Exploring the relationship between working from home, mental and physical health and wellbeing: a systematic review

Background

Understanding the impact of working from home on health and wellbeing is of great interest to employers and employees alike, with a strong need for up-to-date guidance. The aim of this systematic review was to identify, appraise and synthesise existing research evidence that explores the impact of home working on health and wellbeing outcomes for working people and health inequalities in the population.

Methods

We conducted a systematic review of qualitative, quantitative and observational studies. We searched databases, reference lists and UK grey literature and completed citation searching of included papers. We extracted and tabulated key data from the included papers and synthesised narratively. Factors associated with the health and wellbeing of people working at home reported in the literature were displayed by constructing mind maps of each individual factor which had been identified. The findings were combined with an a priori model to develop a final model, which was validated in consultation with stakeholders.

Results

Of 96 studies which were found to meet the inclusion criteria for the review, 30 studies were published before the COVID-19 pandemic and a further 66 were published during the pandemic. The quality of evidence was limited by the study designs employed by the authors, with the majority of studies being cross-sectional surveys (n = 59). For the most part, for studies which collected quantitative data, measures were self-reported. The largest volume of evidence identified consisted of studies conducted during the COVID-19 pandemic which looked at factors which influence the relationship between working from home and measures relating to mental health and wellbeing. Fifteen studies which considered the potential for working at home to have different effects for different subgroups suggested that working at home may have more negative consequences during the COVID-19 pandemic for women and in particular, mothers. There was very little evidence on age (two studies), ethnicity (one study), education or income (two studies) in terms of moderating home working effects, and very limited evidence from before the COVID-19 pandemic. The concept of enforced working from home and having 'no choice' was reported in only one paper prior to the pandemic and two papers reporting on working from home as a result of COVID-19. However, the concept of lack of choice around working from home was implicit in much of the literature - even though it was not directly measured. There were no clear patterns of wellbeing measures which changed from positive to negative association (or vice versa) during the pandemic.

Limitations

The quality of the evidence base was very much limited by study designs, particularly for studies published during the COVID-19 pandemic, with the majority of studies consisting of data collected by cross-sectional surveys (often online). Due to the rapidly expanding nature of the evidence on this topic, it is possible that new studies were published after the final citation searches were conducted.

Discussion

The evidence base for the factors which influence the relationship between home working and health-related outcomes has expanded significantly as a result of the need for those whose work could be done from home to work at home during the COVID-19 pandemic. Our findings suggest that there are factors relating to the external context, the role of employers and the circumstances of the employee which contribute to determining whether someone works at home and what the associated impacts on health and wellbeing may be. Learning from the COVID-19 lockdown experience will be important to inform future policy on home and hybrid working.

Future work

There is a need for better-quality studies of the health impact of home working, in particularly studies which recruit a range of participants who are representative of the working population and which are designed to minimise sampling/recruitment biases and response biases.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (project reference 18/93 PHR Public Health Review Team) and will be published in full in Public Health Research; Vol. 11, No. 4. See the NIHR Journals Library website for further project information. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

Study registration

This study is registered as PROSPERO 2021 CRD42021253474.

Understanding the experience of initiating community-based group physical activity by people with serious mental illness: A systematic review using a meta-ethnographic approach

BACKGROUND

People living with serious mental illness (SMI) experience debilitating symptoms that worsen their physical health and quality of life. Regular physical activity (PA) may bring symptomatic improvements and enhance wellbeing. When undertaken in community-based group settings, PA may yield additional benefits such as reduced isolation. Initiating PA can be difficult for people with SMI, so PA engagement is commonly low. Designing acceptable and effective PA programs requires a better understanding of the lived experiences of PA initiation among people with SMI.

METHODS

This systematic review of qualitative studies used the meta-ethnography approach by Noblit and Hare (1988). Electronic databases were searched from inception to November 2017. Eligible studies used qualitative methodology; involved adults (≥18 years) with schizophrenia, bipolar affective disorder, major depressive disorder, or psychosis; reported community-based group PA; and captured the experience of PA initiation, including key features of social support. Study selection and quality assessment were performed by four reviewers.

