Journal of Pediatric Psychology, Vol. 22, No. 3, 1997, pp.

281-295

Supplemental Stimulation of Premature Infants:

A Treatment Model1

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John N. I. Dieter2 and Eugene K. Emory
Emory University

Received December 15, 1995; accepted April 1, 1996

Examined the human infant literature on supplemental stimulation to delineate a

course of intervention based no the ontogeny of the nervous system and the
impact that systematic stimulation may have on behavioral organization in the
premature infant. Effects of vestibular, tactile! kinesthetic, auditory, and oral
stimulation are discussed with respect to their similarity to the intra- or extra-
uterine environment. Long-standing theoretical and methodological problems
are discussed, and a "sequential multimodal treatment model" is introduced.

KEY WORDS: prematurity; stimulation; tactile; vestibular; kinesthetic.

Between 5 and 15% of all live births in the United States are premature (i.e., born
before 38 weeks of gestation). They are disproportionately high among African
American women with 18% of all live black births being premature. Only 8.5% of
live births to Caucasian women are preterm. African American neonates account
for 31% of all premature deaths (Emory, Hatch, Blackmore, & Strock 1993). The
etiology of prematurity is not fully understood. Preterm birth is related to fetal
abnormalities, maternal age and health, parity, and multiple births: other factors
include poor prenatal care, cigarette smoking, psychosocial stress, low education,
and socioeconomic status (SES) of the mother (Wittenberg, 1990).

'Supported by National Institute of Mental Health Fellowship 1 F3I MH11161-01 to John Dieter and
Grant ROI-HD28382 to Eugene Emory. The authors express their appreciation to Tiffany Field for
her thoughtful comments and suggestions.
2
AII correspondence should be sent to John Dieter, Department of Psychology, Emory University,
Atlanta, Georgia 30322.
281
OI46-8693/97rt)6<XM)281S12.50/0 © 1997 Plenum Publishing Corporation
282 Dieter and Emory

Numerous reports indicate that prematurity is associated with substantial

developmental impairment. Initial difficulties include problems with autonomic
control, state organization, and attention regulation (Als, 1986). More long-
standing problems include auditory and visual deficits and delays in cross-modal
transformations (Rose, Gottfried, & Bridger, 1978); abnormal reflexes (Howard,
Parmelee, Kopp, & Littman, 1976), inferior grasping and hand use; lower IQ,
language and reading difficulties, academic underachievement (Cohen, Parme-
lee, Beckwith, & Sigman, 1986); and behavioral problems such as hyperactivity
and internalizing disorders (Rose, Feldman, Rose, Wallace, & McCarton, 1992).

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SUPPLEMENTAL STIMULATION: AN OVERVIEW

In an effort to decrease the immediate adversities and developmental deficits

associated with prematurity, numerous researchers have investigated the effects
of various types of supplemental stimulation. The different forms of stimulation
have included vestibular, tactile, kinesthetic, auditory, oral, and various multi-
modal combinations. These interventions have been initiated to compensate for
environmental deprivation, or to accelerate the development of the premature
infant. A point of contention among the exponents of the various approaches has
been whether stimulation should attempt to capture elements of the intra- or
extrauterine environments (Cornell & Gottfried, 1976).
Advocates of vestibular stimulation generally view the premature infant as
an "extrauterine fetus" (Als, 1986) who has been denied the full benefits of the
vestibular stimulation inherent to the womb (Korner, 1990). Supplemental ves-
tibular stimulation has been provided through spinning hammocks (Neal, 1968),
rocking cribs (Van den Daele, 1970), oscillating waterbeds (Korner, Kraemer,
Haffner, & Cosper, 1975), and cradled rocking (Rice, 1977). Most proponents of
tactile stimulation maintain that its benefits arise from the touching inherent in
the mother-infant relationship (Korner & Thoman, 1972). Supplemental tactile
stimulation has included extra holding (Hasselmeyer, 1964), cephalocaudal rub-
bing (Solkoff, Yaffe, Weintraub, & Blase, 1969), gentle stroking (Kramer,
Chamorro, Green, & Knudtson, 1975), and passive touching (Jay, 1982). Kin-
esthetic stimulation, in the form of passive limb movements, is usually adminis-
tered conjointly with massage (Scafidi et al., 1986).
Exponents of auditory stimulation have taken both an intra- and extrauterine
approach to treatment. Auditory stimulation is usually a component of a multi-
modal protocol. Some investigators have presented recordings of heartbeat to the
preterm infant (e.g., Schmidt, Rose, & Bridger, 1980); others have used record-
ings of the mother's voice (e.g., Segall, 1972) or the live speech of the therapist
(e.g., Leib, Benfield, & Guidubaldi, 1980).
Oral stimulation facilitates nonnutitive sucking via a pacifier. This cost-
Supplemental Stimulation 283

