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Examining parent responsiveness to sensory reactivity and regulation cues of infants with developmental risk factors

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Examining parent responsiveness to sensory reactivity and regulation cues of infants with developmental risk factors

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Content Copyright 2023 Emily Campi

EXAMINING PARENT RESPONSIVENESS TO SENSORY REACTIVITY AND
REGULATION CUES OF INFANTS WITH DEVELOPMENTAL RISK FACTORS
by
Emily Campi

A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(OCCUPATIONAL SCIENCE)

August 2023

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Acknowledgements
I would like to extend my sincerest gratitude to my advisor and dissertation committee.
To Dr. Grace T. Baranek: thank you for the constant support, encouragement, and opportunities
for professional and personal development. You are an incredible mentor and leader, and I am so
grateful for this opportunity to learn from you. To Drs. Dorian Traube, John Sideris, Mary
Lawlor, and Linda Watson: I have learned so much from all of you throughout this process and
greatly appreciate your time spent answering questions, reviewing my written work, and
discussing ideas. Thank you to Drs. Samia Rafeedie, Alison Cogan, and Leah Stein Duker, who
were the first to encourage me to consider pursuing a PhD. Thank you to all those who have
mentored me – I hope to be half the mentor you are to my own future students.
I would like to sincerely thank those who dedicated time and energy to complete
secondary article screening: Elizabeth Choi, Elizabeth Fey, Ayiana Saunders-Newton, Serg Lam,
Brett Landin, Natasha Hikita, and Michelle Waters. A huge thank you especially to Elizabeth
Nye, who approached article screening and video coding with passion, energy, and dedication
throughout the progression of these dissertation studies.
Thank you to my parents and sister for teaching me the value of hard work, integrity, and
not taking myself too seriously. Thank you to my whole family for the love, encouragement, role
modeling, and support throughout my life, and especially during this wild academic journey. I
would also like to thank Faris Sweiss for all the prayers, dinners delivered, breaks from work,
and unending support.
Thank you to my work friends who became lifelong friends throughout this journey.
Thank you to Allison Phillips, Emily Sopkin, Savannah Gluck, Julia Lisle, Elizabeth Choi-Tucci,

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Miranda Donnelly, and so many others for the camaraderie, constant support, outdoor lunch
breaks, and much-needed comedic breaks.
I would also like to acknowledge the families who participated in all three of the studies
from which data were drawn for this work. Thank you for the time, energy, and windows into
your world that you chose to share with our team.
Acknowledgement of Funding Sources: I would like to acknowledge the funding sources for
the newly collected data for this dissertation: University of Southern California Center for the
Changing Family Student Research Grant and the Mrs. T.H. Chan Division of Occupational
Therapy and Occupational Therapy Margaret Rood Dissertation Award. Additionally, extant data
used in these studies was drawn from a larger project funded by the NIH/Eunice Kennedy
Shriver National Institute of Child Health and Human Development (R21HD091547).

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Table of Contents
Acknowledgements..........................................................................................................................ii
List of Tables..................................................................................................................................vi
List of Figures................................................................................................................................vii
Overall Abstract............................................................................................................................viii
Chapter 1: Background and Introduction.........................................................................................1
Sources of Developmental Risk.................................................................................1
Sensory Reactivity and Regulation in Infancy...........................................................3
Parent Responsiveness to Infant Cues........................................................................4
Understanding Parent Responsiveness across Groups..............................................6
Parent Responsiveness to Sensory Reactivity and Regulation..................................9
Conceptual Framework............................................................................................10
Present Studies.........................................................................................................15

Chapter 2: Systematic Review of Parent Responsiveness.............................................................17
Abstract....................................................................................................................17
Background and Introduction..................................................................................17
Method.....................................................................................................................21
Results.....................................................................................................................26
Discussion................................................................................................................49

Chapter 3: Measurement Development for Parent Responsiveness to Sensory
Reactivity and Regulation Cues.................................................................................52
Abstract....................................................................................................................52
Background and Introduction..................................................................................52
Method.....................................................................................................................56
Results.....................................................................................................................59
Discussion................................................................................................................67
Chapter 4: Validating the New Measure of Parent Responsiveness..............................................70
Abstract....................................................................................................................70
Background and Introduction..................................................................................70
Method.....................................................................................................................74
Results.....................................................................................................................81
Discussion................................................................................................................90
Chapter 5: Conclusion....................................................................................................................95
Research Implications..............................................................................................95
Conceptual Implications...........................................................................................96
Future Directions.....................................................................................................98
Conclusion...............................................................................................................99

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References....................................................................................................................................100
Appendices...................................................................................................................................152
Appendix A: Study 1 Search Strategy...................................................................152
Appendix B: Study 1 Full-Text Screening Decision Guide...................................158
Appendix C: Additional Themes Emerging from Expert Interviews....................160
Appendix D: New Scheme Coding Manual...........................................................163

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List of Tables
Table 2.1 Examples of key search terms......................................................................................22
Table 2.2 Identified dimensions of parent responsiveness with associated citations...................33
Table 3.1 Strengths and challenges of the existing measure of parent responsiveness and
solutions integrated in the new measure.......................................................................................66
Table 4.1 Descriptive data on demographic and clinical characteristics of the sample...............75
Table 4.2 Internal consistency values across coded video segments............................................82
Table 4.3 Inter-rater reliability by video segment........................................................................82
Table 4.4 Comparison of characteristics of interest within Triad A............................................84
Table 4.5 Comparison of characteristics of interest within Triad B............................................86
Table 4.6 Comparison of characteristics of interest within Triad C............................................88

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List of Figures
Figure 1.1 Conceptual model depicting parent responsiveness as it is influenced by risk
group and parent, infant, and environmental characteristics......................................................14
Figure 2.1 Decision tree number 1 for age inclusion criteria during title and abstract
screening.....................................................................................................................................23
Figure 2.2 Decision tree number 2 for primary focus on parent responsiveness inclusion
criteria during title and abstract screening..................................................................................24
Figure 2.3 Consort diagram demonstrating the article selection process...................................27
Figure 2.4 Percentage of articles endorsing each dimension by location of definition
within the article.........................................................................................................................28
Figure 2.5 Conceptual diagram of the definition of parent responsiveness...............................33

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Overall Abstract
Parents are widely known to be primary caregivers and important attachment figures for
their children, thereby substantially influencing their children’s development, especially during
infancy and toddlerhood when children are completely dependent upon adult care for all daily
occupations. Parent responsiveness to their infants’ cues is an important component of parenting
behavior, given that infants and toddlers learn pragmatic and social-emotional skills as a result of
back-and-forth interactions with their parents. Additionally, parent responsiveness is known to
promote some positive developmental outcomes. There are several important sources of
developmental risk for which parent responsiveness may be a resilience factor. First, infants at
elevated likelihood of autism may benefit from parent behavior that is responsive to potentially
ambiguous or less frequent cues resulting from the early signs of autism. Second, infants whose
parents lacked good parenting role models, such as those with foster system history, could
benefit from parenting behavior that promotes social-emotional development through
responsiveness. However, this construct has been less studied in populations at such elevated
likelihood of suboptimal infant development due to social determinants of health (SDH). Given
potentially similar presentations among infants at elevated likelihood autism and those with
social-emotional challenges due to SDH, certain parent responsiveness behaviors may be similar
across these populations. However, no study to date has examined similarities and differences in
parenting behavior in parents of infants at elevated likelihood of autism versus suboptimal
development due to SDH. The purpose of these dissertation studies was three-fold:
1. To establish a comprehensive definition of parent responsiveness across existing
literature.
2. To adapt a measure of parent responsiveness for applicability across populations.

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3. To test the new measure.
Study 1 was a systematic review of the literature on parent responsiveness to their
infants’ cues when infants were 6-18 months old. Articles were identified from several relevant
databases using search terms related to parent responsiveness and infant age. The initial search
returned 18,978 unique articles, 463 of which were included in the final review. Definitions of
parent responsiveness used in each article were extracted and thematically coded to yield a
comprehensive, multidimensional definition of this important construct.
Study 2 included (a) focus groups and individual interviews based on the definition
identified in Study 1 and (b) measure adaptation. Focus groups or interviews were conducted
with three distinct groups of experts:
1. Researchers with demonstrated experience researching with parents who are former
foster youth.
2. Clinicians with at least one year of experience working with this population.
3. Experts by experience who themselves were parents and spent time in foster care as
children.
Interviews determined that many of the dimensions of parent responsiveness identified in Study
1 were relevant to this unique population and that there were a few additional dimensions to
consider.
Study 3 included pilot testing of the new measure with former foster youth (n=3) and
reliability and validity testing of the new measure with an extant dataset collected from (a)
parents of infants at elevated likelihood of autism and (b) parents of children with no known
developmental risk. Additionally, case studies were presented to compare profiles of parent
responsiveness, parent stress, infant sensory reactivity, and infant cognition across groups.

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The development of a measurement tool for examining the key dimensions of parent
responsiveness is useful for research in the areas of infant development with elevated likelihood
of autism or suboptimal development due to SDH. These studies contributed to understandings
of parent responsiveness in various developmental risk groups. The measure developed through
these studies lays the foundation for examining parent responsiveness in a nuanced way across
the groups studied and others. Most importantly, there are growing bodies of literature on
parenting interventions for infants at elevated likelihood of autism and infants whose parents
have foster system histories. The new measurement tool that resulted from these studies will
serve as a foundation for examining commonalities and differences in parent responsiveness
across groups and identifying predictors of positive outcomes with implications for intervention
targets, thereby promoting interdisciplinary sharing of knowledge to ultimately strengthen the
body of research around supporting parents of infants at risk of suboptimal developmental
outcomes.

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Chapter 1: Background and Introduction
The first two years of life are a period of exponential infant development across domains
(Hadders-Algra, 2018; Kent, 2022) and adult development of the parenting role and associated
routines, skills, and practices (Horne et al., 2005; Levin & Helfrich, 2004). Infant experiences
during this crucial developmental period have substantial impacts on a child’s later social-
emotional, motor, and other behavioral outcomes (Hentges et al., 2019; McEwan et al., 1991;
Williams et al., 2017). Parents are often the gatekeepers for their infants’ experiences due to the
high level of dependence infants have on their parents and the common role of the parent as a
primary attachment figure. Thus, parents, and the manner in which they scaffold infant
experiences, may substantially influence infant development (Neel et al., 2019; Stack et al.,
2010). The term “parent” was used throughout this dissertation to refer to the child’s primary
care provider; however, “caregiver” was sometimes used with reference to specific studies that
included a variety of care-providing adults.
Sources of Developmental Risk
Given the fast pace and cascading nature of development during infancy and beyond,
there are many potential perturbations to typical development in this period of life. These
dissertation studies emphasized two distinct sets of developmental risk factors in infancy: factors
that indicate elevated likelihood of autism versus suboptimal development due to SDH related to
parental history of foster care. These risk factors, while distinct, may yield similar behavioral
manifestations in infants due to the social and sensory regulatory early signs of autism (Baranek
et al., 2022) and the social-emotional signs of poor infant mental health (Zhang et al., 2022).
Thus, these two unique populations may benefit from cross-examination of constructs that are
often negatively impacted for both groups.