RESULTS

Sixteen studies were included in the review. We identified a "journey" that depicted a long sequence of phases involved in initiating PA. The journey demonstrated the thought processes, expectations, barriers, and support needs of people with SMI. In particular, social support from a trusted source played an important role in getting people to the activity, both physically and emotionally.

DISCUSSION

The journey illustrated that initiation of PA for people with SMI is a long complex transition. This complex process needs to be understood before ongoing participation in PA can be addressed. Registration-The review was registered on the International Prospective Register of Systematic Reviews (PROSPERO) on 22/03/2017 (registration number CRD42017059948).

Pembrolizumab for Locally Advanced or Metastatic Urothelial Cancer Where Cisplatin is Unsuitable: An Evidence Review Group Perspective of a NICE Single Technology Appraisal

As part of its Single Technology Appraisal (STA) process, the National Institute for Health and Care Excellence (NICE) invited the manufacturer (Merck Sharp & Dohme) of pembrolizumab (Keytruda^®) to submit evidence of its clinical and cost effectiveness for the treatment of locally advanced or metastatic urothelial cancer where cisplatin is unsuitable. The School of Health and Related Research Technology Appraisal Group at the University of Sheffield was commissioned to act as the independent Evidence Review Group (ERG). The ERG produced a detailed review of the evidence for the clinical and cost effectiveness of the technology, based on the company's submission (CS) to NICE. The clinical effectiveness evidence in the CS for pembrolizumab was based on one phase II, single-arm, open-label, non-randomised study (KEYNOTE-052), while the evidence for the comparator (carboplatin plus gemcitabine) was based on four studies, including one randomised controlled trial and three cohort studies. In the absence of head-to-head trials, the company conducted an indirect treatment comparison for both progression-free survival (PFS) and overall survival (OS), by firstly adjusting cross-study differences using a simulated treatment comparison approach and then synthesizing the evidence based on an assumption of constant hazard ratios using a standard meta-analysis model and time-varying hazard ratios using fractional polynomial models. The treatment effect of pembrolizumab was more favourable in the adjusted population compared with the observed effect in the KEYNOTE-052 study. The company submitted a de novo partitioned survival cohort simulation model, which partitions the OS time into PFS and post-progression survival. The probabilistic incremental cost-effectiveness ratio (ICER) for pembrolizumab compared with carboplatin plus gemcitabine was estimated to be £37,081 per quality-adjusted life-year (QALY) gained, based on the results within the company's health economic model. Following a critique of the model, for their preferred base case the ERG corrected some minor model errors, chose a progression approach for estimating utilities, and revised the extrapolation of PFS and OS. The ERG's probabilistic base case ICER was estimated to be £67,068 per QALY gained. The ERG also undertook a range of exploratory sensitivity analyses which suggested that the ICER was highly uncertain. In particular, the choices of extrapolation for the OS of pembrolizumab and the stopping rule for pembrolizumab had the largest impacts on the ICER. The NICE Appraisal Committee recommended pembrolizumab for use within the Cancer Drugs Fund as an option for treating locally advanced or metastatic urothelial carcinoma in adults who have had platinum-containing chemotherapy, provided that pembrolizumab was stopped at 2 years of uninterrupted treatment, or earlier if the disease progresses, and the conditions of the managed access agreement for pembrolizumab are followed.

Assessing prognosis and prediction of treatment response in early rheumatoid arthritis: systematic reviews

BACKGROUND

Rheumatoid arthritis (RA) is a chronic, debilitating disease associated with reduced quality of life and substantial costs. It is unclear which tests and assessment tools allow the best assessment of prognosis in people with early RA and whether or not variables predict the response of patients to different drug treatments.

OBJECTIVE

To systematically review evidence on the use of selected tests and assessment tools in patients with early RA (1) in the evaluation of a prognosis (review 1) and (2) as predictive markers of treatment response (review 2).

DATA SOURCES

Electronic databases (e.g. MEDLINE, EMBASE, The Cochrane Library, Web of Science Conference Proceedings; searched to September 2016), registers, key websites, hand-searching of reference lists of included studies and key systematic reviews and contact with experts.

STUDY SELECTION

Review 1 - primary studies on the development, external validation and impact of clinical prediction models for selected outcomes in adult early RA patients. Review 2 - primary studies on the interaction between selected baseline covariates and treatment (conventional and biological disease-modifying antirheumatic drugs) on salient outcomes in adult early RA patients.

