its suit ability as a good substitution for a tool that assesses sensitivity as proposed by
Ains worth. In comparing these measures, it is worthwhile to note that NCAFS is structured
differently than EAS, MBQS, and AMSS. NCAFS require yes/no decisions about behaviors
that, if occurring even once, are credited to the caregiver, whereas
EVALUATING CAREGIVER SENSITIVITY: MEASURES MATTER 741

EL
B

AT
S

QB
M

SS

MA
,

SF
A

C N,

AE
fo

e
l

gn
o

m
A

o
it

a
l

C
SF

AC
N

AE
S

QB

M
e

n
i

o
f

n
i

o
f

g
l

o
i

s
i

o
t

o
t

i
l
i

n
i

n
i

S
SS

MA
y

t
i

v
i

is
n

S
*

9.

1.

3.

4.

4.

5.

4.

6.
*

6.

r
**

8
.

0
.

0
.

3
.

2
.

4
.

2
.

5
6
.

5
.

r
n

it
a

C
**

8.

2.

3.

4.

4.

4.

2
4.

5.

4.

r
**

7
.

0
.

0
.

3
.

2
.

3
.

3
.

5
.

3
.

r
y

t
ili

a
li

A
*

8.

1.

2.

4.

4.

4.
6

1.

6.

6.

r
**

7
.

0
.

0
.

2
.

2
.

3
.
3

0
.

5
.

5
.

r
e

A
*

8.

0.

2.

4.

3.
*

5.

4.

6.

5.

r
**

7
.

0
.

*3

3
.

2
.
*

4
.

3
.

6
.

4
.

AE
y

t
i

v
i

is
n

S
*

5.

1.

2.

3.
*

4.

r
**

4
.

0
.

*3

2
.
*

2
.

r
g

ir
u

S
**

5.

0.

1.

*
6

2.

3.

r
**

4
.

2
.

1
.
*

2
.

r
s

v
is
u

in
o

N
*1

3.

0.

0.
*

2.

3.

q
7

1
.

1
.

2
.
9

0
.

2
.

q
y

t
i

li
t

hn
o

N
**

4.

0.

0.
3

2.

4.

q
**

3
.

2
.

.
9

0
.

3
.

q
e

QB

M

1.

2.
*

4.

3.

r

.
8

2
.

2
.

r
r

o
f

n
i

a
(

o
f

i
l
l
o

)p

h
r

q
(

h
r

.
e

N
.

u
s

is
n

it
a

ll
e

de
da
hS

)s
e

u
s

SF
A

CN
e

ht

iw
s

it
a

c
t

li

hC

is
r

N
=

SF

CN
;

S-

iv
a

he
B

la
n

QB

il
i

li

la
n

it

AE
;

is
n

la
n

ht
r

iA
=

SS

A
.

n
i

ill
e

S
.

h
t

h
r

h
r

o
c

h
t

n
i

ffi

742 BOHR ET AL .

EAS, MBQS, and AMSS are continuous, global scales that more holistically assess the quality
of a dyadic relationship. The differences between these measures’ methods of assessing
caregivers’ behavior, some focusing more on quality and others more on quantity, should be
taken into consideration when interpreting the results, as should the limitations inherent in
each type of assessment. For example, when minimal dis crete caregiver behaviors are counted
and recorded, lack of genuineness or warmth in the relationship may be missed. As well, with
some scales (e.g., the NCAFS), care givers who show a codable behavior once during the
observation obtain the same score for that behavior as caregivers who show the behavior
repeatedly. Other measures make use of scales that allow for consideration of the quantity
and/or quality of the caregiving behavior. In contrast, global rating systems, while capturing
the subtleties and “flavor” of interactions when used by experienced clinicians, are by
definition more subjective and possibly less reliable when novice coders are involved.
However, relatively stringent reliability requirements and mandatory certification increasingly
address these concerns. What seems to be clear is that researchers need to carefully select
measures to match specific study questions. The current data also suggest that researchers
should be cautious when assembling meta-analyses and reviews of studies based on potentially
divergent methods of assessing a possibly multifocal global con cept such as sensitivity.
Infant mental health and parenting clinicians by necessity tend to select measures that are
user-friendly and cost-effective, again assuming that existing tools are inter changeable when
it comes to assessing dyadic interactions and planning for caregiving interventions. Based on
our findings, clinicians would be well advised to consider a specific measure’s idiosyncrasies
when interpreting caregiver sensitivity scores in clinical settings, as one instrument might
assess a caregiver as more sensitive than another. Clinicians should be aware that currently, no
one instrument provides a definitive assessment of sensitivity and should be wary about
drawing broad conclusions from the results of any single evaluation of parenting, even when
provided by a certified assessor. Clinicians should also be encouraged to select the assessment
tool that best matches their specific purpose in assessing or treatment planning. For example,
researchers or clinicians who want to identify particular behaviors as foci for interven tion
may elect a behaviorally focused measure like the NCAFS, whereas researchers or clinicians
who are interested in the global sensitivity climate created by the mother might choose the
AMSS or MBQS, and researchers or clinicians interested in a global dyadic measure of
sensitivity might elect the EAS.