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Factors Indicating Elevated Likelihood of Autism. Factors indicating elevated
likelihood of autism have been commonly examined in social communication and sensory
reactivity and regulation (SRR) domains, given that early signs in these domains were predictive
of later autism diagnosis in a community sample of infants (Baranek et al., 2022). Factors that
indicate elevated likelihood of autism, such as delayed gesture and language development,
limited eye contact, and delayed or avoidant responses to sensory stimuli, are often detected via
screening tools implemented at 18- and 24-month well-baby appointments (AAP, 2006).
However, these signs may be apparent in infants and influential on a family’s daily routines and
experiences as early as seven months of age (Sacrey et al., 2015; Zwaigenbaum et al., 2015).
Some of these early signs of elevated likelihood of autism, especially differences in responses to
sensory stimuli, begin a developmental cascade of symptoms that later constitute a diagnosis of
autism or other neurodevelopmental disorders (Baranek et al., 2018).
Social Determinants of Health Related to Suboptimal Developmental Outcomes.
Aside from factors that indicate elevated likelihood for autism, many contextual factors can also
put infants at risk for suboptimal developmental outcomes across domains. Specifically, parents
whose own childhoods involved abuse, trauma, and/or foster care placements may have children
who are at elevated likelihood of experiencing these same adverse events, in addition to
suboptimal behavioral and social-emotional outcomes as a result of negative parenting practices,
mental health challenges, and negative parenting role models (Briggs et al., 2014; Folger et al.,
2017; Geiger & Schelbe, 2014; Radey et al., 2016; Schelbe & Geiger, 2017). The cycle of
adverse childhood experiences and poor developmental outcomes is perpetuated through
difficulties with parenting skills that result from lack of parenting role models (Radey et al.,
2016), parents’ own social-emotional challenges (Geiger & Schelbe, 2014; Schelbe & Geiger,

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2017), and other stressors, including domestic violence and socioeconomic disadvantage (Barth
et al., 2010; Pecora et al., 2009; Vinnerljung et al., 2006). It is, however, important to note that
parents with histories of foster care are under substantially more surveillance than their peers
who never entered the system (Connolly et al., 2012). This increased surveillance may explain
the higher prevalence of documented abuse and neglect of children whose parents have foster
system histories. Additionally, the likelihood of birth complications increases with maternal
history of traumatic experiences and insufficient or lacking prenatal medical care (Lev-Wiesel et
al., 2009; Scholl et al., 1994). Even in the absence of personal experiences of trauma, however,
about one-fourth of children whose parents had adverse childhood experiences also go on to have
social-emotional difficulties stemming from parental mental health problems and other adult
adversities (Zhang et al., 2022).
Sensory Reactivity and Regulation in Infancy
SRR is one important domain of infant development that is highly understudied outside
of infants at elevated likelihood of autism and may be influential for early infant experiences and
interactions, given the dominance of sensorimotor play during infancy (Bergen, 2019). SRR
refers to the manner in which an individual takes in and responds to sensory stimuli in his or her
environment. All people, including those with typical development, have sensory preferences, or
certain experiences that they either prefer to engage in or prefer to avoid. Differences in SRR, or
sensory features, however, are often characterized by 3 distinct patterns in infancy, which can
co-occur: sensory hyporeactivity; sensory hyperreactivity; and sensory interests, repetitions, and
seeking (SIRS) (Baranek et al., 2006; Ben-Sasson et al., 2009; Liss et al., 2005). Sensory
hyporeactivity is characterized by a delayed or lack of response to sensory stimuli. For example,
an infant displaying hyporeactivity to auditory input may seem to ignore or miss the sound of

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their parent calling their name. Sensory hyperreactivity is characterized by an aversive or
avoidant response to sensory stimuli, such that a child displaying hyperreactivity to vestibular
input may cry or scream when their parent lays them down on the changing table. SIRS is
characterized by an intense desire for certain types of sensory input. For example, an infant
displaying SIRS behavior may repeatedly rub their hands on certain textures in excess of
developmentally appropriate exploration.
Sensory features are known early signs of autism and other neurodevelopmental
diagnoses (Baranek et al., 2022; Sacrey et al., 2015; Zwaigenbaum et al., 2015) and are
associated with some of the SDH described above, such as birth complications and social-
emotional or mental health concerns, which are often correlated with sensory hyperreactivity
(Bröring et al., 2017; Lev-Wiesel et al., 2009). Some of these sensory features may be
misinterpreted as intentionally “difficult” behavior, which may lead to frustration or ineffective
disciplinary action from adults. For example, sensory hyporeactivity could be interpreted as
intentional ignoring of an adult’s attempts to get the infant’s attention. Sensory hyperreactivity
may be misinterpreted as willful tantrum behavior, and SIRS may be misinterpreted as
stubbornness or refusal to comply with expected behavior. Each of these misinterpretations may
negatively impact a parent’s ability to effectively respond to their infants’ behavior in a manner
that promotes engagement and development.
Parent Responsiveness to Infant Cues
Parent responsiveness is often studied in child development and early intervention
research. This term has been defined through the lens of various disciplinary perspectives,
domains of child development, and types of parent behavior, from sensory sensitivity regarding
changes in infant facial expressions and cries (Donovan et al., 2007) to directiveness in

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interactions (Wan et al., 2012; Wan et al., 2013). For the purposes of the conceptual framework
for this dissertation work, parent responsiveness was defined by (a) sensitivity of parent behavior
to their infants’ cues, (b) timeliness and pacing of parent behavior to match their infants’ needs
and intentions, (c) adjustment of parent behavior based on their infants’ verbal or nonverbal
feedback, and (d) the extent to which parent behavior impacts their infants’ ability to engage
with their environment. That is, parent responsiveness is a gestalt term that captures all of the
aforementioned components of parent behavior and their impacts on the infant’s natural learning
experiences through engagement with the social and physical environment. This definition was
foundational for the conceptualization of these dissertation studies, but was expanded and
revised through Study 1.
Developmental Role of Parent Responsiveness across Domains. Various types of
parent responsiveness have been examined in specific infant populations, such as those with
elevated likelihood of autism due to familial or behavioral risk (Edmunds et al., 2019; Kellerman
et al., 2020). Parent responsiveness is most commonly studied with regard to social
communication and attachment domains of child development (Edmunds et al., 2019; George et
al., 2010; Kellerman et al., 2020; Raval et al., 2001).
Associations between parent responsiveness and later child social communication
outcomes have been studied across several developmental risk populations, including infants at
elevated likelihood of autism. Additionally, much of this work emphasizes parent responsiveness
to verbal or pre-verbal infant cues. Parent verbal responsiveness is known to predict word
production, expressive and receptive language, and directed facial expressions (Kellerman et al.,
2020; Wan et al., 2019). However, associations may depend on the specific type of cue to which
the parent is verbally responding, such that verbal responses to their infants’ focus of attention or

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bids to share attention are more strongly predictive of language and communication outcomes
than verbal responses to requesting behavior (Edmunds et al., 2019; Leezenbaum et al., 2014).
Parent responsiveness to their infants’ cues is also highly relevant in attachment
development literature. In this domain, parent responsiveness is sometimes characterized by
percent of responses to clear infant signals in addition to infant behavior that might constitute a
signal requiring a response (Raval et al., 2001). Additionally, responses to specific types of
infant cues, such as those for distress or attention, and responses to safety-related issues in the
environment have been included in the conceptualization of attachment-related parent
responsiveness (George et al., 2010; Raval et al., 2001). Specifically, a higher percentage of
parent responses to unclear and total infant signals predicted a higher likelihood of secure
attachment status (Raval et al., 2001). Effective parent responsiveness to emotional distress and
safety concerns also predicted secure attachment (George et al., 2010; Raval et al., 2001). These
findings even hold true in family situations categorized as “highly stressful,” such as severe
socioeconomic disadvantage (Finger et al., 2009). Taken together, these findings suggest that
parent responsiveness is a key component of infant attachment development.
Understanding Parent Responsiveness across Groups
Parents of infants at elevated likelihood of autism and those at elevated likelihood of
suboptimal development due to SDH may demonstrate different patterns of parent
responsiveness resulting from differences in parent and infant characteristics that both contribute
to a parent’s ability to respond to their infants’ cues in a well-matched and appropriate manner.
A discussion of some of the potential influences on parent responsiveness in each group is
presented here.

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Parent Responsiveness to Infants at Elevated Likelihood of Autism. Several studies
have demonstrated that there may be differences in the manner in which parents respond to their
infants at elevated versus lower likelihood of autism, especially when the elevated likelihood
status is due to having an older sibling with autism (Srinivasan & Bhat, 2020; Steiner et al.,
2018; Wan et al., 2012). Parents of infants at elevated likelihood of autism tended to use more
directive behavior, such as requesting, attention seeking, and efforts to increase physical
proximity to their infants as compared to parents whose infants had lower likelihood of autism
(Srinivasan & Bhat, 2020; Steiner et al., 2018; Wan et al., 2012). Additionally, use of
“motherese,” or infant-directed speech, tended to decrease in parents of infants at lower
likelihood of autism from 9-18 months, while this decrease was not apparent in infants at
elevated likelihood of autism (Wan et al., 2019). These differences may be due to (a) parents’
successful experiences relying on demanding interactive styles with older children with autism,
(b) parents’ tendency toward infant-directed speech in the absence of frequent clear infant
communicative cues, or (c) parenting stress associated with having an infant at elevated
likelihood of autism (Srinivasan & Bhat, 2020; Wan et al., 2012). It is yet unclear whether these
parent responsiveness differences persist in infants at elevated likelihood of autism from a
community sample without older siblings with autism.
Infant contributions to interactions with their parents are also related to parent
responsiveness, especially with regard to attenuated cues often observed in infants at elevated
likelihood of autism as a result of the early signs of autism. For example, lower frequencies of
functional play acts, clear gestures, and directed vocalizations in infants at elevated likelihood of
autism provide fewer opportunities for parents to (a) recognize and follow into their infants’ play
sequences and (b) respond to their infants’ communicative bids (Leezenbaum et al., 2014; Wan

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et al., 2012; Warlaumont et al., 2014). Additionally, infants at elevated likelihood of autism are
less likely to respond to their parents’ bids for interaction, thereby decreasing opportunities for
parents to scaffold back-and-forth interactions (Kellerman et al., 2020). These infant
contributions to opportunities for parents to demonstrate responsiveness illustrate the manner in
which parent responsiveness is dependent on both parent and infant behavior.
Parent Responsiveness with History of Foster Care. Parent responsiveness requires a
parent to first recognize their infants’ cues, needs, and interests and, second, respond in a manner
that is contingent and developmentally appropriate for the infant. Young parents with history of
foster care may experience several barriers to such sensitive responsiveness. First, parents may
perceive developmentally appropriate infant behavior as intentionally “bad” (Schelbe & Geiger,
2017), which may contribute to inappropriate punitive behavior when a sensitive response to an
infant cue could be more effective to promote a positive interaction. Second, these parents may
expect developmentally inappropriate levels of emotional reciprocity from their infants
(Connolly et al., 2012), thereby potentially yielding unrealistic bids for interaction. Finally,
elevated levels of parenting stress and challenges with self-regulation as a result of childhood
trauma may lead to increased levels of arousal in these parents (Holtrop et al., 2015; Lange et al.,
2019; Rebbe et al., 2017; Shenk et al., 2017), thereby decreasing their ability to co-regulate with
and soothe their infants. Despite these parent characteristics that may influence parent
responsiveness, there is no empirical evidence to date that specifically examines parent
responsiveness in parents with history of foster care.
Comparing Parent Responsiveness across Groups. There may be important
similarities and differences in parent responsiveness behavior across these risk groups. Elevated
parenting stress has a hypothesized role in parent responsiveness for parents of infants at