RESULTS

Review 1 - 22 model development studies and one combined model development/external validation study reporting 39 clinical prediction models were included. Five external validation studies evaluating eight clinical prediction models for radiographic joint damage were also included. c-statistics from internal validation ranged from 0.63 to 0.87 for radiographic progression (different definitions, six studies) and 0.78 to 0.82 for the Health Assessment Questionnaire (HAQ). Predictive performance in external validations varied considerably. Three models [(1) Active controlled Study of Patients receiving Infliximab for the treatment of Rheumatoid arthritis of Early onset (ASPIRE) C-reactive protein (ASPIRE CRP), (2) ASPIRE erythrocyte sedimentation rate (ASPIRE ESR) and (3) Behandelings Strategie (BeSt)] were externally validated using the same outcome definition in more than one population. Results of the random-effects meta-analysis suggested substantial uncertainty in the expected predictive performance of models in a new sample of patients. Review 2 - 12 studies were identified. Covariates examined included anti-citrullinated protein/peptide anti-body (ACPA) status, smoking status, erosions, rheumatoid factor status, C-reactive protein level, erythrocyte sedimentation rate, swollen joint count (SJC), body mass index and vascularity of synovium on power Doppler ultrasound (PDUS). Outcomes examined included erosions/radiographic progression, disease activity, physical function and Disease Activity Score-28 remission. There was statistical evidence to suggest that ACPA status, SJC and PDUS status at baseline may be treatment effect modifiers, but not necessarily that they are prognostic of response for all treatments. Most of the results were subject to considerable uncertainty and were not statistically significant.

LIMITATIONS

The meta-analysis in review 1 was limited by the availability of only a small number of external validation studies. Studies rarely investigated the interaction between predictors and treatment.

SUGGESTED RESEARCH PRIORITIES

Collaborative research (including the use of individual participant data) is needed to further develop and externally validate the clinical prediction models. The clinical prediction models should be validated with respect to individual treatments. Future assessments of treatment by covariate interactions should follow good statistical practice.

CONCLUSIONS

Review 1 - uncertainty remains over the optimal prediction model(s) for use in clinical practice. Review 2 - in general, there was insufficient evidence that the effect of treatment depended on baseline characteristics.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016042402.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

What is the added value of ultrasound joint examination for monitoring synovitis in rheumatoid arthritis and can it be used to guide treatment decisions? A systematic review and cost-effectiveness analysis

BACKGROUND

Synovitis (inflamed joint synovial lining) in rheumatoid arthritis (RA) can be assessed by clinical examination (CE) or ultrasound (US).

OBJECTIVE

To investigate the added value of US, compared with CE alone, in RA synovitis in terms of clinical effectiveness and cost-effectiveness.

DATA SOURCES

Electronic databases including MEDLINE, EMBASE and the Cochrane databases were searched from inception to October 2015.

REVIEW METHODS

A systematic review sought RA studies that compared additional US with CE. Heterogeneity of the studies with regard to interventions, comparators and outcomes precluded meta-analyses. Systematic searches for studies of cost-effectiveness and US and treatment-tapering studies (not necessarily including US) were undertaken.

MATHEMATICAL MODEL

A model was constructed that estimated, for patients in whom drug tapering was considered, the reduction in costs of disease-modifying anti-rheumatic drugs (DMARDs) and serious infections at which the addition of US had a cost per quality-adjusted life-year (QALY) gained of £20,000 and £30,000. Furthermore, the reduction in the costs of DMARDs at which US becomes cost neutral was also estimated. For patients in whom dose escalation was being considered, the reduction in number of patients escalating treatment and in serious infections at which the addition of US had a cost per QALY gained of £20,000 and £30,000 was estimated. The reduction in number of patients escalating treatment for US to become cost neutral was also estimated.