Limitations
Our study sample consisted of participants with a wide range of educational achieve ment,
SES, and mothers’ age, but its ethnic homogeneity may limit the generalizability of the
findings while eliminating variability associated with ethnic variation in or inter pretation of
sensitivity. Another potential limitation of this study pertains to the num ber of correlational
analyses that were conducted simultaneously, with an increased chance that some significant
results may be spurious. That eventuality would, however, favor correlation inflation which
would in turn only reduce the striking unshared vari ance we uncovered. It is also important to
be mindful of the global natures of the EAS, NCAFS, MBQS, and AMSS, as well as
differences in the criteria required by each measure for coding dyadic interactions as optimal.
Most of these measures
EVALUATING CAREGIVER SENSITIVITY: MEASURES MATTER 743

require making a global judgment of the dyad’s functioning, which may be subject to inherent
biases (such caregiver appearance). However, we carefully monitored coder reliability to
ensure consistency across coders. Moreover, the AMSS, EAS, and MBQS call for naturalistic
observations of caregiver–infant interactions, while the NCAFS requires a feeding episode,
and the MBQS is deemed most suitable for coding play interactions. The AMSS and MBQS
are designed to focus on caregiver behavior, whereas the EAS and NCAFS are designed to
assess dyadic behavior. Another consid eration is that based on the MBQS protocol, the
AMSS and MBQS were scored by the same coders. Finally, for the purpose of this study, we
excluded the subscales and total scales that assessed infant behavior to contrast only scales of
the AMSS, EAS, NCAFS, and MBQS that are relevant to caregiver behavior, thus potentially
forfeiting additional helpful information about the quality of dyadic interaction.

Areas for future study


Next steps should involve an examination of common core concepts in a larger sample of
caregivers and perhaps a critical discussion of what exactly is measured when “sen sitivity” is
assessed from different vantages. More comprehensive, longitudinal studies of the predictive
validity of commonly used caregiver sensitivity scales (such as the scales examined here), in
both ethnically homogeneous and culturally diverse samples, are especially recommended.
On the basis of the results of the present study, investigators should be guarded about
drawing conclusions about the caregiving skills of parents based on investiga tions that are
limited to the use of a single measure of sensitivity. Maternal sensitivity does not take the
same form across diverse cultural groups (Bornstein, 2012; Ekmekci et al., 2015; Emmen,
Malda, Mesman, Ekmekci, & van IJzendoorn, 2012; Kelley & Tseng, 1992), and questions
remain about its value when predicting healthy child development in cultures that vary in their
customs from standard Western middle-class caregiver practices (Chan, Penner, Mah, &
Johnston, 2010; Ispa et al., 2004; Jin et al., 2012; Kelley & Tseng, 1992; Keng-Ling &
Li-Jung, 2010; Lieber, Fung, & Leung, 2006; Lin & Fu, 1990; Liu, Chen, Bohr, Wang, &
Tronick, 2017; Wu et al., 2002). Identifying measures of sensitivity that are culturally
appropriate, capture culturally specific aspects of caregiver sensitivity, and are predictive of
healthy child development should be a priority.
CONCLUSION

Caregiver sensitivity is widely considered to be an important index of parenting and to


contribute to positive child development. Nevertheless, questions remain about what it means
for caregivers to be “sensitive” and how “sensitivity” is operationalized. By show ing that four
popular assessment tools used with the same mother–infant dyads share relatively little
common variance when it comes to capturing caregiver sensitivity, the current study confirms
that there is much work left to be done in standardizing and har monizing the definition,
operationalization, and, by extension, assessment of sensitivity. It would appear that different
measures of sensitivity are not interchangeable. Further more, findings from studies that used
diverse instruments should not be pooled in meta analyses that examine the correlates and
outcomes of caregiver sensitivity.
744 BOHR ET AL .

