Journal of Pediatric Psychology. Vol. 21, No. 3. 1996. pp.

401-417
Quality of Attachment as a Predictor of Maternal
Visitation to Young Hospitalized Children
1
Jane R. Robinson
2
Case Western Reserve University
Jane L. Rankin
Drake University
Dennis Drotar
Case Western Reserve University School of Medicine
Received June I. 1994; accepted October 13. 1995
Tested a comprehensive model of factors predicting maternal visitation with
hospitalized children. Subjects were 86 mothers who completed the Spielberger
State-Trait Anxiety Inventory, a 12-item attachment measure derived from the
Waters and Deane Attachment Q-sort, and a demographic questionnaire. Chil-
dren were 10 months to 4 years old (37 female, 49 male) and hospitalized for
acute nonsurgical illness. Hierarchical regression analyses indicated that, of the
subset of variables tested (SES, number of children at home, gender, age, num-
ber of previous hospitalizations, state anxiety, and security of attachment), quali-
ty of attachment was the only significant predictor of maternal visitation rate.
Mothers who reported that their children displayed insecure attachment behav-
'This manuscript is based on the first authors master's thesis which was supervised by the second
author and completed at Drake University. Preparation of this manuscript was supported in part by
National Institute of Mental Health grant 18830. The authors acknowledge Susan Isbill and Susan
Kashubeck for their contributions to this research and to Everett Waters for graciously sharing his
Attachment Q-sort measure. We also thank the students in the pediatric psychology research training
program at Case Western Reserve University for their endless support and editing, along with the
nursing staff of Iowa Methodist Blank's Children's Hospital for their assistance in the data collec-
tion. Finally, this manuscript is lovingly dedicated to, and in memory of my father Dr. James L.
Robinson who died August I, 1995
2
AII correspondence should be sent to Jane R. Robinson, Department of Psychology, Case Western
Reserve University. 10900 Euclid Avenue, Cleveland, Ohio 44106-7123.
401
0H6-8693/96/O600-O40IJW 50/0 C 1996 Plenum Publishing Corp<xlioii

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402 Robinson, Rankin, and Drotar
iors maintained a significantly lower rate of visitation than mothers who reported
that their children displayed secure attachment behaviors. Results of this study
highlight the importance of understanding parent-child attachment in predicting
maternal visitation when a child is hospitalized.
KEY WORDS: attachment; separation distress; maternal visitation rate.
As many as 5 million American children undergo medical procedures each year
for treatment or diagnosis (Bush, Melamed, Sheras, & Greenbaum, 1986), with
many requiring hospitalization. Infants and children between the ages of 0-5 are
the overwhelming majority of these hospital izations (Trad, 1987). It is well
established that the hospitalization of a child is stressful for both the parent and
child alike, as the major factor contributing to the psychological upset of pre-
school children is separation from their parents (Bowlby, 1988; Crowell & Wa-
ters, 1990; Nagera, 1978; Prugh, Staub, Sands, Kirschbaum, & Lenihan, 1953).
Children between the ages of 6 months and 4 years are the age group considered
most vulnerable to the emotional effects of separation and illness (Bowlby, 1969;
Trad, 1987; Wolff, 1969).
Researchers have sought to determine whether interventions such as unre-
stricted visitation and parental rooming-in may reduce the emotional conse-
quences for hospitalized children. Early studies showed that when parents were
allowed to visit longer hours, children's negative behavioral outcomes (e.g.,
increased separation anxiety, increased sleep anxiety, aggression toward authori-
ty, eating disturbances, temper tantrums, and bed wetting) lessened upon return-
ing home (Douglas, 1975; Freiberg, 1972; Illingworth & Holt, 1955; Lehman,
1975; Prugh et al . , 1953).
While hospital visitation policies now frequently allow for unlimited visita-
tion (Alexander, Powell, Williams, White, & Conlon, 1988; Hamlett, Walker,
Evans, & Weise, 1994), not all parents can take advantage of such opportunities
due to responsibilities for other children, work obligations, and level of family
resources. Some children have chronic conditions that require prolonged pedi-
atric hospitalization that severely taxes the ability of parents to sustain visitation
and in some cases affecting the relationship with their children (Hamlett et al.,
1994). For these reasons, identification of factors that sustain or disrupt the
frequency of parental visitation to hospitalized children continues to be important.