RESULTS

Fifty-eight studies were included. Two randomised controlled trials compared adding US to a Disease Activity Score (DAS)-based treat-to-target strategy for early RA patients. The addition of power Doppler ultrasound (PDUS) to a Disease Activity Score 28 joints-based treat-to-target strategy in the Targeting Synovitis in Early Rheumatoid Arthritis (TaSER) trial resulted in no significant between-group difference for change in Disease Activity Score 44 joints (DAS44). This study found that significantly more patients in the PDUS group attained DAS44 remission (p = 0.03). The Aiming for Remission in Rheumatoid Arthritis (ARCTIC) trial found that the addition of PDUS and grey-scale ultrasound (GSUS) to a DAS-based strategy did not produce a significant between-group difference in the primary end point: composite DAS of < 1.6, no swollen joints and no progression in van der Heijde-modified total Sharp score (vdHSS). The ARCTIC trial did find that the erosion score of the vdHS had a significant advantage for the US group (p = 0.04). In the TaSER trial there was no significant group difference for erosion. Other studies suggested that PDUS was significantly associated with radiographic progression and that US had added value for wrist and hand joints rather than foot and ankle joints. Heterogeneity between trials made conclusions uncertain. No studies were identified that reported the cost-effectiveness of US in monitoring synovitis. The model estimated that an average reduction of 2.5% in the costs of biological DMARDs would be sufficient to offset the costs of 3-monthly US. The money could not be recouped if oral methotrexate was the only drug used.

LIMITATIONS

Heterogeneity of the trials precluded meta-analysis. Therefore, no summary estimates of effect were available. Additional costs and health-related quality of life decrements, relating to a flare following tapering or disease progression, have not been included. The feasibility of increased US monitoring has not been assessed.

CONCLUSION

Limited evidence suggests that US monitoring of synovitis could provide a cost-effective approach to selecting RA patients for treatment tapering or escalation avoidance. Considerable uncertainty exists for all conclusions. Future research priorities include evaluating US monitoring of RA synovitis in longitudinal clinical studies.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015017216.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Understanding the experience of initiating community-based physical activity and social support by people with serious mental illness: a systematic review using a meta-ethnographic approach

BACKGROUND

People with long-term serious mental illness live with severe and debilitating symptoms that can negatively influence their health and quality of life, leading to outcomes such as premature mortality, morbidity and obesity. An interplay of social, behavioural, biological and psychological factors is likely to contribute to their poor physical health. Participating in regular physical activity could bring symptomatic improvements, weight loss benefits, enhanced wellbeing and when undertaken in a community-based group setting can yield additional, important social support benefits. Yet poor uptake of physical activity by people with serious mental illness is a problem. This review will systematically search, appraise and synthesise the existing evidence that has explored the experience of community-based physical activity initiation and key features of social support within these contexts by adults with schizophrenia, bipolar affective disorder, major depressive disorder or psychosis using the meta-ethnography approach. This new understanding may be key in designing more acceptable and effective community-based group PA programmes that meet patients' need and expectations.

METHODS

This will be a systematic review of qualitative studies using the meta-ethnography approach. The following databases will be searched: ASSIA, CINAHL, Cochrane Central Register of Controlled Trials, EMBASE, Health Technology Assessment Database, MEDLINE, PsycINFO, Sociological Abstracts, SPORTDiscus and Web of Science. Grey literature will also be sought. Eligible studies will use qualitative methodology; involve adults (≥18 years) with schizophrenia, bipolar affective disorder, major depressive disorder or psychosis; will report community-based group physical activity; and capture the experience of physical activity initiation and key features of social support from the perspective of the participant. Study selection and assessment of quality will be performed by two reviewers. Data will be extracted by one reviewer, tabled, and checked for accuracy by the second reviewer. The meta-ethnography approach by Noblit and Hare (Meta-ethnography: synthesizing qualitative studies 11, 1988) will be used to synthesise the data.

DISCUSSION

This systematic review is expected to provide new insights into the experience of community-based group physical activity initiation for adults who have a serious mental illness to inform person-centred improvements to the management of serious mental illness through physical activity.

SYSTEMATIC REVIEW REGISTRATION

The protocol has been registered on the International Prospective Register of Systematic Reviews (PROSPERO) on 22/03/2017; (registration number CRD42017059948 ).