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elevated likelihood of autism (Wan et al., 2012) and parents with history of child welfare system
involvement (Holtrop et al., 2015; Lange et al., 2019; Rebbe et al., 2017). Because of this shared
influence of parenting stress, there may be some similarities in parent responsiveness across
groups. More specifically, it is possible that parenting stress is a more salient influence on parent
responsiveness than risk group membership. Similarities in infant behavior related to potential
differences in SRR may constitute an additional shared influence on parent responsiveness across
groups. Despite possible similarities due to the role of parenting stress and infant SRR in parent
responsiveness, differences between groups may emerge with regard to the sources of barriers to
parent responsiveness. That is, parent responsiveness may be limited by the attenuated nature of
infant cues in those at elevated likelihood of autism, while parent responsiveness to infants with
elevated likelihood of suboptimal development due to SDH may be limited by parents’
developmental knowledge and poor parenting role models resulting from childhood experiences
in foster care.
Parent Responsiveness to Sensory Reactivity and Regulation
Due to the pervasive nature of SRR and its influences on infants’ participation across
daily occupations (Little et al., 2015), parent responsiveness to SRR cues may be especially
important for development of effective sensory regulation and participation. Evidence regarding
the associations between parent responsiveness and sensory reactivity outcomes in infants at
elevated likelihood of autism, however, is limited to the role of sensory reactivity as it relates to
parent responsiveness and social communication outcomes. One study examined the influence of
sensory reactivity and social communication on parent responsiveness and found that infant
sensory hyporeactivity was linked to parents responding with fewer verbalizations and more play
acts, especially when the infant’s social communication abilities were limited (Kinard et al.,

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2017). Authors hypothesized that lower frequency of verbal responses to children with sensory
hyporeactivity may exacerbate the negative language outcomes already associated with this
pattern of sensory processing (Kinard et al., 2017). In support of Kinard and colleagues’ (2017)
hypothesis, one study found that parent verbal responsiveness did, in fact, mitigate the negative
impact of sensory hyporeactivity on infant communication skills approximately one year later
(Grzadzinski et al., 2021). Taken together, these studies demonstrate that there may be a
developmental benefit of high parent verbal responsiveness for infants with sensory
hyporeactivity, but it is still unclear how parent responsiveness is influenced by SRR and affects
infant outcomes with regard to sensory processing.
Parent responsiveness as it relates to SRR has not been examined in populations of
infants with developmental risk factors that are not related to autism. Conceptually, parent
responsiveness to their infants’ SRR cues may be related to a parent’s ability to manage their
own sensory preferences in order to provide regulating, engaging experiences for their infants.
Because young parents with mental health diagnoses and trauma histories related to their
experiences in the child welfare system may have associated sensory processing differences
(Armstrong-Heimsoth et al., 2021; Dowdy et al., 2020), managing one’s own sensory
preferences in order to be responsive to those of another may be especially challenging for this
population. No studies to date have examined links between parent responsiveness to SRR cues
and history of foster care.
Conceptual Framework
Examination of parent responsiveness in these dissertation studies was anchored in three
key occupational science concepts and theories: meaning; doing, being, becoming, and
belonging; and transactional perspectives on occupation. For the purposes of these studies,

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occupation was defined as a personally meaningful activity. Occupational science studies about
parenting during early development are few in number, though the existing literature recognizes
that occupations in infancy are highly dependent upon interaction with a parent or other
caregiver (Pizur-Barnekow et al., 2014; Price & Stephenson, 2009; Whitcomb, 2012), which
signals the potential importance of parent responsiveness in the earliest human occupations.
Parenting as a Meaningful Developmental Process. Meaning is central to the
conceptualization of occupation (Reed & Hocking, 2013) and is particularly salient in the study
of parenting practices and behaviors. Meaning can be conceptualized as a socially influenced
(Reed & Hocking, 2013), though personal, experience of significance or importance assigned to
an occupation (Hasselkus, 2011). Meaning may be particularly informative for studying
parenting with infants at risk of suboptimal developmental outcomes in two primary ways. First,
parenting is commonly considered to be a highly meaningful role that substantially impacts the
occupational rhythms of both the parent and the infant (Horne et al., 2005). Because of the many
influences of personal, cultural, and social factors on the meaning ascribed to a given occupation,
or, in the case of parenting, a set of related occupations, meaning is likely to be highly dependent
on each parent’s past experiences and current life context. Furthermore, a parent’s perception of
meaning in the parenting role may influence the manner in which they interact with their infants
during daily occupations and the way they experience such interactions. These potential
individual differences in ascribed meaning, though they cannot be directly observed by an
outsider, may significantly impact the manner in which parents engage in parent-infant
interactions during daily occupations. That is, parents of infants at risk may ascribe different
meaning to their parenting role than parents of infants without known risk factors. Such
differences may impact parent responsiveness across groups.

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Parenting can also be considered a developmental process through the doing, being,
becoming, and belonging involved in parenting occupations. Doing, being, becoming, and
belonging are dimensions of occupation that capture not only the essence of engaging in
occupation, but also some of the broader functions that occupation may serve in relation to health
and well-being (Hitch et al., 2014a; Hitch et al., 2014b; Wilcock, 1999). This dimensional theory
of occupation as a dynamic and social process may be highly effective to support analysis of the
inter-related processes of development occurring in parents and infants alike during the first few
years of a child’s life. While parents and infants do things together (e.g., playing, feeding,
diapering), they each may have separate and shared experiences of being in relationship with one
another. At the same time, the parent and infant are each becoming something: parents are
becoming competent in their parenting roles (Horne et al., 2005), while infants are becoming
competent in the use of their developmental capacities to act on the world around them.
Together, the parent and infant are belonging to their family unit, and parents may gain a sense
of belonging to a larger community of adults who are raising or have raised children. Each
dimension, and the co-occurrence of processes happening simultaneously across dimensions, can
serve as a perspective from which to analyze parent-infant interaction, learning, and
development. Observed parent responsiveness may be influenced by the exact moment at which
parent-infant interaction is recorded and the relation of this moment to the ongoing, iterative
process of doing, being, becoming, and belonging for parent and infant alike.
Transactional Perspective on Parent Responsiveness. A transactional perspective is
often taken up to inform studies regarding the situated, contextualized flow of participation in
occupations across time. The situation, broadly defined, in which parent responsiveness takes
place may include any number of influences, from the people directly involved in the occupation,

13

to the physical or social environment in which the participants are situated, to the socioeconomic
and historical factors that shape opportunities to engage in parenting behavior (Rosenberg &
Johansson, 2013). Of most salience for the study of parent-infant interactions are the people
involved in the occupation, physical affordances for play and interaction within the environment,
and the nature of early development as a transactional process.
Parents and infants involved in occupations with one another, which are of utmost
importance for infant development (Aldrich & Cutchin, 2013; Whitcomb, 2012), each bring
several key contributions to the social environment. First, a parent’s manner of interacting with
their infants is shaped by their lifetime of social transactions, including their own cultural norms,
experiences of being parented, and parenting beliefs and practices within their social network
(Park et al., 2021). Second, infants are equipped with emerging developmental skills; feedback
they have received through transactions with their parents and other adults in their lives; and a
natural drive to seek safety, security, and survival through attachment behavior (Whitcomb,
2012). Parents and infants both embody the experience of interconnection with one another and
with the physical environment through occupation (Aldrich & Cutchin, 2013). Additionally,
parents and infants provide responses to one another, which build a foundation for the infant and
parent alike to learn about the social world and the manner in which they fit into such a world
(e.g., emerging roles in the family unit and beyond) (Aldrich & Cutchin, 2013; Reed & Hocking,
2013). Thus, during engagement in occupation together, infants and parents are shaped by each
other and the affordances for interaction available within the environment, which allow for a
constantly evolving parent-infant relationship situated in the family’s particular context (Cutchin
& Dickie, 2012), which may include elevated likelihood for autism or suboptimal development
due to SDH.

14

Conceptual Model. The conceptual framework was developed specifically for these
studies and can be visualized through the conceptual model, found in Figure 1.1. A new
conceptual model was developed for these studies due to a lack of parent responsiveness
frameworks in the literature that recognize the potential influence of various developmental risk
factors on parent behavior. The model was not comprehensively tested in these studies, but rather
outlines the many potential influences on parent responsiveness and demonstrates the
relationship between parent responsiveness and occupational science and developmental theory.
Due to the transactional nature of parent-child interaction, parent responsiveness was
characterized by a balance between child characteristics, parent characteristics, and affordances
of the physical environment and the objects available. Parent responsiveness in dyads in which
the infant presents with early signs of autism may be disproportionately affected by infant
characteristics (denoted in blue in Figure 1.1), while parent responsiveness in dyads in which the
parent has a history of foster care may be disproportionately impacted by parent characteristics
(denoted in orange in Figure 1.1). Additionally, influences of parent versus infant characteristics
is not exclusive to either group due to some of the similarities across groups noted above, as
indicated by the overlap between orange and blue circles in Figure 1.1. Environmental
characteristics (denoted in gray in Figure 1.1) are irrespective of infant or parent characteristics
and may be impactful on parent responsiveness regardless of risk group. It is important to note
that the toys and materials available for interaction were controlled through standardization of
materials in these studies.

15

Figure 1.1 Conceptual model depicting parent responsiveness as it is influenced by risk group
and parent, infant, and environmental characteristics.

1
(Kellerman et al., 2020; Leezenbaum et al., 2014; Wan et al., 2012; Warlaumont et al., 2014)
2
(Kinard et al., 2017; Wan et al., 2012)
3
(Leezenbaum et al., 2014; Srinivasan & Bhat, 2020; Warlaumont et al., 2014)
4
(Kinard et al., 2017; Grzadzinski et al., 2021)
5
(Horne et al., 2005)
6
(Holtrop et al., 2015; Lange et al., 2019; Rebbe et al., 2017; Shenk et al., 2017; Steiner et al., 2018; Wan et al.,
2012)
7
(Holtrop et al., 2015; Rebbe et al., 2017)
8
(Connolly et al., 2012; Lev-Wiesel et al., 2009; Rebbe et al., 2017; Sypher et al., 2021)
9
(Schelbe & Geiger, 2017)
10
Inclusion of these environmental factors was based on the observed impact of the toys and activities available
during previous studies from which extant data were drawn.

Present Studies
Considering the wide array of conceptualizations of parent responsiveness across the
literature, in addition to the lack of empirical evidence regarding parent responsiveness (a) in
former foster youth and (b) to infant SRR cues, these dissertation studies were designed to
contribute to this body of literature by synthesizing existing terminology and increasing the
diversity of parents included in the study of this construct. The research questions and specific
aims for each study are listed below.
Study 1: How is parent responsiveness defined across the available literature examining this
construct?