ACKNOWLEDGMENTS

This research was supported by the Eunice Kennedy Shriver National Institute of Child Health
and Human Development, USA, and an International Research Fellow ship in collaboration
with the Centre for the Evaluation of Development Policies (EdoPO) at the Institute for Fiscal
Studies (IFS), London, UK, funded by the Eur opean Research Council (ERC) under the
Horizon 2020 research and innovation pro gramme (grant agreement No
695300-HKADeC-ERC-2015-AdG), and the LaMarsh Centre for Child and Youth Research at
the Faculty of Health, York University. We thank L. Armour, L. Brightling, M. Khourochvili,
J. Hanson, and C. Shih for assis tance. We are grateful to the mother–infant dyads, who have
participated in our research for sharing their time and contributing to caregiver sensitivity
research. We wish to thank the anonymous reviewers who provided valuable feedback. We
declare that there is no conflict of interest regarding the publication of this article.

REFERENCES

Ainsworth, M. D. S. (1969). Maternal sensitivity scales. Power, 6, 1379–1388.


Ainsworth, M., Bell, S., & Stayton, D. (1971). Individual differences in strange-situation behavior of one-year olds. In
H. Schaffer (Ed.), The origins of human social relations (pp. 17–52). London, UK: Academic Press. Ainsworth, M. D.
S., Bell, S. M., & Stayton, D. J. (1974). Infant-mother attachment and social development: Socialization as a product
of reciprocal responsiveness to signals. In M. P. M. Richards (Ed.), The integra tion of a child into a social world (pp.
99–135). London, UK: Cambridge University Press. Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S.
(1978). Patterns of attachment: A psychological study of the strange situation. Hillsdale, NJ: Erlbaum.
Atkinson, L., Niccols, A., Paglia, A., Coolbear, J., Parker, K. C., Poulton, L., ... Sitarenios, G. (2000). A meta-analysis
of time between maternal sensitivity and attachment assessments: Implications for internal working models in
infancy/toddlerhood. Journal of Social and Personal Relationships, 17, 791–810.
Badr, L. K., Bookheimer, S., Purdy, I., & Deeb, M. (2009). Predictors of neurodevelopmental outcome for preterm
infants with brain injury: MRI, medical and environmental factors. Early Human Development, 85, 279–284.
Bailey, H. N., Moran, G., Pederson, D. R., & Bento, S. (2007). Understanding the transmission of attach ment using
variable-and relationship-centered approaches. Development and Psychopathology, 19, 313–343.
Bakermans-Kranenburg, M. J., van IJzendoorn, M. H., &Juffer, F. (2003). Less is more: Meta-analyses of sensitivity
and attachment interventions in early childhood. Psychological Bulletin, 129, 195–215. Barnard, K. (1978). Nursing
child assessment feeding scale. Seattle, WA: University of Washington, School of Nursing.
Bernier, A., Carlson, S. M., & Whipple, N. (2010). From external regulation to self-regulation: Early parent ing
precursors of young children’s executive functioning. Child Development, 81(1), 326–339. Bigelow, A. E., MacLean,
K., Proctor, J., Myatt, T., Gillis, R., & Power, M. (2010). Maternal sensitivity throughout infancy: Continuity and
relation to attachment security. Infant Behavior and Development, 33 (1), 50–60.
Biringen, Z. (2008). Emotional availability (EA) scales manual (4th ed.): Part 1. Infancy/early childhood version
(child aged 0–5 years). Colorado State University. Unpublished manuscript.
Biringen, Z., Robinson, J. L., & Emde, R. N. (1998). Emotional Availability Scales (3rd ed.). Fort Collins, CO:
Department on Human Development and Family Studies, Colorado State University. Unpublished manual.
Bornstein, M. H. (2012). Cultural approaches to parenting. Parenting, 12, 212–221. Bornstein, M. H. (2015).
Children’s parents. In M. H. Bornstein, & T. Leventhal (Eds.), Ecological settings and processes in developmental
systems. Volume 4 of the handbook of child psychology and developmental science (7th ed., pp. 55–132). Hoboken,
NJ: Wiley.
EVALUATING CAREGIVER SENSITIVITY: MEASURES MATTER 745