Promoting and maintaining physical activity in the transition to retirement: a systematic review of interventions for adults around retirement age

It has been argued that transition points in life, such as the approach towards, and early years of retirement present key opportunities for interventions to improve the health of the population. Research has also highlighted inequalities in health status in the retired population and in response to interventions which should be addressed. We aimed to conduct a systematic review to synthesise international evidence on the types and effectiveness of interventions to increase physical activity among people around the time of retirement. A systematic review of literature was carried out between February 2014 and April 2015. Searches were not limited by language or location, but were restricted by date to studies published from 1990 onwards. Methods for identification of relevant studies included electronic database searching, reference list checking, and citation searching. Systematic search of the literature identified 104 papers which described study populations as being older adults. However, we found only one paper which specifically referred to their participants as being around the time of retirement. The intervention approaches for older adults encompassed: training of health care professionals; counselling and advice giving; group sessions; individual training sessions; in-home exercise programmes; in-home computer-delivered programmes; in-home telephone support; in-home diet and exercise programmes; and community-wide initiatives. The majority of papers reported some intervention effect, with evidence of positive outcomes for all types of programmes. A wide range of different measures were used to evaluate effectiveness, many were self-reported and few studies included evaluation of sedentary time. While the retirement transition is considered a significant point of life change, little research has been conducted to assess whether physical activity interventions at this time may be effective in promoting or maintaining activity, or reducing health inequalities. We were unable to find any evidence that the transition to retirement period was, or was not a significant point for intervention. Studies in older adults more generally indicated that a range of interventions might be effective for people around retirement age.

Peer rejection in childhood: effects on maternal depression and behavior problems in toddlers

The aim of this study was to develop a conceptual model that would clarify how a woman's recollections of peer and parent rejection in childhood influence her emotional well-being and, resultantly, her own child's behavior problems. Given current interest in peer versus parent influences, the authors used a design and analysis to reveal the unique contributions of peer and parent rejection. The participants were a community sample of 88 mothers and their 2 1/2-year-old children. The study found that mothers' recollections of peer rejection in childhood were significantly associated with depressive symptomatology, but recollections of parental rejection in childhood were unrelated to current depressive symptoms. Recollections of peer rejection during childhood, internal representation of self, and depressive symptoms made significant, unique contributions to the variance in behavior problems in their children. Together, these variables significantly explained 27% of the variance in the final model.

Internalizing and externalizing behavior of children with enlisted Navy mothers experiencing military-induced separation

OBJECTIVES

To examine whether children with Navy mothers exhibit higher levels of internalizing and externalizing behavior than children in civilian families and whether deployment affects children's internalizing and externalizing behavior.

METHOD

Navy mothers who experienced deployment completed a measure assessing children's internalizing and externalizing behavior before and after a deployment (and at similar intervals for the Navy and civilian comparison groups). Data collection took place between 1996 and 1998.

RESULTS

Navy children with deployed mothers exhibited higher levels of internalizing behavior than children with nondeployed Navy mothers. Navy children whose mothers experienced deployment were more likely to exhibit clinical levels of internalizing behavior than Navy children with nondeployed mothers or civilian children. Group differences, however, were modest and overall mean scores were in the normal range.

CONCLUSIONS

Findings do not suggest greater pathology in children of Navy mothers; however, findings do indicate we should be particularly attentive of deployed mothers and their children.

Separation anxiety in parents of adolescents: theoretical significance and scale development

Parents of adolescents commonly face separation-related issues associated with children's increasing independence and imminent leave-taking. The aims of this investigation were (1) to develop a reliable and valid measure of parental emotions associated with separation and (2) to validate the measure by relating it to other attributes (attachment relationship quality, parent-child communication, and parent-adolescent differentiation) assessed in mothers, fathers, and their adolescents. The newly constructed, 35-item Parents of Adolescents Separation Anxiety Scale (PASAS) was administered to 686 parents of teenagers in grades 6, 8, 10, and 12 or college-bound freshmen and seniors. Factor analyses supported formation of two subscales: Anxiety about Adolescent Distancing (AAD) and Comfort with Secure Base Role (CSBR); both subscales showed distinctive patterns of change with child age. Parents' reports indicated that healthy adult attachment styles were associated with lower AAD and higher CSBR scores; children of parents who had higher AAD scores reported lower quality of attachment to both mothers and fathers.