Prior studies concerning maternal visitation have focused, almost exclu-
sively, on assessing the influence of maternal anxiety on visitation to the hospi-
talized child. However, the frequency of parental visitation and rooming-in can
be affected by multiple factors that have not been described in a comprehensive
framework, nor empirically tested. Based on dimensions proposed by Prugh et
al. (1953), J. R. Robinson (1994), and previously cited psychological studies
Hospitalizatkm and Attachment 403
(e.g., Alexander et al., 1988; Berenbaum & Hatcher, 1992; Freiberg, 1972;
Hamlett et al., 1994; D. Robinson, 1968; Skipper, 1966), a comprehensive
model of influences on parental anxiety and parental visitation was developed to
provide a framework for the present investigation (see Figure 1).
This model describes the relationship among several factors that are hy-
pothesized to predict maternal rates of visitation. These include overall level of
family resources (e.g., socioeconomic status), family and parental demands
(e.g., number of children at home), parental mood slate (e.g., anxiety), quality
of parent-child relationship (e.g., security of attachment), child characteristics
(e.g., gender, age, previous hospitalizations, nature and severity of illness), and
'Socioecooomic Stuns:
L^VCl Of O^DG^QOQ,
Tnmpoftarjon/Proximjty to bcopittl
Number of Children it home
FiniHy Strcsson
Pireoal perception of tevcrity of \S\xa
QtmtioD of bospitilizxtioa
Burden of iHaess
ftriiri Chtnrtrrittiri
Gender
Ae
'Number of previoui hocpiulualioas
'Nature & Severity of mnen
'Security of Atttchment
\
Anxicty (Stiic)
Depression
Confusion
*R*te of Milcnul VUrtatioo
StifiyPircnl Contmunicitjoo
Sleeping Aoconun
Encouragement of parents to room-in/visil
Pcrcepooo of psxcntxl role
partW-jpiiinn of f*nu\y when dntd is ill
Fig. I. Conceptual model of factors hypothesized to predict maternal visitation rates and state
anxiety. * = Variables tested in this model.
404 Robinson, Rankin, and Drotar
other contextual factors (e.g., quality of hospital support provided to parents),
and cultural factors (e.g., family response to the child's illness, and patterns of
family participation in the child's care). The role of several of these factors,
(e.g., family resources, maternal anxiety) have received empirical support in
prior research while others (e.g., quality of accommodations and support pro-
vided to parents in the hospital) are supported by clinical observation but have
not been tested empirically, to our knowledge.
It has been suggested that maternal anxiety stems from a variety of sources,
such as anxiety over seeing other ill children in the hospital (Freiberg, 1972),
lack of information concerning the ill child's diagnosis and treatment (Freiberg,
1972; Skipper, 1966), fear of criticism from the hospital staff, and judgments of
the mother's effectiveness as a parent (Prugh, 1983). More recently, Berenbaum
and Hatcher (1992), found higher levels of maternal distress (e.g., anxiety,
depression, and confusion) were associated with younger parental age, increased
family stressors, prior experience with hospitalization, and maternal appraisal of
her child's illness as severe.
Several studies have suggested that the level of maternal anxiety affects the
frequency of maternal visitation. Early research (e.g., Prugh et al., 1953;
D. Robinson, 1968) reported that as a mother's own fear of hospitalization
increased, time spent visiting her ill child decreased. In a study of non-rooming-
in and rooming-in mothers of hospitalized children, Alexander et al. (1988)
found elevated anxiety levels in non-rooming-in mothers that correlated pos-
itively with the number of children at home, and negatively with maternal educa-
tion level, occupation, and social status. Comparisons between groups demon-
strated that non-rooming-in mothers had higher state anxiety, lower
socioeconomic status (SES), fewer rooming-in experiences with their hospi-
talized children, and more children at home than did rooming-in mothers.