Bornstein, M. H., Hahn, C.-S., Suwalsky, J. T. D., & Haynes, O. M. (2011). Maternal and infant behavior and context
associations with mutual emotion availability. Infant Mental Health Journal, 32(1), 70–94. Bornstein, M. H., Jager, J.,
& Putnick, D. L. (2013). Sampling in developmental science: Situations, short comings, solutions, and standards.
Developmental Review, 33, 357–370.
Bowlby, J. (1969). Attachment and loss, Vol. 1: Attachment. New York, NY: Basic Books. Bretherton, I. (2013).
Revisiting Mary Ainsworth’s conceptualization and assessments of maternal sensitivity insensitivity. Attachment &
Human Development, 15, 460–484.
Britton, J. R., Britton, H. L., & Gronwaldt, V. (2006). Breastfeeding, sensitivity, and attachment. Pediatrics, 118,
1436–1443.
Byrne, M. W., & Keefe, M. R. (2003). Comparison of two measures of parent-child interaction. Nursing Research,
52(1), 34–41.
Cairns, R. B., & Green, J. A. (1979). How to assess personality and social patterns: Observations or ratings? In R. B.
Cairns (Ed.), The analysis of social interactions: Methods, issues, and illustrations (App. A) (pp. 209–226).
Hillsdale, NJ: Erlbaum.
Chan, K., Penner, K., Mah, J. W., & Johnston, C. (2010). Assessing parenting behaviors in Euro-Canadian and East
Asian immigrant mothers: Limitations to observations of responsiveness. Child & Family Behav ior Therapy,
32(2), 85–102.
Clarke-Stewart, K. A., & Hevey, C. M. (1981). Longitudinal relations in repeated observations of mother child
interaction from 1 to 2½ years. Developmental Psychology, 17, 127–145.
De Wolff, M. S., & van IJzendoorn, M. H. (1997). Sensitivity and attachment: A meta-analysis on parental
antecedents of infant attachment. Child Development, 68, 571–591.
Diener, M., Nievar, M. A., & Wright, C. (2003). Attachment security among mothers and their young chil dren living
in poverty: Associations with maternal, child, and contextual characteristics. Merrill-Palmer Quarterly, 49,
254–282.
Ekmekci, H., Yavuz-Muren, H. M., Emmen, R. A. G., Mesman, J., van IJzendoorn, M. H., Yagmurlu, B., ... Malda,
M. (2015). Professionals’ and mothers’ beliefs about maternal sensitivity across cultures: Toward effective
interventions in multicultural societies. Journal of Child and Family Studies, 24, 1295– 1306.
Emde, R. N. (1980). Emotional availability: A reciprocal reward system for infants and parents with implica tions for
prevention of psychosocial disorders. In P. M. Taylor (Ed.), Parent-infant relationships (pp. 87– 115). Orlando, FL:
Grune & Stratton.
Emmen, R. A. G., Malda, M., Mesman, J., Ekmekci, H., & van IJzendoorn, M. H. (2012). Sensitive parent ing as a
cross-cultural ideal: Sensitivity beliefs of Dutch, Moroccan, and Turkish mothers in the Nether lands. Attachment
& Human Development, 14, 601–619.
Faul, F., Erdfelder, E., Lang, A. G., & Buchner, A. (2007). G * Power 3: A flexible statistical power analysis program
for the social, behavioral, and biomedical sciences. Behavior Research Methods, 39, 175–191. Feldman, R.,
Eidelman, A. I., & Rotenberg, N. (2004). Parenting stress, infant emotion regulation, maternal sensitivity, and the
cognitive development of triplets: A model for parent and child influences in a unique ecology. Child Development,
75(6), 1774–1791.
Goldsmith, H. H., & Alansky, J. A. (1987). Maternal and infant temperamental predictors of attachment: A
meta-analytic review. Journal of Consulting and Clinical Psychology, 55, 805–816.
Hirsh-Pasek, K., & Burchinal, M. (2006). Mother and caregiver sensitivity over time: Predicting language and
academic outcomes with variable-and person-centered approaches. Merrill-Palmer Quarterly, 52, 449–485.
Hollingshead, A. B. (1975). The four-factor index of social status. Department of Sociology, Yale University.
Unpublished manuscript.
Isabella, R. A., Belsky, J., & von Eye, A. (1989). Origins of infant-mother attachment: An examination of
interactional synchrony during the infant’s first year. Developmental Psychology, 25(1), 12–21. Ispa, J. M., Fine, M.
A., Halgunseth, L. C., Harper, S., Robinson, J., Boyce, L., ... Brady-Smith, C. (2004). Maternal intrusiveness,
maternal warmth, and mother–toddler relationship outcomes: Variations across low-income ethnic and acculturation
groups. Child Development, 75(6), 1613–1631. Jager, J., Putnick, D. L., & Bornstein, M. H. (2017). More than just
convenient: The scientific merits of homo geneous convenience samples. Monographs of the Society for Research in
Child Development, 82, 13–30. Jin, M. K., Jacobvitz, D., Hazen, N., & Jung, S. H. (2012). Maternal sensitivity and
infant attachment secu rity in Korea: Cross-cultural validation of the Strange Situation. Attachment & Human
Development, 14(1), 33–44.
Kelley, M. L., & Tseng, H.-M. (1992). Cultural differences in child rearing: A comparison of immigrant Chi nese and
Caucasian American mothers. Journal of Cross-Cultural Psychology, 23, 444–455.
746 BOHR ET AL .