effective method has proven useful for shortening the transition from tubal to
bottle feeding (Porter-Measel & Anderson, 1979); maturing the suck reflex
(Bembaum, Gilberto, Watkins, & Peckham, (1983); promoting oxygenation
(Burroughs, Asonye, Anderson-Shanklin, & Vidyasgar, 1978) and weight gain
(Field, et al., 1982); soothing preterm infants during invasive procedures (Field
& Goldson, 1984), and for regulating state (Gill, Behinke, Conlon, McNeely, &
Anderson, 1988).
Multimodal strategies have included various combinations of vestibular,
auditory, and/or tactile (-kinesthetic) stimulation. Although visual processing has

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been examined in premature infants (e.g., Allen & Caputo, 1986), very few
multimodal (and apparently no unimodal) intervention studies have included
visual stimulation. A common rationale for omitting visual stimulation is that
this system is not fully developed at the time when most preterm infants are
born.
Across studies there is considerable evidence that supplemental stimulation
produces positive effects on development which include decreased apnea, more
stable organization of state, increased weight gain, a decrease in abnormal re-
flexes, superior sensory and motor performance on behavioral assessments, and
earlier hospital discharge (Field, 1980, 1988). Although the effects of stimulation
upon later neurological and psychological development have been questioned
(e.g., Russman, 1986), Harrison (1985) reported increased Bayley scores on
follow-up, accelerated social development, and higher infant intelligent scores.

Methodological Concerns

Supplemental stimulation research arose primarily from a desire for inter-

vention. Considering the developmental deficits associated with prematurity, a
clinically oriented approach is understandable, however, numerous authors have
criticized research on supplemental stimulation because it lacks theoretical direc-
tion and sound experimental methodology (Ottenbacher et al., 1987).
Subject Variables. The most persistent criticisms with regard to subjects
include the use of small samples, the failure to include sick preterms, and the
means with which subjects are assigned to experimental and control conditions
(Harrison, 1985). An evaluation of recent studies indicates that efforts have been
taken to correct these shortcomings. A problem that persists is that the range of
gestational ages and birth weights which compose most samples is quite broad.
These samples are generally treated as homogeneous when statistical analyses
are conducted. In 14 investigations in which either tactile or vestibular stimula-
tion (the most common forms of intervention) was the predominant treatment,
the average range of gestational ages across experimental and control subjects
was almost 5'/2 weeks. Within-sample birth weights were also quite disparate
284 Dieter and Emory

and varied across subjects by over 700 grams. These variations across studies
make comparisons fairly difficult, and fail to consider maturity as a factor affect-
ing the outcome of supplemental stimulation.
Design Issues. Two group designs have been the standard. In general,
experimental groups receive supplemental stimulation and control groups do not.
Efficacy has been evaluated with either pre- and posttests, or posttest-only
evaluations. Dependent variables commonly include growth measures, activity
levels, sleep-wake organization, and performance on developmental assess-
ments. Independent variables have been defined along four dimensions; the