While these studies have enhanced our understanding of the factors that
influence maternal visitation, several methodological problems limit the conclu-
sions that can be drawn from them. For example, Alexander et al. (1988) col-
lected data from rooming-in mothers 2 months to 2 years after data on the non-
rooming-in mothers. For this reason, differences in anxiety levels could reflect
dissimilar environmental and/or societal stressors that were present at the differ-
ent periods. Moreover, the measure of rooming-in or not rooming-in used by
Alexander et al. (1988) forced subjects into descriptive categories. A continuous
measure of the extent of maternaJ visitation might afford a more complete de-
scription and greater statistical sensitivity.
Prior studies that assessed maternal anxiety (Alexander, White, & Powell,
1986; Alexander et al., 1988; Berenbaum & Hatcher, 1992; D. Robinson, 1968)
have included small samples (2030 subjects per group), thus reducing statistical
power. Children in these previous studies were hospitalized for a variety of
reasons, some general (e.g., bronchitis, pneumonia), and others for more serious
Hospitalization and Attachment 405
illnesses such as head trauma and cardiac surgery, which may have a very
different impact. It has been shown that more serious illnesses induce higher
levels of maternal anxiety (Berenbaum & Hatcher, 1992). The age of the hospi-
talized children in these studies also varied from infancy (D. Robinson, 1968)
through 12 years of age (Alexander et al., 1986, 1988; Berenbaum & Hatcher,
1992; Prugh et al., 1953; D. Robinson, 1968; Skipper, 1966). Such wide vari-
ability in the ages of these children makes it difficult to clarify the specific factors
that contribute to maternal anxiety in particular age groups.
This study was designed to address some of the methodological problems of
past research by including the following procedures: (a) The percentage of time
spent with the child was the primary measure of parental visitation (rather than a
general measure of parental rooming-in); (b) to eliminate variability in measure-
ment that could result from higher anxiety during the first 24 hours, matemai
anxiety was assessed after the first 24 hours of hospitalization and no later than
the third day; (c) diagnosis of the child was limited by including specific condi-
tions typical of childhood illnesses requiring acute hospitalization but not sur-
gery; (d) the number of subjects was much larger than in prior research, thus
affording greater statistical power to detect potential influences; and (e) the age
of the hospitalized child included only children age 10 months to 4 years.
This study tested the utility of a subset of variables from a comprehensive
model, described in Figure 1, in predicting matemai visitation. A novel factor in
the model, not tested in previous research, is attachment. Attachment theorists
and researchers have strongly implicated matemai sensitivity to infant cues in the
development of a secure infant-mother attachment relationship (Ainsworth,
Blehar, Waters, & Wall, 1978; Bowlby, 1969). Therefore, it was hypothesized
that higher levels of mothers' sensitivity when their children were hospitalized
would be displayed through more frequent visitation by mothers of securely
attached infants. However, some insecure patterns of attachment are charac-
terized by behaviors in which the child shows signs of detachment when dis-
tressed (Ainsworth et al., 1978). In such situations, these mothers might interpret
their children's behavior as signaling that they were not needed, thus giving rise
to less visitation. Therefore, we hypothesized that mothers with children classi-
fied as insecurely attached would exhibit less sensitive behaviors towards their ill
children as shown by less frequent visitation.
We also sought to extend previous findings by testing whether higher rates
of matemaJ visitation would be predicted by greater family resources (higher
SES), lower family demands (fewer children at home), child characteristics
(female, younger children, and fewer previous hospitalizations of the child), and
lower maternal state anxiety. Past studies have suggested that family resources,
family demands, hospital support (e.g., systematic staff-parent communication),
child characteristics, and nature and severity of the child's illness predict ele-
ments of parental mood state, particularly state anxiety (Alexander et al., 1986,
406 Robinson, Rankin, and Drotar
1988; Berenbaum & Hatcher, 1992; D. Robinson, 1968; Skipper & Leonard,
1968). Therefore, it was hypothesized that lower levels of maternal state anxiety
would be predicted by greater family resources (higher SES), fewer family
demands (fewer children at home), and the child characteristics of being female
and of preschool age, and having a greater number of previous hospitalizations.
METHOD
Subjects
Participants were recruited from a pediatric unit of Iowa Methodist Blank's
Children's Hospital. To increase the homogeneity of the sample, all mothers
selected for the study had to have a hospitalized child who met three criteria.