Keng-Ling, L., & Li-Jung, C. (2010). Play behaviors of mothers of preschoolers: Attachment and cultural
comparison. Chinese Journal of Psychology, 52, 397–423.
Lemelin, J.-P., Tarabulsy, G. M., & Provost, M. (2006). Predicting preschool cognitive development from infant
temperament, maternal sensitivity, and psychosocial risk. Merrill-Palmer Quarterly, 52, 779–804. Lieber, E., Fung, H.,
& Leung, P. W.-L. (2006). Chinese child-rearing beliefs: Key dimensions and contributions to the development of
culture-appropriate assessment. Asian Journal of Social Psychology, 9, 140–147. Lin, C.-Y. C., & Fu, V. R. (1990). A
comparison of child-rearing practices among Chinese, immigrant Chi nese, and Caucasian-American parents. Child
Development, 61, 429–433.
Lindhiem, O., Bernard, K., & Dozier, M. (2011). Maternal sensitivity: Within-person variability and the util ity of
multiple assessments. Child Maltreatment, 16(1), 41–50.
Liu, C. H., Chen, S. H., Bohr, Y., Wang, L., & Tronick, E. (2017). Exploring the assumptions of attachment theory
across cultures: The practice of transnational separation among Chinese immigrant parents and children. In H.
Keller, & K. A. Bard (Eds.), Meaning and methods in the study and assessment of attach ment. Contextualizing
attachment: The cultural nature of attachment. Strungmann Forum Reports € , vol. 22, J. Lupp, series editor (pp.
171–192). Cambridge, MA: MIT Press.
Longo, F., McPherran Lombardi, C., & Dearing, E. (2017). Family investments in low-income children’s achievement
and socioemotional functioning. Developmental Psychology, 53, 2273–2289. Lounds, J. J., Borkowski, J. G.,
Whitman, T. L., Maxwell, S. E., & Weed, K. (2005). Adolescent parenting and attachment during infancy and early
childhood. Parenting: Science and Practice, 5, 91–118. Maccoby, E. E., & Martin, J. A. (1983). Socialization in the
context of the family: Parent-child interaction. In E. M. Hetherington, & P. H. Mussen (Eds.), Handbook of child
psychology: Vol. 4. Socialization, person ality and social development (pp. 1–101). New York, NY: Wiley.
Massouda, J., Davis, D. W., & Logsdon, M. C. (2011). Maternal sensitivity: A concept analysis. In D. W. Davis, & M.
C. Logsdon (Eds.), Maternal sensitivity: A scientific foundation for practice (pp. 17–30). New York, NY: Nova
Science Publishers, Inc.
McElwain, N. L., & Booth-LaForce, C. (2006). Maternal sensitivity to infant distress and nondistress as pre dictors of
infant-mother attachment security. Journal of Family Psychology, 20, 247–255. McGraw, K. O., & Wong, S. P.
(1996). Forming inferences about some intraclass correlation coefficients. Psychological Methods, 1, 30–46.