16

Aim 1: Conduct a systematic review of the literature to identify peer-reviewed articles
that examine parent responsiveness to infants ages 6-18 months.
Aim 2: Establish a comprehensive definition of parent responsiveness that incorporates
key dimensions outlined in the existing literature.
Study 2: To what extent do experts on former foster youth who are parenting agree or disagree
with the definition of parent responsiveness established during Study 1?
Aim 1: Collect expert opinions from researchers, clinicians, and experts by experience
regarding the dimensions of parent responsiveness identified in Study 1.
Aim 2: Synthesize data collected during focus groups and Study 1 to inform measure
development for an observational measure of parent responsiveness to SRR.
Study 3: How does parent responsiveness differ across developmental risk groups and compared
to parents of infants with no known developmental risk?
Aim 1: Pilot test the new measure with former foster youth who are currently parenting
infants ages 6-18 months.
Aim 2: Establish reliability and validity of the new parent responsiveness measure
developed in Study 2.
Aim 3: Examine profiles of parent responsiveness, parenting stress, and infant SRR and
compare across matched triads (1 participant from each group).

17

Chapter 2: Systematic Review of Parent Responsiveness
Abstract
Parent responsiveness to their infants’ cues has been widely studied, especially in the
context of infant attachment, mental health, and likelihood of autism. Across studies, parent
responsiveness is defined as it relates to different areas of focus, such as verbal responses,
sensitivity, timeliness, physical proximity to the infant, and bids for the infant’s attention.
Additionally, evidence for the specific associations of parent responsiveness with child
developmental outcomes is mixed. Differences in findings may be partially attributable to
differing conceptualizations of parent responsiveness. Additionally, the potentially divergent
perspectives taken up in the literature on parent responsiveness may limit the field’s ability to
engage in cross-disciplinary collaborations, which are important to best serve populations in
most need of support to develop responsive parenting behavior. The purpose of this systematic
review was to establish a multidimensional definition of parent responsiveness based upon
thematic coding of existing definitions of parent responsiveness in the literature. Inclusion
criteria for articles in this review were: (a) study focus on behavioral parent responsiveness; (b)
average age of study participants between 6-18 months; and (c) included a specific, in-depth
definition of parent responsiveness. This study yielded a comprehensive, multidimensional
definition of parent responsiveness to their infants’ cues. This definition can serve as a
foundation for future studies of parent responsiveness, its impact on child development, and
factors that influence a parent’s ability to respond to their infants’ cues.
Background and Introduction
Parents are a major source of regulatory, communicative, and safety-related cues for their
children, especially during infancy. Though the amount of time parents spend interacting

18

affectively and instrumentally (e.g., diaper changing, bathing) with their infants varies depending
on work demands, family context, and parenting role, parents are a major part of their infants’
daily learning experiences (Booth et al., 2002; Kotila et al., 2013; Marshall, 2011). Given this
consistent interaction between parents and their infants, parent behavior, especially the manner in
which parents respond to their infants’ cues, is important to thoroughly examine in order to
inform understanding of the role of parenting in child development and the role of various parent
variables in the development of the parent-infant interactive style.
The Cyclical Nature of Parent Responsiveness in the Interactive Context
Parent-infant interactions are commonly considered reciprocal, or transactional, cycles
between parent and infant, in which each party is an active participant (Edmunds et al., 2019;
Grzadzinski et al., 2021; Kinard et al., 2017; Leezenbaum et al., 2014; Wan et al., 2012; Wan et
al., 2013). These cycles include infant’s intentional or unintentional cues, which elicit parent
behavior, which thereby prompts further infant behavior, which then leads to another parent
response, continuing in this reciprocal manner throughout an interaction and over time
(Leezenbaum et al., 2014; Wan et al., 2019). Each step in a parent-infant interaction is dependent
to some degree on the contribution of the other party in the previous step (Leezenbaum et al.,
2014). Infants’ behavior is influenced by parent responses, such that, for example, infants’ next
vocalizations were more likely to be speech-related if the parent responded contingently to
infants’ previous speech-related vocalization (Warlaumont et al., 2014). Parents’ responses are
also impacted by their infants’ behavior, such that, for example, frequency of object sharing
initiated by infants predicted parent use of gestures directed to the infant (Srinivasan & Bhat,
2020). Furthermore, the parents’ likelihood of verbally responding to their infants’ vocalizations
was associated with the infants’ use of speech-related versus non-speech-related sounds

19

(Warlaumont et al., 2014). The parent may change their manner of interacting with their infant
over time, such as decreasing infant-directed speech as infants gain verbal skills (Wan et al.,
2019), which then reciprocally alters the infant’s experiences. With time, these cycles become
the patterns of social communication and self-regulation behaviors that the infant learns through
transactional interactions with their parent (Jaegermann & Klein, 2010; Leezenbaum et al., 2014;
Wan et al., 2013; Wan et al., 2019). Because of the transactional nature of parent-infant
interactions, parent responsiveness is complex, multidimensional, and dependent on both parent
and infant skills and behavior. These complexities allow for the study of parent responsiveness
through many perspectives and with several possible areas of focus, which contribute to the
diversity of empirical evidence examining this construct.
Roles of Parent Responsiveness in Infant Development
Though parent verbal responsiveness is known to predict certain social communication
outcomes in their infants at elevated likelihood of autism (Kellerman et al., 2020; Wan et al.,
2019), results of intervention studies targeting parent responsiveness across populations
complicate these documented correlational findings. One study with 2-4 year-olds with autism
found that parent responsiveness increased from baseline to the immediate endpoint of
intervention, and increases only in child initiation of communication were found approximately
six years later, but not at the intervention endpoint (Pickles et al., 2016). These long-term
findings may indicate that improved parent responsiveness only supports child development over
a substantial period of time, lending further evidence to the cyclical perspective on parent-child
interactions. Child expressive and receptive language skills in this study did not differ between
treatment and control groups at endpoint nor follow-up (Pickles et al., 2016). Other studies with
infants at elevated likelihood of autism or with sensory processing disorder found similar

20

increases in parents’ use of responsive intervention strategies, but found positive changes in child
behavior only on a select few social communication outcomes (Jaegermann & Klein, 2010;
Yoder et al., 2021). These mixed findings suggest that emphasis on changing parents’ responsive
behavior may only be an effective intervention strategy for a specific subset of child outcomes.
Differences in diagnostic status, length of follow-up, and developmental period at which parent
responsiveness strategies were applied (Edmunds et al., 2019) may also contribute to disparate
findings across correlational studies and randomized control trials. Additionally, differences in
the manner in which parent responsiveness is defined and measured across studies is likely to
affect findings regarding the developmental impact of certain types or components of parent
responsiveness.
Several review studies exist to compare and contrast conceptualizations of parent verbal
responsiveness, or caregiver talk (Bottema‐Beutel & Kim, 2021; Edmunds et al., 2019). Studies
that measured parent verbal responsiveness with examination of specific behaviors versus a
global rating were more likely to find associations with later child developmental outcomes
(Edmunds et al., 2019). In children with autism (mean age 48 months), studies regarding parent
verbal responsiveness were distinguished based on the child behavior to which parents were
responding: communicative acts or focus of attention (Bottema‐Beutel & Kim, 2021). These
reviews suggest that there are several ways to conceptualize parent responsiveness, and that each
may be differentially associated with various child outcomes. However, no literature review to
date examines definitions and key components of parent responsiveness across studies and
populations during infancy.

21

Purpose
Given the growing body of literature examining parent responsiveness to their infants’
cues and associations of this construct with developmental outcomes, a unifying understanding
of parent responsiveness is needed to move the field forward. The purpose of this study was to
develop a comprehensive, multidimensional definition of parent responsiveness. The resulting
definition is rooted in existing literature and is useful to (a) inform measurement development to
examine parent responsiveness, (b) provide an organizing framework for studying the nuances of
parent responsiveness, and (c) inform future studies about the key ingredients of parent
responsiveness that are most important for supporting child development.
Method
This study was a systematic review of the literature on parent responsiveness to infant
cues. Qualitative content analysis of the text of each definition of parent responsiveness was used
to establish a single, comprehensive, multidimensional definition.
Procedures
A systematic review of the literature regarding parent responsiveness to infant cues was
conducted in order to extract definitions of parent responsiveness for thematic coding to examine
key dimensions of this construct. Covidence online systematic review organization software was
used to track articles throughout the process. Articles were identified using the search terms in
Table 2.1, along with other related terms. Database-specific controlled vocabulary terms were
used for all three databases (see Appendix A for complete search strategies for each database).
Databases searched were PubMed, CINAHL Complete, and ProQuest Nursing and Allied
Health. Duplicate articles were removed using the automated Covidence de-duplication process.

22

Duplicate articles that were not filtered out in this automated process were manually marked as
duplicates during title and abstract screening.
Table 2.1 Examples of key search terms.
Parent Responsiveness Age of Infants
Parent responsiveness
OR parental responsivity
OR caregiver sensitivity
OR maternal response
OR paternal reciprocity
OR parent-child synchrony
infant
OR infancy
OR baby
OR early
OR first year(s)
OR toddler
Note: All combinations of the first and second words in the terms in the “parent responsiveness” column were
included.
Next, the title and abstract from each article was screened by two independent, trained
study personnel. In total, the principal investigator screened all articles, and six other trained
study personnel acted as the secondary screener for different subsets of the articles. Article
inclusion criteria were (a) infant participants with a mean age of 6-18 months (or at least one
time point including measurement of parent responsiveness within the target age range in the
case of a longitudinal study), (b) primary focus on parent responsiveness, and (c) definition of
parent responsiveness that was sufficiently in-depth to allow for thematic analysis of the
dimensions of parent responsiveness. “Sufficiently in-depth” was defined as at least one sentence
long and including defining characteristics beyond the search terms used to identify articles.
Non-peer-reviewed articles, articles without behavioral parent responsiveness as the primary
focus of the study, or articles with a mean age of infant participants outside of the specified age
range were excluded. Articles with physiological measures of responsiveness (e.g., neurological
measures, cortisol synchrony) were only included if an emphasis on behavioral responsiveness
was also present. Additionally, articles with simulated parent-infant interaction (e.g., parents
responding to videos, photos, or audio recordings of infant cries) were excluded. A “primary
focus” on parent responsiveness was operationally defined as either (a) using a measure of parent

23

responsiveness, (b) listing parent responsiveness in the study purpose or research question, (c)
reporting parent responsiveness outcomes in the results, or (d) foregrounding parent
responsiveness in the discussion. Articles that did not meet the first and second inclusion criteria
(third inclusion criterion could not be assessed from title and abstract only) or met any exclusion
criterion were excluded from the full-text review. See Figures 2.1 and 2.2 for the decision trees
used to determine article inclusion or exclusion in the title and abstract screening phase.
Figure 2.1 Decision tree number 1 for age inclusion criteria during title and abstract screening.

24

Figure 2.2 Decision tree number 2 for primary focus on parent responsiveness inclusion criteria
during title and abstract screening.

Two independent study personnel, the principal investigator (all articles) and one of four
others (subsets of articles), completed full-text review of the articles to confirm that each article
satisfied all three inclusion criteria and did not meet exclusion criteria. During full text screening,
different studies using the same framework or definition for parent responsiveness (e.g., studies
by the same research group defining parent responsiveness in the same way) were considered
duplicates. In this case, the first published article in any series of related articles with the same
definition of parent responsiveness was selected for inclusion in this review. Articles that passed
both stages of review comprised the study sample. See Appendix B for the decision guide used
for full-text screening.