First, because the focus was on young children who are most vulnerable to the
effects of separation, the hospitalized child had to be between the ages of 10
months and 4 years. The 10-month cutoff was used because of the lack of validity
for the attachment measure below that age (Waters & Deane, 1985). Second, the
cause of hospitalization had to be respiratory distress, gastrointestinal illness,
rule-out sepsis (ROS), respiratory syncytial virus (RSV), or a combination of the
above. These diagnoses were the most frequent nonsurgical causes of hospital-
ization, as determined by hospital data. Moreover, treatment of these conditions
requires acute hospitalization, thus allowing parents and children little time for
advanced preparation (e.g., to plan changes in their schedule). Mothers of chil-
dren who required surgery, were terminally ill, or in critical condition were
excluded from the sample. Surgical procedures are usually scheduled in advance,
allowing parents to plan for schedule changes. Terminally ill children and their
parents are a unique subgroup who often have multiple hospitalizations associ-
ated with chronic conditions. Third, children with obvious indications of serious
developmental delay (e.g., Down syndrome) or physical handicap (e.g., spina
bifida) were excluded because such conditions could have affected the child's
attachment behaviors.
One mother declined participation in the study while 144 parents agreed.
However, 44 of those people either failed to return the questionnaire or were
discharged before they had an opportunity to complete it. (Due to their small
number and potential gender effects, the 9 fathers were dropped from the analy-
sis. Six additional subjects were omitted due to missing data.) The remaining 86
participants included the biological mother and her child between the ages of 10
months and 4 years (A/ = 22.8 months, SD = 10.5) who was hospitalized for
acute nonsurgical illness. Nearly all (85%) had children hospitalized for either
respiratory distress (51%) or gastro/dehydration-related illness (34%) with an
average hospital stay at the time of questioning to be 2.4 days. Most mothers
Hospitalization and Attachment 407
(74%) were married with an average age of 28 years. Teenage mothers (n = 5)
made up only 6% of the sample. In addition, all three SES groups were found to
be representative of national norms (Hollingshead, 1965). Sample characteristics
are shown in Table I.
Procedure
The first author checked the nurses' diagnosis board between 9 and 11 a.m.
Monday through Sunday. If a child was identified as having one of the specified
diagnoses, the researcher contacted the nurse in charge of the child's care,
verified the diagnosis, and ascertained that there were no complications or devel-
opmental delays. Parents were approached by the first author and asked to
volunteer for the study after the first 24 hours of their child's hospitalization and
no later than the third day. The child's attachment figure was identified by a brief
Table I. Sample Characteristics
Variable
MotheiV education (years)
Age of mother (years)
Age of Hospitalized Child (months)
Days of hospitalization at the time of questioning
Gender of child
Male
Female
Diagnosis
Respiratory
Gastro/dehydration
Rule-out sepsis
Respiratory syncytial virus
Combination of the above diagnosis
Mantal status
Mamed
Single never married
Divorced/currently single
Race
European American
African American
Asian American
Hispanic American
Other
Family socioeconomic status"
Upper (major business/professionals)
Middle (semiskilled workers)
Lower (unskilled labor)
M
13.0
27.6
22.3
2.4
SD
2.0
5.8
10.6
0.88
Range
9-17
16-42
10-48
1-5
%
57
43
51
34
9
5
1
74
19
7
79
13
5
2
1
36
34
26
"Hollingshead four-factor index (1965).
408 Robinson, Rankin, and Drotar
interview (i.e., the person who takes care of the child the majority of the time
and is relied upon by the child during times of stress). This person was asked to
respond to the questionnaire. All participants were given an informed consent
sheet describing the general purposes and procedures of the study, including
assurances of confidentiality and the right to withdraw without penalty. They
were asked to seal their questionnaire in an envelope upon completion, and
return it to the first author or the charge nurse.
Measures of Predictor Variables
Family Resources, Family and Parental Demands, Child Characteristics
A demographic questionnaire requested information about the parent's age,
gender, relationship status, ethnicity, and SES. The Hollingshead Four-Factor
Index of Social Status (1965), which considers education, occupation, sex, and
marital status was used to compute SES. Participants were also asked questions
about staying overnight with their ill child, the number of children at home, and
if their child had been hospitalized in the past.