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sensory modalities stimulated: the form of stimulation; the use of uni- or multi-
modal stimulation, and the time of onset, intensity, periodicity, frequency, and
duration of stimulation. The most common approach to analysis is the evaluation
of the experimental and control subjects on a number of preselected variables
(e.g., weight gain). Most researchers utilize various forms of analysis of variance
and covariance which are then supplemented by planned comparisons. Cornell
and Gottfried (1976) raised concerns about the overreliance upon two-group
pre- and posttreatment designs: Specifically, they argued that standardized pre-
treatment assessments (e.g., the Brazelton) can serve as contaminating stimula-
tion. As an alternative, they recommended the four-group design of Solomon and
Lessac (1968) because it combines the posttest-only and pre- and posttest ap-
proaches. While a four-group design might prove fruitful, it appears that the
recommendation of Cornell and Gottfried (1978) has not been followed.
Procedural Issues. Others report that common procedural inadequacies in-
clude a reliance upon short-term follow-ups, and a lack of attention to individual
needs (Field, 1980). In those cases when follow-up measures are obtained, the
follow-up has been limited to the first year. A recent advance in this area has
been the introduction of home-based stimulation programs (Resnick, Armstrong,
& Carter, 1988) which include longer assessment periods. Field (1980) criticized
individualized approaches to stimulation for research purposes. In contrast, Les-
ter and Tronick (1990) proposed that an individual infant's reaction to stimulation
can be used to guide intervention (e.g., signs of stress or avoidance). Although
this suggestion is important for clinical efforts, this approach would confound
uniform administration of treatments across research subjects. Another pro-
cedural criticism is that stimulus parameters have often been arbitrarily selected
(Ross, 1984). As Rose, Schmidt, Riese, and Bridger (1980) argue, "The design
of intervention programs is complicated by the fact that there is no compelling
rationale for selecting any specific type, quality, or patterning of stimulation"
(p. 417). Furthermore, when arbitrarily selected protocols demonstrate positive
results, they are often adopted without additional assessment.
Theoretical Concerns. While the criticism of Rose et al. (1980) may be
overstated, it does highlight the need for more theoretically oriented research.
The relevant theoretical issues can be grouped under three broad concerns:
Supplemental Stimulation 285

Impact of Adverse Stimulation in the Early Preterm Neonate's Environment.

This issue relates to the integrity of the premature nervous system, environment
of the neonatal intensive care unit (NICU), and the impact of premature delivery
on social-emotional development. There has been considerable debate about
whether the days or weeks that most premature infants spend in the incubator are
harmful or helpful with respect to behavioral organization (Tronick, Scanlon, &
Scanlon, 1990). The NICU environment can have negative effects (e.g., Law-
son, Daum, & Turkewitz, 1977) although researchers have not documented
definitively whether developmental deficits relate to sensory deprivation, over-

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stimulation, or a pattern of inappropriate stimulation.
Consensus Over Which Underlying Mechanisms Are Responsible for Im-
provement. Occasional reference to the work of Hebb (1947) and Piaget (1952)
indicates that stimulation may facilitate the development of associative cortical
tissue via sensory-motor activation (Wright, 1971). Some support for this view
comes from the work which examines the effects of environmental deprivation
and enrichment on the neurochemistry and behavior of rodents and primates
(e.g., Harlow, 1958; Schanberg, Evoniuk, & Kuhn, 1984). However, others
object to the use of animal "brain plasticity models" to interpret the findings of
human stimulation programs. (Lester & Tronick, 1990). Another important de-
bate is whether the benefits of intervention arise from techniques which arouse or
soothe the infant. Many investigators maintain that the benefits of intervention
come from its effect upon behavioral state (e.g., Horowitz, 1990; Tronick et al.,
1990). However, the relationship between modality of stimulation and its effect
on the preterm infant is not clear-cut. The complexity of this debate can be
illustrated by the example of weight gain, a common benefit of supplemental
stimulation. Using very different approaches both Field et al. 1986 (cephalocau-
dal massage) and Field et al. (1982) (oral stimulation via a pacifier) found that
their experimental subjects gained more weight than controls. These similar
findings were surprising given that tactile stimulation is thought to produce
alertness, while oral stimulation usually soothes infants and promotes quiet atten-
tiveness. Uvnas-Moberg, Wildstrom, Marchini, and Winberg (1987) has specu-
lated about why different forms of supplemental stimulation enhance growth.
They suggest that stimulation such as massage and nonnutritive sucking activate
the vagal nerve which in turn promotes the release of gastrointestinal (GI) hor-
mones such as gastrin and cholecystokinin. The effect of these hormones in-
cludes the stimulation of GI motoric and secretary activity, the growth of the GI
tract, the promotion of glucose-induced insulin release, and the enhancement of
the infant's energy economy. Unvnas-Moberg et al. (1987) hypothesized that
sucking enhances GI functioning through the activation of sensory nerves in the
oral mucosa which stimulates the vagal nerves. Tactile stimulation is thought to
promote vagal mediation via the direct stimulation of peripheral nerves such as
the sciatica.
286 Dieter and Emory