Meins, E., Fernyhough, C., Fradley, E., & Tuckey, M. (2001). Rethinking maternal sensitivity: Mothers’ comments on
infants’ mental processes predict security of attachment at 12 months. Journal of Child Psy chology and Psychiatry,
42, 637–648.
Mesman, J., & Emmen, R. A. G. (2013). Mary Ainsworth’s legacy: A systematic review of observational instruments
measuring parental sensitivity. Attachment & Human Development, 15, 485–506. Mesman, J., van IJzendoorn, M. H.,
& Bakermans-Kranenburg, M. J. (2012). Unequal in opportunity, equal in process: Parental sensitivity promotes
positive child development in ethnic minority families: Maternal sensitivity in ethnic minorities. Child Development
Perspectives, 6, 239–250.
Moran, G., Pederson, D., & Bento, S. (2009). Maternal Behavior Q-Sort (MBQS)–Overview, available materi als and
support. University of Western Ontario. Unpublished.
Moran, G., Pederson, D. R., & Tarabulsy, G. M. (2011). Becoming sensitive to sensitivity: Lessons learned from the
development of the Maternal Behavior Q-Sort. Hauppauge, NY: Nova Science Publishers. Moss, E., Dubois-Comtois,
K., Cyr, C., Tarabulsy, G. M., St-Laurent, D., & Bernier, A. (2011). Efficacy of a home-visiting intervention aimed at
improving maternal sensitivity, child attachment, and behavioral outcomes for maltreated children: A randomized
control trial. Development and Psychopathology, 23(1), 195–210. Muller-Nix, C., Forcada-Guex, M., Pierrehumbert,
B., Jaunin, L., Borghini, A., & Ansermet, F. (2004). Pre maturity, maternal stress and mother –child interactions. Early
Human Development, 79, 145–158. Nozadi, S. S., Spinrad, T. L., Eisenberg, N., Bolnick, R., Eggum-Wilkens, N. D.,
Smith, C. L., ... Sallquist, J. (2013). Prediction of toddlers’ expressive language from maternal sensitivity and
toddlers’ anger expres sions: A developmental perspective. Infant Behavior and Development, 36, 650 –661. Oxford,
M. L., & Findlay, D. M. (2015). NCAST caregiver/parent-child interaction feeding manual (2nd ed.). Seattle, WA:
NCAST Programs, University of Washington, School of Nursing.
Paavola, L., Kemppinen, K., Kumpulainen, K., Moilanen, I., & Ebeling, H. (2006). Maternal sensitivity, infant
co-operation and early linguistic development: Some predictive relations. European Journal of Devel opmental
Psychology, 3(1), 13–30.
Page, M., Wilhelm, M. S., Gamble, W. C., & Card, N. A. (2010). A comparison of maternal sensitivity and verbal
stimulation as unique predictors of infant social–emotional and cognitive development. Infant Behavior and
Development, 33(1), 101–110.
EVALUATING CAREGIVER SENSITIVITY: MEASURES MATTER 747