Parent-Child Relationship
The child's security of attachment was assessed with a modification of
Waters and Dearie's (1985) Attachment Behavior Q-sort. The Q-sort was devel-
oped to facilitate a more naturalistic assessment of the attachment relationship
and is a behaviorally specific measure that permits valid assessment of security
of attachment outside of the laboratory (Pederson et al., 1990; Waters & Deane,
1985). The Q-sort provides a continuous metric that consists of 90 behavioral
descriptions that are sorted into nine piles according to similarity with the infant's
behavior. Items most characteristic of the child are placed at one end of the
distribution (Piles 9, 8, and 7) and those most unlike the child are placed at the
opposite end. Vaughn and Waters (1990) found that Strange Situation reunion
behaviors were significant predictors of home-based attachment security as mea-
sured by the Q-sort. Data on instrument development and construct validity are
available in several reports (Vaughn & Waters, 1990; Waters & Deane, 1985).
Use of the Waters and Deane (1985) instrument, which measures sociability
and dependency in addition to security of attachment, was not feasible for a study
of hospitalized children because it required too much time of the mother. For this
reason, 12 items identified by Vaughn and Waters (1990) as discriminating
between secure and insecure attachment were selected from Waters' (1991) re-
vised Attachment Q-set.
The items selected were reworded to ask parents directly about their child
Hospitalization and Attachment 409
instead of the original wording which was designed for outside observers. Par-
ents were asked to rate their children on a 9-point Likert scale with anchors and
behavioral descriptors that corresponded precisely to the Attachment Q-sort. The
12-item scale for assessing child attachment behaviors (Cronbach's a = .52)
included questions such as, "If given a choice, my child would rather play with
toys than adults" and "If I move very far, my child follows along and continues
his/her play in the area I have moved to." Parents were instructed to respond to
the items by reporting their child's typical behavior prior to their illness and
hospitalization.
A total attachment score was calculated by summing the 12 individual
Likert items, with greater scores indicating maternal reports of more secure child
behaviors. These Likert scale items were based on the 12 Q-sort items that
statistically discriminated (/-test values) between secure and insecure attachment
groups based on observations of infants and mothers in the Ainsworth Strange
Situation (Vaughn & Waters, 1990). The individual means for each statistically
significant item were reported for both groups. For our purposes, the dividing
point between secure and insecure attachment was determined by summing the
means of the 12 items for the two attachment groups as reported by Vaughn and
Waters (1990), and using these numbers as a guideline for selecting our cutoff
score of 72.
Maternal Psychological State: Anxiety Measure
The State-Trait Anxiety Inventory (STAI) Form Y (Spielberger, Gorsuch, &
Lushenc, 1983) assesses two forms of anxiety and can be completed in approx-
imately 10 minutes, does not exceed a 6th-grade reading level, and has relatively
high (.80 and .90) internal consistency reliability for both the A-Trait and A-State
forms. Construct validity for both A-State and A-Trait forms has been demon-
strated in multiple ways and the two tests have been shown to have construct
validity with other tests of anxiety (Anastasi, 1986).
Dependent Measure
Rate of Visitation
Participants were asked to indicate the number of hours (day and evening)
they had spent at the hospital since their child was admitted. In the calculation of
overall visitation rates, those mothers who spent the night were credited with
8 hours for each night they stayed. Maternal rate of visitation was calculated by
summing the number of reported hours of visitation, including hours spent over-
night, and dividing by the total number of hours the child was hospitalized at the
410 Robinson, Rankin, and Drotar
time of questioning. For those mothers who did not stay the night, there was an
open-ended question in which they were asked to describe why they had made
that choice.