An Absence of Consensus Over Which Sensory Modality Should be Stimu-

lated, and When and How Much Intervention is Appropriate. The selection of
which sensory modality to stimulate and the course that intervention should take
has been either an arbitrary decision, or has been based upon whether the investi-
gator believes that stimulation should mimic the intra- or extrauterine environ-
ments. Korner (1984) has maintained that initial stimulation should be similar to
that experienced in the womb (e.g., oscillations that match the frequency of the
mother's respiration). As an added but related dimension, Korner (1990) and
Greenough (in Rose, 1984) suggest that stimulation should reflect the ontogeny

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of the senses. However, no specific details have been provided as to how this
suggestion might be accomplished.

THE POTENTIAL ROLE OF ONTOGENY

IN SUPPLEMENTAL STIMULATION

When reference to a possible relationship between ontogeny and supple-

mental stimulation is made (e.g., Greenough in Rose, 1984), the seminal work of
Gottlieb (1971) is most often cited. Gottlieb proposed a sequential development
of sensory systems which was essentially invariant across mammalian and avian
species. Based upon work on chick embryos, and later synthesized with findings
from other research, he proposed a chronological sequence of sensory develop-
ment consisting of cutaneous/tactile, vestibular, auditory, and visual. Further-
more, sensory stimulation plays a major role in regulating "species-typical"
maturation, especially with development of perceptual abilities. Gottlieb pro-
posed that variation in the developmental rate in any one system could alter the
rate in another system.

An Intervention Caveat

Turkewitz and Kenny (1985) warned that supplemental stimulation of im-

mature sensory systems has been shown to have detrimental effects on more
mature systems in animals (e.g., surgically opening the eyes of rat pups prior to
age limited the rats' ability to differentiate scent and produced abnormalities in
homing patterns). These authors proposed that the sequential development of
sensory functions provide a basis for their organization and integration. Stimula-
tion of a less mature system creates a condition of sensory competition which
disrupts development. In an investigation of ducklings, Gottlieb, Tomlinson, and
Radell (1989) found that premature experience with pattern vision suppressed
these animals' learning of a maternal call.
Findings on full-term healthy human newboms further indicates that supple-
Supplemental Stimulation 287

mental simulation that is inappropriate to a system's level of maturity is detri-

mental. Using a multimodal approach which consisted of vestibular (a spinning
hammock), auditory (stimulated heartbeat), and tactile (massage) stimulation,
Koniak-Griffin and Ludington-Hoe (1987) found that after 1 month of daily
treatment (lasting hours at a time), the performance by the treated infants on the
Brazelton Scale (Brazelton, 1973) showed less mature orientation, motor, and
state regulation behaviors than the control group. The authors concluded that
while attempts to provide stimulation that is similar to that experienced in the
womb might be beneficial to the immature CNS of the preterm, such efforts

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appear to retard the development of full-term infants.

GUIDELINES FOR INTERVENTION

As indicated, there is little current agreement across investigators about the

course that premature infant stimulation should take. Authors seem to be leaning
towards the direction that the type of stimulation may be less important than
whether it promotes state regulation (Horowitz, 1990). This is typified by Rose's
(1984) statement that "intervention in any modality can provide the 'fuel for
organization'" (p. 97). However, others canvas for a unimodal approach (in
order to avoid overstimulation, e.g., Lester & Tronick, 1990) and because pre-
terms lack multimodal contingencies (Turkewitz & Kenny, 1985), and a few
argue for a specific treatment (e.g., Korner for vestibular). The suggestion of
Thoman, Ingersoll, and Acebo (1991) that stimulation should be adapted to the
individual needs of the infant offers an important alternative to how one might
plan intervention. The best approach towards intervention may be one that avoids
overstimulation of the visual and auditory systems and focuses instead upon
more mature systems (e.g., tactile and vestibular).
Potential clinical guidelines for the supplemental stimulation of preterms
may lie in an examination of the effects the different treatments have upon the
behavioral organization of the infant. The crucial factor may be how well the
infant tolerates stimulation in relationship to its gestational age and health status.
Although little research has been directed towards confirming this hypothesis,
the findings of representative studies of vestibular, auditory, oral, and tac-
tile/kinesthetic stimulation do delineate possible treatment strategies.