25

Data Analysis
Extraction of Definitions of Parent Responsiveness. As part of the inclusion criteria for
this review, each article contained a working definition of the type of parent responsiveness
examined in that study. The text of these definitions was independently identified during full-text
screening by each of the two study personnel who screened each article. Definition texts and key
study information (e.g., participant characteristics, country in which data collection occurred)
were extracted by the principal investigator using the Covidence software data extraction tool. A
spreadsheet containing article information and definitions was exported from Covidence and
used for thematic coding.
Content Analysis of Definitions of Parent Responsiveness. The text of the definitions
was qualitatively analyzed by the two independent, trained study personnel to identify
dimensions of parent responsiveness. This content analysis included (a) open coding to capture
the breadth of information in the definitions of parent responsiveness; (b) consensus discussion
to cluster themes uncovered during the open coding into groups of similar ideas, or dimensions;
and (c) summarizing and titling each dimension based on the codes that comprised each
dimension (Peräkylä et al., 2020). The first step was done independently by each of the study
personnel, while the second and third steps were completed via consensus discussions. The
complete definition of parent responsiveness was assembled to reflect each of the dimensions
identified during the analysis process.
Descriptive Analysis of Definitions of Parent Responsiveness. In order to describe the
definitions and dimensions identified across articles, the location of the definition within each
article and the number of articles that endorsed each dimension were tracked throughout the
review process. Descriptive analyses were conducted in SPSS version 29.0, and included

26

frequencies of location of each definition (e.g., introduction, measures, etc.) and number of
articles that endorsed each dimension.
Results
Article Selection
The original search returned 22,173 articles, 3,194 of which were duplicates, leaving
18,978 articles for inclusion in title and abstract screening. After title and abstract screening,
1,623 articles were selected for inclusion in full text screening. Of these, 185 were excluded due
to a lack of primary focus on parent responsiveness, 463 were excluded due to age of participants
outside of 6-18 months, 382 were excluded due to a missing or insufficient definition of parent
responsiveness, 76 were excluded due to lack of full text availability, 29 were excluded due to
not being peer reviewed, and 25 were considered additional duplicates due to having the same
first author and same definition of parent responsiveness. These exclusions left 463 articles for
inclusion in the final review. See Figure 2.3 for a consort diagram illustrating the review process.
Thirty-seven different countries were represented by the participants in the included articles.

27

Figure 2.3 Consort diagram demonstrating the article selection process.

Note: CINAHL = Cumulated Index to Nursing and Allied Health Literature; PR = parent responsiveness.
Location of Definitions
Articles varied widely in the location of the definition of parent responsiveness within the
publication. The majority of articles (n=286; 61.7%) operationally defined parent responsiveness
in the measures section, followed by the introduction (n=92; 19.9%), procedures (n=22; 4.8%), a
separate measures table (n=20; 4.3%), the method section without a subheading (n=18; 3.9%),
abstract (n=5; 1.1%), data analysis (n=3; 0.7%), results (n=2; 0.4%), discussion (n=2; 0.4%), and
appendices (n=2; 0.4%). Definitions included in different locations within the articles showed
variability in percentage endorsing each dimension of parent responsiveness, as illustrated in
Figure 2.4.

28

Figure 2.4. Percentage of articles endorsing each dimension by location of definition within the
article.

Dimensions of Parent Responsiveness
Content analysis of the definitions of parent responsiveness resulted in 15 dimensions.
Dimensions are defined here in order from most commonly endorsed to least commonly
endorsed. See Figure 2.5 for a conceptual diagram representing the relative amounts of articles
that endorsed each dimension.
Contingent Responses. This dimension was endorsed by 327 of the included articles.
Contingent responses include parent behaviors that are dependent upon their infants’ cues.
Contingent responses include those that are well matched and appropriate to the infant’s current
needs, desires, or intentions (Abel et al., 2018; Aboud et al., 2008). Contingency included

29

appropriate judgement of what the infant finds to be enjoyable (Ereky‐Stevens, 2008) as well as
relevance to the child’s current focus of attention (Fagan & Doveikis, 2019).
Affect. This dimension was endorsed by 229 articles. The majority of these articles
emphasized the importance of warmth, positive regard, animation, and positive affect during
parent-child interaction (Góngora & Farkas, 2009; Herbers et al., 2020; Landry et al., 2006).
Others recognized the importance of emotional connectedness between parent and child (Høivik
et al., 2018). Finally, this dimension involved delight in interaction with the child, expressions of
affection, and smiling and laughter (Landry et al., 2013; Pungello et al., 2009; Wu & Gros-Louis,
2015).
Following the Child’s Lead. Following the infant’s lead was endorsed as a dimension of
parent responsiveness by 170 articles. This dimension was characterized by supporting the
infant’s interests and actions by joining in the infant’s activity (Faure et al., 2017; Malmberg et
al., 2016). Additionally, following the infant’s lead involved a sense of the interaction being
directed by the infant’s agenda, not the parent’s agenda (Akai et al., 2008; Butti et al., 2018). The
opposite of this dimension was intrusiveness, in which the parent behaved in an over-controlling
or directive manner (Early et al., 2002; Gros-Louis & Wu, 2012).
Well-Timed. This dimension was endorsed by 164 of the included articles. Well-timed,
or prompt, parent behavior was characterized by responses that occur within two to five seconds
of the infant’s behavior (Ambrose, 2016; Fagan & Doveikis, 2019; Gros-Louis & Wu, 2012;
Leezenbaum et al., 2014). Additionally, this dimension included that the overall pace or rhythm
of the interaction was well-matched to the infant’s needs and arousal level (Alston & St. James-
Roberts, 2005; Berlin et al., 2018; Brandes-Aitken et al., 2020; Coffman et al., 1995).

30

Attention toward the Infant. This dimension was endorsed by 162 of the included
articles. Attention toward the infant was primarily an orientation of gaze from the parent toward
the child (Rifkin‐Graboi et al., 2018; Van den Boom, 1994). Additionally, general awareness of,
attunement to, or recognition of the infant’s cues was included in this dimension (Stiles, 2004;
Tétreault et al., 2017; Whitt & Casey, 1982).
Verbal Communication. Verbal communication was listed as a dimension of parent
responsiveness in 123 of the included articles. This dimension referred to parent behavior that
involves language, especially that which was relevant to the infant’s current experience (Doom et
al., 2020; Ereky‐Stevens, 2008; Munz et al., 2010).
Developmentally Appropriate. One hundred twenty of the included articles mentioned
developmental appropriateness as a key component of parent responsiveness. This dimension
referred to parent behavior that was well-matched to their infants’ current level of ability (Ereky‐
Stevens, 2008; Wallace et al., 1998) or that promoted opportunities for the infant to learn and
develop (Brown & Cox, 2020; Finegood et al., 2016; Wagner et al., 2019). Developmental
appropriateness also included parent behavior that provided their infants with opportunities to act
independently or exert autonomy, due to the key role autonomy plays in development (Ispa et al.,
2017; Kok et al., 2013; Lecuyer-Maus, 2000). Finally, this dimension included taking
appropriate control of the interaction in order to maintain the infant’s safety (Out et al., 2009).
Transactional. This dimension of parent responsiveness was endorsed by 107 of the
included articles. The transactional nature of parent responsiveness referred to the manner in
which parents and children alike adapt their behavior to effectively coordinate the interaction
(Aboud et al., 2008; Aureli & Presaghi, 2010; Bosquet Enlow et al., 2014). Transactional parent
responsiveness also described the sense of connection and mutual enjoyment between the parent

31

and child during interaction (Brown & Cox, 2020; Newland et al., 2016). In Figure 2.5, this
dimension is located around the outside of the other dimensions due to the transactional nature of
the other dimensions. That is, each of the dimensions of parent responsiveness must occur in a
transactional manner in order to be maximally responsive.
Accurate Interpretation. Eighty-three of the included articles endorsed accurate
interpretation of the infant’s cues as a dimension of parent responsiveness. Accurate
interpretation described the parent’s ability to assign meaning to their infants’ signals that
matched the infant’s intentions (Otomo, 2001; Schoppe‐Sullivan et al., 2006). Accurate
interpretation also consisted of the degree to which the parent’s behavior met their infants’ needs
(Landau et al., 2009).
Physical Touch and Proximity. This dimension was endorsed by 72 of the included
articles. Physical touch included the importance of gentle, affectionate physical contact between
parent and infant (Doom et al., 2020; Early et al., 2002; Feldman, 2010; Leerkes, 2011). Close
but non-intrusive physical proximity to the infant was also described within this dimension (Out
et al., 2009; Sansavini et al., 2015).
Effective Conflict Resolution. Sixty-five of the included articles described effective
conflict resolution as an important component of parent responsiveness. Effective conflict
resolution included handling the infant’s expression of distress appropriately (Feldman 2010),
avoiding aggressive or frustrating behavior (Baker et al., 2010; Gartstein et al., 2008; Gerlach et
al., 2022; Shai & Belsky, 2017), preventing potential problems (Hammer et al., 2019), and
assisting the infant in problem-solving if needed (Lecuyer-Maus, 2000; Yatziv et al., 2018).
Consistency. The importance of consistency throughout interactions was endorsed by 40
of the included articles. This dimension included using a predictable style of interaction

32

(Feldman & Eidelman, 2005) and regularly responding in a similar manner throughout the
interaction (Coffman et al., 1995).
Being Present. Twenty-six of the included articles endorsed being present as a
dimension of parent responsiveness. Being present described the parent’s provision of comfort to
their infants (Dubois-Comtois et al., 2017), in addition to a sense of supportive presence
throughout the interaction (Tétreault et al., 2017). Delight and pleasure taken in the interaction
was also included in this dimension (Fuchs et al., 2017).
Mirroring, Reflecting, or Imitating. This dimension was endorsed by 24 of the
included articles. Mirroring, reflecting, or imitating includes repetition or imitation of the
infant’s behavior or vocalization (Glanemann et al., 2013; Otomo, 2001; Smith, 2018), mirroring
the infant’s affective state or movements (Ereky‐Stevens, 2008; Stacks et al., 2014), and
demonstrating empathy for the infant’s affective experience (Leerkes et al., 2004).
Effective Interaction. Effectiveness of the interaction was endorsed by 19 of the
included articles. Effectiveness refers to the resourcefulness, variety, and creativity that the
parent demonstrates while interacting with their infants (M. D. Beijersbergen et al., 2012; Kiang
et al., 2004). The parent’s ability to support their infants to maintain their optimal level of
arousal was also included here (Egotubov et al., 2020).

33

Figure 2.5. Conceptual diagram of the definition of parent responsiveness.