RESULTS
Rate of Visitation
Mothers in this study responded to the questionnaires after their child's first
24 hours of hospitalization and no later than the third day. On average, children
were hospitalized 2.4 days (SD = 0.9) at the time of questioning. During the first
day of their child's hospitalization, mothers visited an average of 16 hours (SD =
7). A total of 78 mothers reported visitation hours for the first and second day of
their child's hospitalization, indicating they visited an average of 15.5 hours (SD
= 9) during the second day. The majority of mothers (87%) roomed-in. When
asked whey they did not stay the night, more than half (55%) of the 11 non-
rooming-in mothers reported they were needed at home by other children. At the
time of questioning, average overall rates of visitation indicated that mothers had
spent 65% (SD = 27) of their child's hospitalization with their ill child.
Prediction of State Anxiety
Pearson product-moment correlations were calculated to test the hypothesis,
depicted in Figure I, that higher SES, fewer children at home, female children,
older children, and greater numbers of previous hospitalizations, would correlate
with lower levels of state anxiety. No statistically significant relationships were
detected between state anxiety and any of these variables. In fact, not even
marked associations were found among the variables. Results are presented in
Table II.
Predictors of Visitation Rate
Hierarchical multiple regression analysis was used to test the hypothesized
model (see Figure 1) that state anxiety, SES, number of children at home, age
and gender of child, number of previous hospitalizations, and attachment, would
predict rate of maternal visitation. Security of attachment was entered last to test
the strength of its relationship to maternal visitation after accounting for the
association of all other variables. As shown in Table III, these results indicate
that security of attachment was the only significant predictor variable of maternal
visitation rate. Mothers who described more secure attachment behaviors in
Hospitalization and Attachment 411
Table II. Correlation Matnx for Maternal State Anxiety and Rate of Maternal Visitation, Family
Resources, Family and Parental Demands, Child Characteristics, and Parent-Child Relationship"
1. ANX
2. SES
3. DIA
4. AGE
5. GEN
6. HOS
7. VIS
8. CHO
9. ATT
2
- . 01

3
- . 09
.01

4
- . 18
- . 13
- . 03

5
.22
- . 10
- . 00
- . 20

6
.11
.21
- . 20
.19
- . 05

7
- 19
- . 23
.03
- . 14
- . 15
- 25

8
05
25
.08
- 02
.05
.03
- 07

9
- . 06
- . 12
05
- . 09
- 0 6
- 07
33*
00

"ANX = maternal state anxiety; SES = socioeconomic status; DIA = diagnosis; AGE = age of
child; GEN = gender, HOS = no. of previous hospilalizalions; VIS = rate of maternal visitation;
CHO = no. of children at home, ATT = security of attachment
h
p < .01.
their children demonstrated higher overall rates of visitation, R
2
change = .08,
F(l, 78) = 2.61, p < .01.
In the regression analysis, security of attachment was a continuous measure.
To better relate these findings to past research on attachment, which has utilized a
dichotomous classification of children as secure versus anxious/avoidant, chil-
dren were classified as secure or insecure. Maternal visitation rates were then
compared between the two groups. Based on an attachment cutoff score of 72,
sixty mothers rated their children (70%) as scoring the secure attachment range
(M = 80, SD = 7), and 26 mothers rated their children (30%) in the insecure
attachment range (M = 63, SD = 8). This distribution was similar to that
reported by Ainsworth et al. (1978).
Table III. Hierarchical Multiple Regression Analyses: Maternal Rate of Visitation
Step variable
1. State anxiety
2. Family characteristics
No of children at home
SES score
3. Child characteristics
No. of previous hospitalmuons
Gender of child
Age of child
4. Attachment
R
2
.03
06
13
2 1 "
3
1
1
2
F
.1
.5
.7
.61
df
1, 84
3, 82
6, 79
7, 78
B
-. 1 0
- 05
.13
- . 1 8
- . 1 1
- . 07
.28
Adjusted
Ri
.03
.02
.05
.13
Adj .
R
2
-change
03
.07
. 08"
"p < .01
412 Robinson, Rankin, and Drotar
80
Insecure
Fig. 2. Visitation rate as predicted by quality of attachment.
Consistent with the findings from the regression analysis, mothers who
reported their children displayed insecure attachment behaviors maintained a
significantly lower rate of visitation overall (Af = 56%, SD = 27) than parents
who reported that their children displayed secure attachment behaviors (M =
69%, SD = 26, t = 4.12, p < . 05). (See Figure 2.)