Vestibular Stimulation

Across full-term and preterm infants, vestibular stimulation (e.g., cradled

rocking, spinning hammocks, oscillating waterbeds) reduces state level. Further-
more, in full-term infants, the reduction of activity and distress appears to be a
288 Dieter and Emory

positive function of the speed and amplitude with which stimulation occurs (Van
Den Daele, 1970). Using rocking boxes, Pederson and Ter Vrugt (1973) found
that higher rocking amplitudes and frequencies soothed infants regardless of their
initial state. Often infants who were awake and restless would be in quiet sleep at
the conclusion of the 15-minute treatment interval.
In premature infants, Korner and associates found that protracted waterbed
treatment had profound effects upon behavioral stability across the awake and
sleep domains. Beginning when preterm infants were 4 days old, and continuing
vestibular stimulation (i.e., head-to-toe oscillations of 12-14 cpm, amplitude

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2.4 mm) until the 34th or 35th conceptual week, Korner and Schneider (1983)
observed reduced irritability and/or hypertonicity, fewer and shorter incidences
of crying, and less tremulousness and frenetic activity. Furthermore, these in-
fants were twice as often in a visually alert inactive state. Likewise, Korner,
Ruppel, and Rho (1982) found that 4 days of continuous waterbed stimulation
significantly reduced the number of mixed or transitional states in preterm infants
sick with respiratory distress syndrome. These preterms also fell asleep faster,
exhibited greater and longer durations of quiet and active sleep, and demon-
strated increased periods of rapid eye movement. From her extensive research
program, Korner hypothesized that vestibular stimulation reduces the intensity of
internal needs (e.g., crying or state disorganization) which permits the infant to
turn outward and attend to external events (through the promotion of quiet
alertness).
Although tentative, and in need of experimental confirmation, higher rock-
ing speed (e.g., 25-30 cpm; Kramer & Pierpont, 1976) may produce a state of
"restorative quiescence" which should promote the stability of state across the
sleep and awake domains, as well as help preserve physiological reserves. As the
premature infant exhibits greater state organization (as assessed through formal
behavioral observation), a slower rocking speed (e.g., 12-16 cpm; Korner &
Schneider, 1983) could be initiated in an effort to enhance the infant's interface
with the environment through the promotion of quiet alertness. Such a state
would be expected to increase the frequency of integrated sensory/social experi-
ences which underlie early learning.

Auditory Stimulation

Preterm unimodal auditory stimulation has not been extensively studied.

The investigation of Schmidt et al. (1980) appears to be the sole experiment to
examine the impact of auditory stimulation on state. In preterm infants who had
not received prior supplemental stimulation, a one-trial presentation of heartbeat
increased the duration of sleep states by decreasing the length of the first active
sleep epoch and increasing the duration of the first quiet sleep epoch.
Supplemental Stimulation 289

As is the case with vestibular stimulation, auditory intervention also seems

to enhance environmental adaptation. Using a methodology offered by Katz
(1971), Segall (1972) concluded that several weeks of auditory stimulation (a
tape-recording of the infant's mother reading a prepared monolog) enhanced
adaptation as demonstrated by cardiac response. Experimental subjects showed a
greater amount of cardiac acceleration (generally viewed as an avoidance re-
sponse) in reaction to a novel stimulus (i.e., white noise), and greater cardiac
deceleration (accepted as an orienting response) to their mother's voice.
Although in need of empirical examination, the similarity between auditory

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and vestibular stimulation may lie in their rhythmic patterning. The fact that all
of the major forms of supplemental stimulation (vestibular, auditory, oral, tac-
tile/kinesthetic) involve repetition has led T. Field (personal communication,
January 24, 1996) to suggest that rhythmic patterning may be a common thera-
peutic parameter.