Summary. In summary, according to the 463 articles included in this review, parent
responsiveness was defined as:
Transactional, well-timed, developmentally appropriate, consistent parent behavior
that includes: attention directed toward the infant, being present in the interaction,
contingent responses, verbal communication, physical touch and proximity, effective
conflict resolution, and following the infant’s lead.
See Table 2.2 for a list of citations of articles that endorsed each dimension.
Table 2.2 Identified dimensions of parent responsiveness with associated citations.
Dimension Associated Citations
Contingent
(n=327; 70.6%)
(Aarestrup et al., 2020)
(Abel et al., 2018)
(Ablow et al., 2013)
(Aboud et al., 2008)
(Hepworth et al., 2021)
(Hibel et al., 2011)
(Hobson et al., 2005)
(Hodges et al., 2008)
(Noroña-Zhou et al., 2020)
(Nover et al., 1984)
(Nozadi et al., 2013)
(Nuttall et al., 2012)

34

(Adams et al., 2018)
(Akai et al., 2008)
(Albers et al., 2010)
(Alston & St. James-Roberts,
2005)
(Alvarenga et al., 2020)
(Ambrose, 2016)
(Anderson et al., 2012)
(Anzman-Frasca et al., 2018)
(Athari et al., 2021)
(Augustine et al., 2018)
(Aytuglu & Brown, 2022)
(Bai et al., 2020)
(Baker et al., 2010)
(Bakermans-Kranenburg &
van Ijzendoorn, 2006)
(Banerjee et al., 2022)
(Barnett et al., 2008)
(Barry et al., 2008)
(Beckwith, Cohen, et al.,
1999)
(Bedford et al., 2015)
(Behrendt et al., 2019)
(Behrens et al., 2012)
(Belsky, 1980)
(Berkel et al., 2015)
(Berlin et al., 2018)
(Bernier et al., 2010)
(Bernier et al., 2018)
(Berry et al., 2013)
(Berry et al., 2017)
(Bilgin & Wolke, 2020)
(Biringen et al., 1997)
(Biringen et al., 2000)
(Birmingham et al., 2017)
(Bisceglia et al., 2012)
(Blandon & Scrimgeour,
2015)
(Bliznashka et al., 2022)
(Blunden et al., 2022)
(Bornstein et al., 2008)
(Bosquet Enlow et al., 2014)
(Bouvette-Turcot et al.,
2017)
(Bradley & Corwyn, 2007)
(Brandes-Aitken et al., 2020)
(Hofer et al., 2008)
(Hohman et al., 2017)
(Holdsworth & Schell,
2017)
(Horodynski et al., 2015)
(Huang et al., 2012)
(Huffmeijer et al., 2020)
(Hurley et al., 2008)
(Huston & Rosenkrantz
Aronson, 2005)
(Isabella, 1993)
(Jacobvitz et al., 2006)
(Javakhishvili &
Vazsonyi, 2021)
(Jonsson & Clinton,
2006)
(Joosen et al., 2012)
(Juffer et al., 2005)
(Kachadourian et al.,
2009)
(Kaitz, Maytal, et al.,
2010)
(Kaitz, Shalev, et al.,
2010)
(Kalinauskiene et al.,
2009)
(Kaplan et al., 2009)
(Karasik et al., 2014)
(Karl, 1995)
(Karrass & Braungart-
Rieker, 2003)
(Kiang et al., 2004)
(Kiel et al., 2011)
(Kinard et al., 2017)
(King et al., 2016)
(King et al., 2021)
(Kivijärvi et al., 2004)
(Klausli & Owen, 2009)
(Klein Velderman et al.,
2006)
(Kochanska, 1998)
(Kochanska & Coy,
2002)
(Kochanska et al., 2008)
(Kochanska et al., 2015)
(Olson & Masur, 2011)
(Oosterom et al., 2020)
(Otomo, 2001)
(Out et al., 2009)
(Paavola-Ruotsalainen et
al., 2018)
(Padilla‐Walker et al.,
2020)
(Pallewaththa et al., 2021)
(Parade et al., 2018)
(Parade et al., 2019)
(Paul et al., 2014)
(Paul et al., 2019)
(Pauli-Pott et al., 2004)
(Pearson et al., 2012)
(Pederson et al., 1990)
(Pederson et al., 1998)
(Pedroso & Gubert, 2021)
(Perone et al., 2020)
(Perrone et al., 2021)
(Pianta et al., 1989)
(Pickles et al., 2013)
(Riddell et al., 2011)
(Planalp et al., 2019)
(Propper et al., 2008)
(Provenzi et al., 2020)
(Puura et al., 2019)
(Quan et al., 2017)
(Quigley et al., 2017)
(Raby et al., 2012)
(Ravn et al., 2011)
(Reichmuth et al., 2013)
(Rifkin-Graboi et al.,
2021)
(Roberts & Hampton,
2018)
(Rodrigues et al., 2021)
(Rosenblum et al., 2020)
(Ruffman et al., 2020)
(Ruggiero et al., 2020)
(Sakkalou et al., 2021)
(Salo et al., 2010)
(Pia Santelices et al., 2010)
(Savage et al., 2018)
(Schlansker, 1980)

35

(Braungart-Rieker et al.,
2010)
(Braungart-Rieker et al.,
2014)
(Bretherton, 2013)
(Broesch et al., 2016)
(Brooks-Gunn et al., 2002)
(Brown et al., 2012)
(Brown et al., 2017)
(Brown & Cox, 2020)
(Buehler et al., 2011)
(Butti et al., 2018)
(Caldera & Lindsey, 2006)
(Campbell & Johnston,
2009)
(Cassidy et al., 2010)
(Cha, 2017)
(B. Choi et al., 2020)
(Boin Choi et al., 2020)
(Clark et al., 2000)
(Coe et al., 2021)
(Coffman et al., 1995)
(Conway, 2020)
(Cooper et al., 2009)
(Crockenberg & Leerkes,
2003)
(Daniels et al., 2012)
(Dáu et al., 2017)
(Dayton et al., 2016)
(de Sousa et al., 2019)
(DiSantis et al., 2011)
(DiSantis et al., 2013)
(Donovan & Leavitt, 1978)
(Early et al., 2002)
(Eggum et al., 2009)
(Elmadih et al., 2014)
(Elmlinger et al., 2019)
(Ereky‐Stevens, 2008)
(Evans & Porter, 2009)
(Fagan & Doveikis, 2019)
(Farkas et al., 2017)
(Farrell et al., 2019)
(Fearon et al., 2006)
(Fearon et al., 2017)
(Feldman et al., 1999)
(Feldman et al., 2009)
(Kopystynska et al.,
2016)
(Koren-Karie et al.,
2002)
(Kretchmar & Jacobvitz,
2002)
(Kuzava et al., 2019)
(Landau et al., 2009)
(Landry et al., 1997)
(Landry et al., 2003)
(Landry et al., 2006)
(Landry et al., 2013)
(Laxman et al., 2015)
(Leerkes, 2011)
(Leerkes & Qu, 2017)
(Leerkes, Buehler, et al.,
2020)
(Leerkes, Bailes, et al.,
2020)
(Legerstee et al., 2007)
(Leigh et al., 2011)
(Level et al., 2021)
(Li et al., 2022)
(Lickenbrock &
Braungart-Rieker, 2015)
(Lieberman et al., 2019)
(Lin et al., 2017)
(Lloyd & Masur, 2014)
(Logsdon et al., 2014)
(Logsdon et al., 2015)
(Lombardi, 2021)
(Lowe et al., 2017)
(Lucassen et al., 2011)
(Maas et al., 2013)
(Maas et al., 2016)
(Madigan et al., 2015)
(Mah et al., 2017)
(Malmberg et al., 2016)
(Masur et al., 2005)
(Mateus et al., 2021)
(Matvienko-Sikar et al.,
2018)
(McElwain & Booth-
LaForce, 2006)
(McMahon & Newey,
2018)
(Schofield & Weaver,
2016)
(Schoppe‐Sullivan et al.,
2006)
(Scorza et al., 2021)
(Shannon et al., 2006)
(Sharma, 2022)
(Silberman et al., 2020)
(Smaling et al., 2016)
(Smith & Pederson, 1988)
(Smith et al., 1996)
(Smith et al., 2005)
(Smith et al., 2007)
(Steiner et al., 2018)
(Snijders et al., 2020)
(Sosa, 2016)
(Spangler et al., 2009)
(Spangler, 2013)
(Spencer & Meadow‐
Orlans, 1996)
(Spinrad et al., 2007)
(Stacks et al., 2014)
(Stacks et al., 2019)
(Stayton et al., 1971)
(Stein et al., 2012)
(Steiner et al., 2018)
(Stiles, 2004)
(Eriko & Yasue, 2013)
(Tamis-Lemonda et al.,
1998)
(Tamis‐LeMonda et al.,
2001)
(Tarabeh et al., 2019)
(Tarullo et al., 2020)
(Teramoto et al., 2010)
(Tétreault et al., 2017)
(Tharner et al., 2012)
(Thomas et al., 2017)
(Thompson et al., 2015)
(Towe-Goodman et al.,
2014)
(McMahan True et al.,
2001)
(Underwood & Gartstein,
2022)
(Vaccaro et al., 2021)

36

(Feldman, 2010)
(Ferber et al., 2008)
(Finegood et al., 2016)
(Finet et al., 2021)
(Flemington et al., 2015)
(Foss, 2001)
(Fourment et al., 2021)
(Frankel et al., 2015)
(Freitag et al., 1996)
(Frick et al., 2018)
(Frost et al., 2021)
(Gartstein et al., 2008)
(Gedaly & Leerkes, 2016)
(Geeraerts et al., 2020)
(Gerlach et al., 2022)
(Gillani et al., 2021)
(Goldberg et al., 2002)
(Grant et al., 2010)
(Julie & Miller, 2018)
(Gunnar & Donahue, 1980)
(Gunnar et al., 1996)
(Hakanen et al., 2019)
(Hallers-Haalboom et al.,
2017)
(Halligan et al., 2013)
(Haltigan et al., 2013)
(Haltigan et al., 2014)
(Hammer et al., 2019)
(Harker et al., 2016)
(Harris et al., 2020)
(Harrison & Ungerer, 2002)
(Hart & Behrens, 2013)
(Hepworth et al., 2021)
(McNally et al., 2019)
(Meijssen et al., 2010)
(Meins, 2013)
(Mermelshtine & Barnes,
2016)
(Merras‐Salmio et al.,
2013)
(Mesman et al., 2016)
(Michl-Petzing et al.,
2019)
(Miller et al., 2019)
(Mills-Koonce, Propper,
et al., 2007)
(Mills-Koonce, Gariepy,
et al., 2007)
(Mills-Koonce et al.,
2008)
(Montirosso et al., 2016)
(Moore et al., 2006)
(Moore et al., 2009)
(Munz et al., 2010)
(Murray & Hornbaker,
1997)
(Murray et al., 2016)
(Natsuaki et al., 2013)
(Newland et al., 2016)
(Rockville, 2000)
(Network, 2001)
(Popp et al., 2008)
(Pratt et al., 2019)
(Prime et al., 2020)
(Nicol-Harper et al.,
2007)
(Norcross et al., 2020)
(Vallotton et al., 2017)
(Van den Boom, 1994)
(van Dijk et al., 2018)
(Van Ijzendoorn &
Hubbard, 2000)
(van Vliet et al., 2022)
(Vazir et al., 2013)
(Wade et al., 2015)
(Wagner et al., 2019)
(Wallace et al., 1998)
(Wan et al., 2012)
(Wasserman et al., 1987)
(Waters et al., 2015)
(Watson et al., 2017)
(Whitt & Casey, 1982)
(Woodhouse et al., 2020)
(Worobey et al., 2009)
(Wu, 2021)
(Xing et al., 2016)
(Yarger et al., 2016)
(Yatziv et al., 2018)
(Zajac et al., 2019)
(Zeegers et al., 2018)
(Zhang et al., 2014)
Positive or
Neutral Affect
(n=229; 49.5%)
(Ablow 2013)
(Abraham et al., 2016)
(Anderson 2012)
(Aubuchon-Endsley et al.,
2020)
(Augustine 2019)
(Aureli & Presaghi, 2010)
(Aytuglu 2022)
(Azak & Raeder, 2013)
(Baker 2010)
(Banerjee 2022)
(Barnett 2008)
(Ha et al., 2002)
(Høivik et al., 2018)
(Halford & Petch, 2010)
(Hallers-Haalboom et al.,
2017)
(Halligan et al., 2013)
(Haltigan et al., 2013)
(Hammer et al., 2019)
(Harker et al., 2016)
(Harrison & Ungerer
2002)
(Mills-Koonce 2008)
(Mingo & Easterbrooks,
2015)
(Montirosso 2016)
(Moore et al., 2009)
(Moore et al., 2016)
(Munz et al., 2010)
(Natsuaki et al., 2010)
(Natsuaki et al., 2013)
(Neumann et al., 2020)
(Newland et al., 2016)
(Rockville, 2000)