DISCUSSION
The major finding of the present study was that mothers with lower rates of
visitation to their hospitalized children also rated their children as displaying
insecure patterns of attachment. These findings are consistent with observations
made as early as 1953 when Prugh et al. noted that parents who visited their ill
children less frequently (below 30%) also displayed unsatisfactory relationships
with their children. However, to our knowledge, this is the first study that has
empirically demonstrated that security of attachment, which may reflect qualities
of the parent-child relationship (Ainsworth et al., 1978) predicts differences in
frequency of maternal visitation rates.
There are several possible explanations for these findings. Our results sug-
gest that attachment patterns that exist prior to hospitalization may influence
frequency of maternal visitation during hospitalization. It is relatively well docu-
mented that parentchild relationships characterized by insecure attachment may
reflect insensitive maternal responses to a range of infant distress cues
Hospitalization and Attachment 413
(Ainsworth et al., 1978; Belsky, Rovine, & Taylor, 1984). Thus, lower rates of
maternal visitation may reflect preexisting patterns of less than optimal mother-
child relationships (e.g., lower maternal sensitivity to the child's needs). On the
other hand, it is also possible that lower maternal visitation rates may reflect
maternal reactions to their infants' behaviors that are characteristic of insecure
attachments, especially avoidant attachments. Some mothers may have inter-
preted their infants' avoidant or "aloof" behavior as a sign that their children did
not need them or that their child was content to be left among strangers (e.g.,
nursing staff). The present study cannot distinguish between these two alterna-
tive explanations, either or both of which may have contributed to the relation-
ship between attachment and maternal visitation.
This research does not support the hypothesized comprehensive predictive
model, which postulated that maternal anxiety would be affected by SES, num-
ber of children at home, gender and age of the child, and the number of previous
hospitalizations (Alexander et al., 1986, 1988; Berenbaum & Hatcher, 1992;
Pmgh et al., 1953) and failed to corroborate previous findings (Alexander et al.,
1988; Freiberg, 1972; Prugh et al., 1953; D. Robinson, 1968) that state anxiety
in mothers of hospitalized children would predict hospital visitation. Differences
in methods, including the timing of anxiety measures and selection of partici-
pants could account for the lack of agreement with past research. For example,
all of the parents in this study were approached after the first 24 hours of
hospitalization, when anxiety levels are likely to be lower than at the time of
admission, and all had young children who were hospitalized for acute nonsurgi-
cal, time-limited procedures.
The lack of support for the proposed comprehensive model may also reflect
special characteristics of this particular setting that rendered the model less
sensitive to individual variations in maternal anxiety and visitation patterns. For
example, on this pediatric unit the nursing staff encouraged parents to room-in
with their children, provided free breakfast, and made private showers available
for parents only. Of the 86 mothers surveyed, 75 did room-in with their ill
children. Moreover, the children in our sample were hospitalized for acute ill-
nesses that required short-term hospitalization. Tests of the proposed comprehen-
sive model in a hospital setting that provides lower levels of support for parental
visitation, and where parental visitation patterns are more variable, or with
children who are hospitalized for more serious illnesses and extensive periods of
time, may reveal the influence of family supports and resources that were not
found in this study.
It is also possible that the hypothesized model, which was an initial attempt
to integrate a wide range of variables in our framework, needs further develop-
ment. One means of developing the model, especially in cases of children with
long-term or chronic illnesses, would be to assess, in greater detail, how family
resources (e.g., family income) and parental demands (e.g., needs of other
414 Robinson, Rankin, and Drotar
children at home) are stressed by the burden of a chronically ill child. Additional
family stress, especially in lower SES groups where resources are already ten-
uous, may contribute to a reduction in visitation and possibly contribute to poor
psychological outcomes for the ill child. Douglas (1975), in a longitudinal study,
and Quinton and Rutter (1976) found that children who were hospitalized multi-
ple times in early childhood displayed later behavioral disturbance, especially
children from lower SES family backgrounds. Therefore, an interesting, and
largely unexplained question is how family resources and SES contribute to
maternal visitation when a child is frequently hospitalized or admitted for exten-
sive hospitalization. Other measures of maternal psychological states (e.g., con-
fusion, anger, depression) associated with distress may also predict visitation
rates. Maternal distress induced by the hospitalization of a child and com-
pounded by younger maternal age, increased severity of the child's illness, and
greater experience with hospitalization (Berenbaum & Hatcher, 1992) may cause
mothers to avoid the hospital environment, therefore decreasing their emotional
discomfort, but reducing visitation rates.