Oral Stimulation

Oral stimulation focuses upon the use of pacifiers to promote nonnutritive

sucking (NNS). Nonnutritive sucking also has a substantial effect upon state and
behavioral organization. As with vestibular and auditory stimulation, NNS in-
creases restfulness and decreases activity (Field et al., 1982). Woodson, Drink-
win, and Hamilton (1985) showed that ad lib. access to a pacifier increased the
time term and preterm infants spent in quiet states; decreased the number of state
transitions, and reduced motoric output.
As previously indicated, the rhythmic pattern of oral stimulation may under-
lie such immediate benefits as increased quiescence. In addition, there may be an
inherent "hedonic" quality to sucking (Crook & Lipsitt, 1976). Although the work
of Lipsitt and his colleagues focuses on the pleasures of nutritive oral stimulation
(i.e., a pacifier delivering sucrose solution), their findings provide further evi-
dence that sucking can have a significant physiological impact beyond the area of
the mouth (e.g., on heart rate, vagal tone, respiration, and gustatory functioning;
Lipsitt, Reilly, Butcher, & Greenwood, 1976; Porges & Lipsitt, 1993).

Tactile!Kinesthetic Stimulation

Across investigations, tactile/kinestnetic (T/K) protocols have been quite

similar and usually reflect minor derivations of the method introduced by White
and Labarba (1976). Tactile (rubbing and/or stroking) and kinesthetic (passive
flexing and extending of limbs) stimulation are administered sequentially (e.g.,
first tactile, then kinesthetic) during a session and the procedural sequence is
often quite precise (e.g., Field et al., 1986).
290 Dieter and Emory

Early studies of tactile-only stimulation failed to include formal state anal-

ysis. Regardless, there is evidence that the benefits obtained from tactile inter-
vention involve heightened alertness and increased activity. Using a procedure
consisting of nonrhythmic massage of the neck, back, and arms (5 minutes,
each hour of the day for 15 days), Solkoff et al. (1969) found that stimulated
infants were more alert and active than controls. Similarly, Adamson-Macedo
(1985) found that providing cephalocaudal massage to sleeping very low birth
weight (VLBW) preterms produced a state change which ranged from drowsy
to alert. On Brazelton exam, Solkoff and Matuszak (1975) reported that prema-

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ture infants who had received 1,200 minutes of extra stroking (7'/2 minutes per
hour for 16 hours per day for 10 days) were more alert and changed state more
often.
In two recent investigations, Scarfidi et al. (1986, 1990) examined the effect
of T/K on state. In both studies, it was found that during T/K stimulation,
preterms became more active as evident by significant increases in multiple limb
movements and facial expressions. Unlike vestibular and oral stimulation, T/K
did not appear to promote an inactive alert state.
In posttreatment examinations of behavioral organization, Scafidi et al.
(1986) demonstrated that stimulated infants exhibited a greater amount of awake
time. Once again, T/K did not enhance periods of inactive alertness. Overall,
T/K appears to energize the infant towards activity: Scafidi et al. (1986) found
that treated preterms exhibited an active alert state 14% of the time, while
nonstimulated infants failed to show such a state during observation.
The persistent finding that during massage infants often become alert and
exhibit increased motor activity raises the question of whether T/K should be
administered to preterms who are very sick or who are state disorganized. Al-
though the impact of T/K on state during periods of treatment and nontreatment
needs further investigating, it is clear that T/K can be administered to preterms of
younger gestational ages (e.g., 23 weeks) and lower birth weights (e.g., 630
grams) as long as they are clinically stable (Acolet et al., 1993); likewise,
Wheeden et al. (1993) found that medically stable preterms who were exposed to
cocaine in utero responded positively to T/K (i.e., enhanced weight gain, fewer
postnatal complications, fewer stress responses).
Along with such benefits as enhanced weight gain, T/K has been found to
have positive effects upon the biochemistry of premature infants. Kuhn et al.
(1991) reported preterms who received 10 days of T/K demonstrated significant
increases in urinary excretion of norephinephrine and epinephrine. These find-
ings were interpreted as indicating maturation of the sympathetic nervous sys-
tem. Massage has also been shown to reduce plasma cortisol levels. This led
Acolet et al. (1993) to conclude that the procedure is both pleasurable and
valuable for ameliorating pain. More recently, Moyer-Mileur, Luetkemeler,
Broomer, and Chan (1995) found that a 4-week kinesthetic procedure (i.e.,
Supplemental Stimulation 291

passive limb movements) led to increases in bone width, mineral density, and
content.