37

(Barrera & Vella, 1987)
(Barry 2008)
(Bedford 2015)
(Bedford et al., 2017)
(Behrendt 2019)
(Beijersbergen et al., 2012)
(Belsky et al., 2015)
(Berkel 2015)
(Berlin 2018)
(Bernier 2018)
(Berry 2013)
(Berry 2017)
(Bigelow et al., 2010)
(Bilgin & Wolke, 2020)
(Biringen 1997)
(Biringen 2000)
(Blandon & Scrimgeour,
2015)
(Bohr et al., 2010)
(Bradley & Corwyn, 2007)
(Brandes-Aitken et al., 2020)
(Bretherton 2013)
(Brooks-Gunn et al., 2002)
(Brown et al., 2012)
(Brown et al., 2017)
(Brown & Cox, 2020)
(Buehler et al., 2011)
(Butti et al., 2018)
(Cassidy et al., 2010)
(Cerezo et al., 2008)
(Cha 2017)
(Clark et al., 2000)
(Coe 2021)
(Coffman et al., 1995)
(Conway 2020)
(Cooper et al., 2009)
(Crockenberg & Leerkes,
2003)
(Dáu et al., 2017)
(Dáu et al., 2019)
(Degnan et al., 2015)
(de Sousa et al., 2019)
(Din et al., 2009)
(Donovan & Leavitt, 1978)
(Doom et al., 2020)
(Early et al., 2002)
(Hazell Raine et al.,
2019)
(Hepworth et al., 2021a)
(Hepworth et al., 2021b)
(Herbers et al., 2020)
(Hibel et al., 2011)
(Hintermair et al., 2017)
(Hobson et al., 2005)
(Hofer et al., 2008)
(Holditch‐Davis et al.,
2011)
(Huang et al., 2012)
(Gillani et al., 2021)
(Huston & Rosenkrantz
Aronson, 2005)
(Isabella & Belsky,
1991)
(Ispa et al., 2017)
(Iverson et al., 2020)
(Jaffari-Bimmel et al.,
2006)
(Javakhishvili &
Vazsonyi, 2021)
(Jonsson et al., 2001)
(Jonsson & Clinton,
2006)
(Kachadourian et al.,
2009)
(Kaitz, Maytal, et al.,
2010)
(Kaitz, Shalev, et al.,
2010)
(Kaplan et al., 2009)
(Karasik et al., 2014)
(A. M. Kellerman et al.,
2020)
(Kiang et al., 2004)
(Kim & Kochanska,
2012)
(King et al., 2016)
(Kivijärvi et al., 2004)
(Klausli & Owen, 2009)
(Kochanska, 1998)
(Kochanska et al., 2008)
(Kochanska et al., 2015)
(R. Kok et al., 2013)
(Network, 2001)
(Nicholson et al., 2016)
(Noroña-Zhou et al., 2020)
(Nozadi et al., 2013)
(Ojo et al., 2021)
(O’Neal et al., 2017)
(Oosterom et al., 2020)
(Out et al., 2009)
(Pallewaththa et al., 2021)
(Parade et al., 2018)
(Paradis & Koester, 2015)
(Pearson et al., 2011)
(Pearson et al., 2012)
(Perone & Gartstein, 2019)
(Perone et al., 2020)
(Perrone et al., 2021)
(Pickles et al., 2013)
(Riddell et al., 2011)
(Pratt et al., 2019)
(Propper et al., 2008)
(Provenzi et al., 2020)
(Pungello et al., 2009)
(Puura et al. 2019)
(Quigley et al., 2017)
(Ravn et al., 2011)
(Rifkin-Graboi et al.,
2018)
(Robertson et al., 2011)
(Salo et al., 2010)
(Sarfi et al., 2011)
(Schoenmaker et al., 2015)
(Schofield & Weaver,
2016)
(Shai & Belsky, 2017)
(Sharma, 2022)
(Snijders et al., 2020)
(Spangler et al., 2009)
(Spencer & Meadow-
Orlans, 1996)
(Stacks et al., 2014)
(Stacks et al., 2019)
(Stams et al., 2002)
(Szajnberg et al., 1989)
(Tamis-LeMonda et al.,
2001)
(Tarullo et al., 2020)

38

(Eggum et al., 2009)
(Ereky-Stevens 2008)
(Fagan & Doveikis, 2019)
(Farkas et al., 2020)
(Faure et al., 2017)
(Favez et al., 2016)
(Fearon et al., 2017)
(Feldman & Eidelman, 2005)
(Feldman, 2007)
(Feldman 2009)
(Feldman 2010)
(Ferber et al., 2008)
(Finegood et al., 2016)
(Forman et al., 2007)
(Fourment et al., 2021)
(Frost et al., 2021)
(Fuchs et al., 2017)
(Góngora & Farkas, 2009)
(Gartstein et al., 2008)
(Geeraerts et al., 2020)
(Gerlach et al., 2022)
(Gibson et al., 2000)
(Godleski et al., 2016)
(Goldberg et al., 2002)
(Goodman et al., 2017)
(Gordon et al., 2010)
(Granat et al., 2017)
(Grant et al., 2010)
(Guzell & Vernon‐Feagans,
2004)
(Koren-Karie et al.,
2002)
(Kuzava et al., 2019)
(Landry et al., 1997)
(Landry et al., 2003)
(Landry et al., 2006)
(Landry et al., 2013)
(Lecuyer-Maus, 2000)
(Leerkes et al., 2004)
(Leerkes, 2011)
(Leerkes & Wong, 2012)
(Leerkes & Qu, 2017)
(Leerkes, Buehler, et al.,
2020)
(Legerstee et al., 2007)
(Leigh et al., 2011)
(Level et al., 2021)
(Lin et al., 2017)
(Lindhiem et al., 2011)
(Little et al., 2019)
(Lombardi, 2021)
(Maas et al., 2016)
(Mah et al., 2017)
(Malatesta et al., 1986)
(Meins et al., 2001)
(Merras-Salmio et al.,
2013)
(Messina et al., 2020)
(Michl-Petzing et al.,
2019)
(Miller et al., 2019)
(Mills-Koonce 2007a)
(Mills-Koonce 2007b)
(Tétreault et al., 2017)
(Tereno et al., 2019)
(Tester‐Jones et al., 2017)
(Thompson et al., 2015)
(Towe-Goodman et al.,
2014)
(Underwood & Gartstein,
2022)
(Vaccaro et al., 2021)
(Væver et al., 2022)
(Vallotton et al., 2017)
(van Bakel & Riksen‐
Walraven, 2008)
(Vazir et al., 2013)
(Vernon-Feagans et al.,
2016)
(Wade et al., 2015)
(Wagner et al., 2019)
(Willoughby et al., 2013)
(Wu & Gros-Louis, 2015)
(Wu et al., 2016)
(Wu, 2021)
(Yatziv et al., 2018)
(Zajac et al., 2019)
Following
Child’s Lead
(n=170; 36.7%)
(Ablow 2013)
(Akai et al., 2008)
(Alston & St. James-Roberts,
2005)
(Alvarenga et al., 2020)
(Aubuchon-Endsley et al.,
2020)
(Augustine 2019)
(Barry et al., 2008)
(Beckwith et al., 1999)
(Behrendt et al., 2019)
(Behrens et al., 2012)
(Belsky et al., 2015)
(Hintermair et al., 2017)
(Hobson et al., 2005)
(Holditch-Davis et al.,
2011)
(Huffmeijer et al., 2020)
(Huston & Rosenkrantz
Aronson, 2005)
(Isabella & Belsky,
1991)
(Isabella, 1993)
(Ispa et al., 2017)
(Iverson et al., 2020)
(Norcross et al., 2020)
(Noroña-Zhou, 2020)
(Nozadi et al., 2013)
(Nuttall et al., 2012)
(Paavola-Ruotsalainen et
al., 2018)
(Padilla-Walker et al.,
2020)
(Paradis & Koester, 2015)
(Pedroso & Gubert, 2021)
(Perone & Gartstein, 2019)
(Perone et al. 2020)
(Perrone et al., 2021)

39

(Berkel 2015)
(Berlin 2018)
(Bernier 2018)
(Berry 2017)
(Bigelow et al., 2004)
(Blandon & Scrimgeour,
2015)
(Bosquet Enlow et al., 2014)
(Bradley & Corwyn, 2007)
(Brandes-Aitken et al., 2020)
(Brooks-Gunn et al., 2002)
(Brown et al., 2012)
(Buehler et al., 2011)
(Butti et al., 2018)
(Cassidy et al., 2010)
(Cerezo et al., 2008)
(Clark et al., 2000)
(Coffman et al., 1995)
(Conway & McDonough,
2006)
(Conway 2020)
(Dàu et al., 2017)
(Dàu et al., 2019)
(Doiron & Stack, 2017)
(Doom et al., 2020)
(Dubois-Comtois et al.,
2017)
(Early et al., 2002)
(Ensink et al., 2017)
(Ereky-Stevens 2008)
(Fagan & Doveikis, 2019)
(Faure et al., 2017)
(Favez et al., 2016)
(Fearon et al., 2017)
(Feldman & Eidelman, 2005)
(Ferber et al., 2008)
(Forcada-Guex et al., 2006)
(Forman et al., 2007)
(Frost et al., 2021)
(Fuchs et al., 2017)
(Garnett et al., 2020)
(Gartstein et al., 2008)
(Gerlach et al., 2022)
(Gibson et al., 2000)
(Glanemann et al., 2013)
(Goodman et al., 2017)
(Javakhishvili &
Vazsonyi, 2021)
(Kachadourian et al.,
2009)
(Kaitz et al., 2010)
(Karl, 1995)
(Kiang et al., 2004)
(Kinard et al., 2017)
(King et al., 2016)
(Klausli & Owen, 2009)
(Kochanska & Coy
2002)
(Kochanska et al., 2005)
(Kok et al., 2013)
(Koren-Karie et al.,
2002)
(Kretchmar & Jacobvitz,
2002)
(Kuzava et al., 2019)
(Landry et al., 1997)
(Landry et al., 2003)
(Landry et al., 2006)
(Landry et al., 2013)
(Lee et al., 2022)
(Leerkes et al., 2004)
(Leerkes, Buehler et al.,
2020)
(Legerstee et al., 2007)
(Leigh et al., 2011)
(Lickenbrock &
Braungart-Rieker, 2015)
(Lloyd & Masur 2014)
(Lombardi, 2021)
(Maas et al. 2016)
(Madigan et al., 2015)
(Malmberg et al., 2016)
(Masur et al., 2005)
(McMahon & Newey,
2018)
(McNally et al., 2020)
(Michl-Petzing et al.,
2019)
(Mills-Koonce, Gariepy
et al., 2007)
(Mills-Koonce et al.,
2008)
(Pickles et al., 2013)
(Popp et al., 2008)
(Pridham et al., 2001)
(Quan et al., 2017)
(Ravn et al., 2011)
(Reichmuth et al., 2013)
(Ruggiero et al., 2020)
(Sakkalou et al., 2021)
(Schoenmaker et al., 2015)
(Schofield & Weaver,
2016)
(Scorza et al., 2021)
(Sharma, 2022)
(Short et al., 2020)
(Smith & Pederson, 1988)
(Smith et al., 1996)
(Smith et al., 2007)
(Spangler et al., 2009)
(Spencer & Meadow-
Orlans, 1996)
(Spinrad et al., 2007)
(Stacks et al., 2014)
(Stayton et al., 1971)
(Stein et al., 2012)
(Steiner et al., 2018)
(Tamis-LeMonda et al.,
2001)
(Tarabeh et al., 2019)
(Tétreault et al., 2017)
(Tester-Jones et al., 2017)
(Tharner et al., 2012)
(Thompson et al., 2015)
(Vaccaro et al., 2021)
(Vallotton et al., 2017)
(van Bakel & Riksen-
Walraven, 2008)
(Wade et al., 2015)
(Wan et al., 2012)
(Warren et al., 2003)
(Wasserman et al., 1987)
(Watson et al., 2017)
(Whitt & Casey, 1982)
(Wu et al., 2016)
(Wu, 2021)
(Yarger et al., 2016)
(Yatziv et al., 2018)