The relation of problem behaviors in preschool children to depressive symptoms in mothers and fathers

The relation of maternal and paternal depressive symptoms to problem behaviors in a nonclinical sample of preschool children was examined. Data were collected from 46 women, their husbands, and their 4-year-old, first-born children. Observed maternal restrictive and punishing behavior and attachment security of the child were considered additional sources of risk for externalizing and internalizing problem behaviors. Different predictors for child externalizing and internalizing behaviors were identified via hierarchical multiple regression analyses. Maternal and paternal depressive symptoms and maternal restrictive and punishing behavior emerged as salient predictors of child internalizing behaviors. For externalizing behaviors, there were significant gender differences: For girls, maternal depressive symptoms made a significant contribution to the model; the model for boys was not significant. The results perhaps reflect different etiological pathways for externalizing and internalizing behaviors, supporting the suggestion that those behaviors are distinct clinical phenomena, even among very young children. The findings also suggest that nonclinical levels of parental symptomatology show systematic relations to children's problem behaviors.

Maternal separation anxiety: relations to adult attachment representations in mothers of infants

Guided primarily by attachment theory, this longitudinal study explored how adult mental representations of attachment relationships and memories of childhood experiences with parents contributed to a mother's anxiety about separation from her own infant. The Maternal Separation Anxiety Scale, the Adult Attachment Interview, and the Mother-Father-Peer Scale were administered to a sample of 49 first-time mothers. The mothers with insecure attachment representations, when asked to remember details of their own childhood, reported more negative recollections of early parental caregiving, particularly rejection and discouragement of independence. When their own infants were 2 months old, these mothers experienced heightened levels of maternal separation anxiety. The findings provide theoretical and empirical support for the view that very high levels of maternal separation anxiety may indicate dysfunction.

Preexisting lung disease and lung cancer among nonsmoking women

Preexisting lung disease was examined as a risk factor for lung cancer in a population-based, case-control study of nonsmoking women in Missouri conducted between June 1, 1986, and April 1, 1991. A history of lung disease was reported by approximately 41% of 618 cases and 35% of 1,402 controls (odds ratio (OR) = 1.2; 95% confidence interval (Cl) 1.0-1.5. The risk was more pronounced when next-of-kin interviews were excluded (OR = 1.5). Previous lung disease was significantly related both to adenocarcinoma (OR = 1.4), which accounted for 62% of the cancers, and to all other cell types of lung cancer combined (OR = 1.8). Despite having discontinued smoking for more than 15 years, long-term ex-smokers were at a 2.2-fold risk of lung cancer compared with lifetime nonsmokers. Among lifetime nonsmokers, significant risks were noted for asthma (OR = 2.7) and pneumonia (OR = 1.5). Emphysema (OR = 2.6) and tuberculosis (OR = 2.0) were also significantly related to lung cancer, but only among former smokers. Chronic bronchitis was linked to elevated risks of nonadenocarcinomas only (OR = 2.3). Pleurisy was not reported more frequently by cases than by controls. Approximately 16% of all lung cancers among nonsmoking women could be attributed to previous lung diseases, most notably asthma, pneumonia, emphysema, and tuberculosis.

Maternal separation anxiety: its developmental course and relation to maternal mental health

Maternal separation anxiety is a construct that describes a mother's experience of worry, sadness, or guilt during short-term separations from her child. This investigation examined potential differences in psychological correlates between mothers with high and low levels of anxiety when their children were 8 months, 3 1/2 years, and 6 years of age. High levels of maternal separation anxiety had different psychological correlates contingent upon the age of the child. Depressive symptomatology and separation anxiety were unrelated at times 1 and 2, but when the children were 6 years old, mothers who had the highest levels of anxiety tended to have more depressive symptomatology, fewer coping skills, a more negative representation of self, and embraced more traditional sex-role values. Study findings are discussed with respect to their relevance to the mother's role as developmental partner to the child and linked to major theoretical perspectives that address the mother-child relationship.

Employed mothers' concerns about separation from the first- and second-born child

The effect of birth order on mothers' anxiety about separation from their infants was examined. Forty employed mothers were assessed in 1982 when their firstborns were 7 months old and again when their second-borns were 7 months old. Assessment included two measures: an Interview-Based Rating Scale (IBRS) and the Maternal Separation Anxiety Scale (MSAS). Findings revealed that mothers felt less guilt and anxiety about separation from their second-borns than they had from their first-borns at a similar age. They were more positive about the effects of separation on the child; however, their concerns about employment-related separation did not change.