Pederson, D. R., Bailey, H. N., Tarabulsy, G. M., Bento, S., & Moran, G. (2014). Understanding sensitivity: Lessons
learned from the legacy of Mary Ainsworth. Attachment & Human Development, 16, 261 –270. Pederson, D. R.,
Moran, G., Sitko, C., Campbell, K., Ghesquire, K., & Acton, H. (1990). Maternal Sensitiv ity and the Security of
Infant-Mother Attachment: A Q-Sort Study. Child Development, 61, 1974 –1983. Pillhofer, M., Spangler, G.,
Bovenschen, I., Kuenster, A. K., Gabler, S., Fallon, B., ... Ziegenhain, U. (2015). Pilot study of a program delivered
within the regular service system in Germany: Effect of a short term attachment-based intervention on maternal
sensitivity in mothers at risk for child abuse and neglect. Child Abuse & Neglect, 42, 163–173.
Posada, G., Trumbell, J., Noblega, M., Plata, S., Pena, P., Carbonell, O. A., ~ ... Lu, T. (2016). Maternal sen sitivity
and child secure base use in early childhood: Studies in different cultural contexts. Child Develop ment, 87(1),
297–311.
Roger Mills-Koonce, W., Willoughby, M. T., Zvara, B., Barnett, M., Gustafsson, H., & Cox, M. J. (2015). Mothers’
and fathers’ sensitivity and children’s cognitive development in low-income, rural families. Jour nal of Applied
Developmental Psychology, 38, 1–10.
Rothabum, F., & Crockenberg, S. (1995). Maternal control and two-year-old’s compliance and defiance. International
Journal of Behavioral Development, 18, 193–210.
Secco, M. L., & Moffatt, M. E. K. (2003). Situational, maternal, and infant influences on parenting stress among
adolescent mothers. Issues in Comprehensive Pediatric Nursing, 26, 103–122. Shin, H., Park, Y.-J., Ryu, H., &
Seomun, G.-A. (2008). Maternal sensitivity: A concept analysis. Journal of Advanced Nursing, 64, 304 –314.
Shrout, P. E., & Fleiss, J. L. (1979). Intraclass correlations: Uses in assessing rater reliability. Psychological Bulletin,
86, 420–428.
Stams, G.-J. J. M., Juffer, F., & van IJzendoorn, M. H. (2002). Maternal sensitivity, infant attachment, and
temperament in early childhood predict adjustment in middle childhood: The case of adopted children and their
biologically unrelated parents. Developmental Psychology, 38, 806–821.
Sumner, G., & Spietz, A. (1994). NCAST caregiver/parent-child interaction feeding manual. Seattle, WA: NCAST
Publications, University of Washington, School of Nursing.
Tabachnick, B. G., & Fidell, L. S. (2012). Using multivariate statistics (6th ed.). Boston, MA: Pearson.
Tamis-LeMonda, C. S., Briggs, R. D., McClowry, S. G., & Snow, D. L. (2009). Maternal control and sensi tivity, child
gender, and maternal education in relation to children’s behavioral outcomes in African Amer ican families. Journal of
Applied Developmental Psychology, 30, 321–331.
Tarabulsy, G. M., Provost, M. A., Bordeleau, S., Trudel-Fitzgerald, C., Moran, G., Pederson, D. R., ... Pierce, T.
(2009). Validation of a short version of the maternal behavior Q-set applied to a brief video record of mother–infant
interaction. Infant Behavior and Development, 32, 132–136.
Tryphonopoulos, P. D., Letourneau, N., & DiTommaso, E. (2016). Caregiver-infant interaction quality: A review of
observational assessment tools. Comprehensive Child and Adolescent Nursing, 39, 107–138. Vallotton, C. D.,
Mastergeorge, A., Foster, T., Decker, K. B., & Ayoub, C. (2017). Parenting supports for early vocabulary
development: Specific effects of sensitivity and stimulation through infancy. Infancy, 22, 78–107.
Vandell, D. L., Belsky, J., Burchinal, M., Steinberg, L., & Vandergrift, N. (2010). Do effects of early child care extend
to age 15 years? Results from the NICHD study of early child care and youth development. Child Development, 81,
737–756.
van den Boom, D. C. (1997). Sensitivity and attachment: Next steps for developmentalists. Child Develop ment, 64,
592–594.
Waters, E. (1978). The integrated child. Contemporary Psychology: A Journal of Reviews, 23, 243–245. Whipple, N.,
Bernier, A., & Mageau, G. A. (2011). Broadening the study of infant security of attachment: Maternal
autonomy-support in the context of infant exploration: Autonomy-support and security of attachment. Social
Development, 20(1), 17–32.
World Health Organization (2004). The world health report: 2004: Changing history. Retrieved from http://
www.who.int/whr/2004/en/report04_en.pdf?ua=1
Wu, P., Robinson, C. C., Yang, C., Hart, C. H., Olsen, S. F., Porter, C. L., ... Wu, X. (2002). Similarities and
differences in mothers’ parenting of preschoolers in China and the United States. International Journal of
Behavioral Development, 26, 481–491.

You might also like