On the other hand, it is possible that the model may be valid, but that some
of the specific variables used to operationalize the concepts are not sufficiently
sensitive. For example, we did not directly examine the relationship of the
families' proximity to the hospital to visitation rates. However, it should be noted
that greater than 80% of all pediatric patients admitted to this hospital live within
a 10- to 30-minute radius of the hospital. Nor did we directly measure maternal
opportunities for visitation. Although the number of children at home is an
indirect assessment of visitation opportunities, a more precise and extensive
evaluation (e.g., parental work schedules) would clarify this variable and its
impact on visitation. Furthermore, certain other variables, such as staff-parent
communication and perception of the parental role, were not assessed in this
study. Another difficulty is posed by the fact that 30% of the parents who were
eligible for the study did not elect to participate. Unfortunately, it was not
possible to obtain information concerning the nonparticipants. It is difficult to
determine what impact this may have had on the present findings.
The results of this study need to be interpreted cautiously in light of the fact
that a brief measure of attachment was used that needs further validation and
refinement, especially in light of the low internal consistency demonstrated in
this initial sample. Future refinement of the instrument could include the addition
of more items and measures of construct validity obtained by having mothers
complete the entire Attachment Q-sort prior to and/or several weeks after the
hospitalization of their child. Nevertheless, it should be noted that this brief Likert-
scale measure, which is quite feasible to use in a hospital setting, was the only
variable that demonstrated predictive utility in a test of the proposed model. Con-
sequently, this finding provides preliminary construct validity for this measure.
Future studies are needed to explore additional factors that predict parental
Hospilalization and Attachment 415
visitation in other populations such as children with chronic pediatric conditions,
especially those who need to be hospitalized for a long period over multiple
occasions. Populations in which predictive models of parental visitation should
be tested include technology-dependent children (Hamlett et al., 1994), children
who are admitted to pediatric rehabilitation hospitals for extended periods of
time, whose hospital stays are typically extended, whose conditions are typically
complex and chronic (Singer & Drotar, 1989), and children who have recurrent
hospitalizations.
The present findings have potential clinical implications. The finding that
mothers of insecurely attached children visit less indicates that such children
have less access to their major attachment figures at a time of significant stress.
In some instances this could serve to jeopardize an already stressed or problemat-
ic parent-child relationship, possibly creating additional apprehension on the
part of the child, and perhaps even progressively less visitation from parents.
Consequently, efforts should be made to identify parents who rarely visit their
children and encourage and support them to do so. When mothers display low
rates of visitation, risk factors associated with insecure attachment should be
considered as explanations (i .e., poor knowledge of caretaking skills (Egeland
& Farber, 1984) and maternal insensitivity (Ainsworth et al., 1978)), along with
environmental resource problems. Moreover, hospital staff may need to consider
special implications of patterns of attachment for the psychological development
of children who are technology-dependent, or require long-term and repeated
hospitalizations, as in the course of a chronic illness (Hamlett et al., 1994). In
such cases, preexisting patterns of insecure attachment could contribute to lower
rates of parental visitation, which in turn could reduce opportunities for parent-
child interactions in ways that eventually threaten the child's psychological de-
velopment. At present, very little is understood about the role of attachment in
the psychological outcomes of these special populations.
Finally, as greater numbers of hospitals allow unlimited visitation, pediatric
psychologists are afforded the opportunity to identify factors that influence ma-
ternal visitation and to determine how maternal visitation patterns influence other
clinically relevant outcomes such as length of stay. The present study identified
only one variable that significantly predicted maternal visitation, quality of at-
tachment. The identification of factors that predict maternal visitation provides
information that could be used to help hospital staff to better assist those mothers
who find it difficult to visit their ill children.
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