Maternal anxiety and sensitive mothering behavior in diabetic and nondiabetic women

To evaluate the effects of a high-risk pregnancy on development of the maternal-infant relationship, the differences in anxiety, sensitive maternal behavior, and maternal separation anxiety in diabetic and nondiabetic mothers were examined. The findings imply that a high-risk pregnancy may not always be accompanied by increased anxiety or disturbances in sensitive maternal behavior. Questions are raised regarding the influences of demographic factors on maternal behavior and the differences that chronic versus sudden onset high-risk pregnancy factors might have on maternal anxiety and behavior. The findings also reinforce the influence of supportive medical and nursing care throughout a high-risk pregnancy.

Infant temperament and noncompliant behavior at four years: a longitudinal study

Noncompliant behavior in early childhood (i.e., exaggerated, but age-appropriate negativism) has been inadequately studied. This longitudinal study explores preschool temperament and maternal behavior as current correlates of negativistic behavior at age 4, and early maternal characteristics and infant temperament as etiological variables in the production of negativism. Longitudinal evidence was collected from 62 mother-child dyads, representative of all social classes. This evidence included home observations of maternal and child behavior at 4 years, a temperament questionnaire at 4 years, a questionnaire about infant temperament, and observational and interview measures at various stages from birth to 3 years, of infant behavior and maternal characteristics. The findings suggest that infant and childhood temperament (especially the degree of infant fussiness) are highly predictive of physical noncompliance, and that physical noncompliance is unrelated to maternal or demographic variables. A combination of maternal variables including warmth, closeness, and verbal directiveness, both positive and negative, as well as child variables, predict verbal noncompliance. Demographic variables, temperament, and maternal attitudes predict passive noncompliance. Noncompliance is viewed as a complex phenomenon in which constitutional and environmental variables interact.

Infants in play groups: time related changes in behavior toward mothers, peers, and toys

Twenty-one 13-month-old infants, nine male and 12 female, were assigned to one of seven playgroups convening for 15 consecutive weekdays . Present at each 20-minute play session were three same-sexed peers with their mothers and an assortment of toys. There were systematic fluctuations in infants' attention to mother, peers, and toys. There findings suggest that a mother may serve different functions at different points in time: (a) as a secure base in initial sessions, (b) as a refueling stop when the infant grew tired, and (c) as an attractive alternative when the infant became bored with toys and peers. Within-day analyses revealed that activity level and toy exploration linearly decreased over time, while intentional contact with mother significantly increased. Social interaction with peers correlated negatively with interaction with mother over the course of the study. Sex differences over time were found to be significant: boys on day one were more interactive with both peers and toys but this level declined thereafter, while girls on day one spent more time in close proximity to mother and later, on subsequent days, increased their peer and toy play.

Behavior toward mother and stranger of infants who have experienced group day care, individual care, or exclusive maternal care

Social behaviors of 60, 12-month-old infants were studied, with the use of a structured observational technique. Infants behaviors were related to sex of infant and to experience in one of three types of care: maternal home rearing, individual babysitter, or group day care. The provision of nonmaternal care and the specific type of nonmaternal care appeared to influence the social behaviors of the two sexes differently. Home-reared girls tended to exhibit fewer and less intense behaviors that were aimed at maintaining or regaining maternal proximity. Girls experiencing nonmaternal care exhibited more maternal proximity attaining behaviors than did home-rearing girls, whereas boys experiencing nonmaternal care exhibited fewer maternal proximity attaining behaviors than home-reared boys. The interactions of type of care and sex of infant led to a consideration of differential sensitivity of the sexes to rearing conditions.

Heart rate variability and cardiac response to an auditory stimulus

While in a state of quiet sleep, 15 full-term male, 15 full-term female, and 15 premature male infants were presented a single auditory stimulus. Heart rate was continuously monitored and scored for mean and standard deviation in the 10-sec prestimulus period, as well as for peak and trough magnitude of the response and the latencies to these points. The infants tended to show a diphasic response, acceleration followed by rebound deceleration below baseline. Prestimulus mean and variability were inversely related, and significantly predictive of the amount of acceleration. Premature infants showed a high resting heart rate, and a milder response to the stimulus. Also evident were larger accelerations and longer latencies to trough for full-term females.