A PRESCRIPTION FOR STIMULATION OF PREMATURE INFANTS

The differential effects which the various interventions have upon behav-
ioral state point to a "sequential multimodal approach" to the supplemental
stimulation of preterms. The specific sequence and duration of each treatment

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component would be determined by the status of the neonate, and its reaction to
each stimulation modality (determined by formal behavioral assessment). In
consideration of the problems that premature infants commonly encounter, the
goals of this approach might include (a) promoting state regulation, (b) facilitat-
ing the infant's interface with the environment, (c) enhancing general neuro-
behavioral development. What is unique about this hypothetical model is that it is
directed towards clinical treatment. Unlike most research paradigms, the course
of intervention does not rely upon the infant having reached a clinically stable
state: In fact, the early stages of treatment are aimed at assisting in achieving
such ends.
Tronick et al. (1990) reported that extremely low birth weight preterms are
very disorganized in all aspects of behavioral functioning. As these infants
become more homeostatic they predominately exhibit a persistent state of still
sleep which the authors have christened "protective apathy." It is argued that this
state protects physiological reserves, aids in the recovery from the stressors of
prematurity and the NICU, and leads to the emergence of differentiated behav-
ioral states. Therefore, for premature infants who are suffering from significant
behavioral disorganization and ill health, those forms of intervention that soothe
and promote deeper and restorative sleep states might first be initialed. Potential
regimes could include the unitary or conjoint use of auditory stimulation and
stable or oscillating waterbed stimulation. Since findings from full-term infants
suggest a positive relationship between speed of rocking and level of quiescience
(Van Den Daele, 1970), research is necessary to determine if less stable preterms
can tolerate higher oscillation rates (e.g., 25-30 cpm) and whether such speeds
promote state organization.
Once homeostasis is achieved, slow oscillating (e.g., 12-16 cpm) waterbed
stimulation should further facilitate the preterm's interface with the environment
through the promotion of quiet alertness and visual pursuit. This stage might also
introduce oral stimulation since it too promotes environmental engagement and
has the added benefit of enhancing weight gain.
Once increased alertness is well-tolerated, T/K stimulation should be initi-
ated. Besides the further promotion of weight gain, it has been argued that there
is an inherent therapeutic quality to touch (Montagu, 1978). In addition, since
292 Dieter and Emory

T/K elicits greater activity, it may be superior to the other approaches for enhanc-
ing motor development.
A preterm's point of entry into this treatment model would depend upon an
assessment of state regulation: For example, a very unstable infant might begin
with unitary auditory stimulation, whereas a more stable preterm might begin
with slow oscillating rocking or T/K. Furthermore, the infant's reaction to each
treatment stage would determine its progress along the algorithmic pathway: An
adverse reaction to a newly introduced stage would result in a return to the
previous form(s) of supplemental stimulation (or in more serious cases, no stimu-

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lation at all).

Comment and Future Directions

In light of the considerable evidence that supplemental stimulation pro-

grams are effective, it is surprising that the number of published reports on this
topic has decreased in the last decade. Theoretical and methodological problems
probably contribute to the apparent reduction in interest. Regardless, the demon-
strated decrease in length of hospitalization, enhanced development, and poten-
tial financial savings should eventually capture the interest of the cost-conscious
health care community. Moreover, supplemental stimulation of preterms infants
in a salient research avenue for furthering our knowledge of the relationship
between human brain plasticity and the impact of the environment on develop-
ment.
At present, we have undertaken a direct comparison of vestibular and tac-
tile/kinesthetic stimulation on premature infants. Specifically, we are attempting
to determine if fast vestibular stimulation (i.e., waterbed oscillations of 25-30
cpm) promotes more frequent and deeper sleep states; slow vestibular stimulation
(i.e., 12-16 cpm) increases periods of quiet alertness; and if tactile/kinesthetic
stimulation (massage/passive limb movement) promotes alertness and motoric
output. Support for these hypotheses will delineate the important components of
the treatment model and lay the groundwork for its application with unstable or
ill premature infants. We feel an important part of this effort is to determine if the
three treatment approaches have differential effects upon development.

REFERENCES

Acolet, D., Modi, N., Giannakoulopoulos, X., Bond, C , Weg, W., Low, A., & Glover, V. (1993).
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