40

(Grant et al., 2010)
(Gros-Louis & Wu, 2012)
(Gunnar et al., 1996)
(Kochanska 1998)
(Guzell & Vernon-Feagans,
2004)
(Halligan et al., 2013)
(Haltigan et al., 2013)
(Hammer et al., 2019)
(Hepworth et al., 2021)
(Mingo & Easterbrooks,
2015)
(Montirosso et al., 2016)
(Moore et al., 2006)
(Murray & Hornbaker,
1997)
(Neumann et al., 2020)
(Network, 2001)
(Salo et al., 2010)
(Rockville, 2000)
(Nicholson et al., 2016)
(Zajac et al., 2019)
Well-Timed
(n=164; 35.4%)
(Adams et al., 2018)
(Albers et al., 2010)
(Alston & St. James-Roberts,
2005)
(Ambrose, 2016)
(Anzman-Frasca et al., 2018)
(Aureli & Presaghi, 2018)
(Aytuglu & Brown, 2022)
(Bakermans-Kranenburg &
van Ijzendoorn, 2006)
(Barry et al., 2008)
(Beckwith, Cohen et al.,
1999)
(Behrendt et al., 2019)
(Berkel et al., 2015)
(Berlin et al., 2018)
(Bernier et al., 2010)
(Bigelow et al., 2010)
(Biringen et al., 2000)
(Bisceglia et al., 2012)
(Bornstein et al., 2008)
(Bosquet Enlow et al., 2014)
(Bouvette-Turcot et al.,
2017)
(Brandes-Aitken et al., 2020)
(Bretherton, 2013)
(Broesch et al., 2016)
(Brown et al., 2012)
(Brown & Cox, 2020)
(Brundin et al., 1988)
(Campbell & Johnston,
2009)
(Cha, 2017)
(Choi et al., 2020)
(Clark et al., 2000)
(Hepworth et al., 2021b)
(Hodges et al., 2013)
(Hofer et al., 2008)
(Hohman et al., 2017)
(Isabella, 1993)
(Iverson et al., 2020)
(Jonsson & Clinton,
2006)
(Joosen et al., 2012)
(Juffer et al., 2005)
(Kalinauskiene et al.,
2009)
(Karasik et al., 2014)
(Kinard et al., 2017)
(King et al., 2016)
(Klein Velderman et al.,
2006)
(Kochanska & Coy,
2002)
(Koren-Karie et al.,
2002)
(Kretchmar & Jacobvitz,
2002)
(Landry et al., 1997)
(Landry et al., 2003)
(Landry et al., 2013)
(Leclère et al., 2014)
(Leerkes, 2011)
(Leerkes & Qu, 2017)
(Leezenbaum et al.,
2014)
(Li et al., 2022)
(Lieberman et al., 2019)
(Little et al., 2019)
(Logsdon et al., 2014)
(Page et al., 2010)
(Paul et al., 2019)
(Pederson et al., 1990)
(Pederson et al., 1998)
(Perone et al., 2020)
(Pretzer et al., 2019)
(Prime et al., 2020)
(Raby et al., 2012)
(Reichmuth et al., 2013)
(Rifkin-Graboi et al.,
2015)
(Rifkin-Graboi et al.,
2018)
(Roberts & Hampton,
2018)
(Rosenblum et al., 2020)
(Sakkalou et al., 2021)
(Savage et al., 2018)
(Schlansker, 1980)
(Schoenmaker et al., 2015)
(Schoppe-Sullivan et al.,
2006)
(Scorza et al., 2021)
(Shannon et al., 2006)
(Silberman et al., 2020)
(Smaling et al., 2016)
(Smith et al., 1996)
(Smith et al., 2005)
(Smith, 2018)
(Sosa, 2016)
(Spangler et al., 2009)
(Spangler, 2013)
(Stacks et al., 2014)
(Stayton et al., 1971)
(Stiles, 2004)

41

(Coffman et al., 1995)
(Conway 2020)
(Crockenberg & Leerkes,
2003)
(DiSantis et al., 2011)
(Eggum et al., 2009)
(Elmlinger et al., 2019)
(Evans et al., 1999)
(Fagan & Doveikis, 2019)
(Farkas et al., 2017)
(Farrell et al., 2019)
(Fearon et al., 2006)
(Feldman et al., 1999)
(Finet et al., 2021)
(Flemington et al., 2015)
(Fourment et al., 2021)
(Freitag et al., 1996)
(Frick et al., 2018)
(Gartstein et al., 2008)
(Gedaly & Leerkes, 2016)
(Gibson et al., 2000)
(Glanemann et al., 2013)
(Gros-Louis & Wu, 2012)
(Gros-Louis, 2018)
(Gunnar & Donahue, 1980)
(Hakanen et al., 2019)
(Hammer et al., 2019)
(Harris et al., 2020)
(Hart & Behrens, 2013)
(Hepworth et al., 2021a)
(Logsdon et al., 2015)
(Lucassen et al., 2011)
(Maas et al., 2013)
(Malatesta et al., 1986)
(Malmberg et al., 2016)
(Matvienko-Sikar et al.,
2018)
(McElwain & Booth-
LaForce, 2006)
(McMahon & Gibson,
2002)
(McNally et al., 2020)
(Meins, 2013)
(Miller et al., 2019)
(Mingo & Easterbrooks,
2015)
(Moreno-Núñez et al.,
2021)
(Murray & Hornbaker,
1997)
(Murray et al., 2016)
(Nicol-Harper et al.,
2007)
(Norcross et al., 2020)
(Northrup & Iverson,
2015)
(Nozadi et al., 2013)
(Nuttall et al., 2012)
(Olson & Masur, 2011)
(Paavola-Ruotsalainen,
2005)
(Talbott et al., 2016)
(Tamis-LeMonda et al.,
1998)
(Tamis-LeMonda et al.,
2001)
(Tarullo et al., 2020)
(Teramoto et al., 2010)
(Tharner et al., 2012)
(Towe-Goodman et al.,
2014)
(Tronick & Cohn, 1989)
(McMahan True et al.,
2001)
(Vaccaro et al., 2021)
(Vallotton et al., 2017)
(van Ijzendoorn &
Hubbard, 2000)
(Vanormelingen et al.,
2015)
(van Vliet et al., 2022)
(Wallace et al., 1998)
(Wasserman et al., 1987)
(Waters et al., 2015)
(Watson et al., 2017)
(Whitt & Casey, 1982)
(Woodhouse et al., 2020)
(Wu & Gros-Louis, 2015)
(Xing et al., 2016)
(Yatziv et al., 2018)
(Zhang et al., 2014)
Attention to the
Child
(n=162; 35.0%)
(Aboud et al., 2008)
(Abraham et al., 2016)
(Acebo & Thoman, 1995)
(Alston & St. James-Roberts,
2005)
(Anderson et al., 2012)
(Aubuchon-Endsley et al.,
2020)
(Augustine et al., 2018)
(Augustine & Leerkes, 2019)
(Bai et al., 2020)
(Bakermans-Kranenburg &
van Ijzendoorn, 2006)
(Barnett et al., 2008)
(Barrera & Vella, 1987)
(Hobson et al., 2005)
(Hodges et al., 2008)
(Holditch-Davis et al.,
2011)
(Holdsworth & Schell,
2017)
(Hurley et al., 2008)
(Isabella, 1993)
(Jacobvitz et al., 2006)
(Jonsson et al., 2001)
(Joosen et al., 2012)
(Juffer et al., 2005)
(Kaitz et al., 2010)
(Kalinauskiene et al.,
2009)
(Mesman et al., 2016)
(Moore et al., 2016)
(Murray & Hornbaker,
1997)
(Murray et al., 2016)
(Norcross et al., 2020)
(Northrup & Iverson,
2020)
(Nozadi et al., 2013)
(Ojo et al., 2021)
(O'Neal et al., 2017)
(Pia Santelices et al., 2010)
(Padilla-Walker et al.,
2020)
(Parade et al., 2018)

42

(Barry et al., 2008)
(Bedford et al., 2017)
(Bernier et al., 2018)
(Bigelow et al., 2004)
(Bigelow et al., 2010)
(Birmingham et al., 2017)
(Bliznashka et al., 2022)
(Bohr et al., 2010)
(Bouvette-Turcot et al.,
2017)
(Brandes-Aitken et al., 2020)
(Braungart-Rieker et al.,
2014)
(Brown et al., 2012)
(Cha, 2017)
(Coe et al., 2021)
(Conway & McDonough,
2006)
(Daniels et al., 2012)
(Dàu et al., 2019)
(Dayton et al., 2016)
(Degnan et al., 2015)
(DiSantis et al., 2013)
(Doiron & Stack, 2017)
(Donovan & Leavitt, 1978)
(Ereky-Stevens 2008)
(Eriko & Yasue, 2013)
(Evans & Porter 2009)
(Farkas et al., 2017)
(Farrell et al., 2019)
(Faure et al., 2017)
(Fearon et al., 2006)
(Feldman & Eidelman, 2005)
(Feldman et al., 2009)
(Feldman, 2010)
(Ferber et al., 2008)
(Flemington et al., 2015)
(Flynn & Masur, 2007)
(Foss, 2001)
(Fourment et al., 2021)
(Frick et al., 2018)
(Frost et al., 2021)
(Geeraerts et al., 2020)
(Godleski et al., 2016)
(Gordon et al., 2010)
(Granat et al., 2017)
(Kaplan et al., 2009)
(Karl, 1995)
(Kellerman et al., 2020)
(Khalsa et al., 2019)
(Kiel et al., 2011)
(Kinard et al., 2017)
(King et al., 2016)
(King et al., 2021)
(Kivijärvi et al., 2004)
(Kochanska & Coy,
2002)
(Kochanska et al., 2005)
(Komoto et al., 2015)
(Kopystynska et al.,
2016)
(Kuzava et al., 2019)
(Landau et al., 2009)
(Lee et al., 2022)
(Leerkes et al., 2004)
(Leerkes & Qu, 2017)
(Leerkes, Buehler et al.,
2020)
(Legerstee et al., 2007)
(Li et al., 2022)
(Lickenbrock &
Braungart-Rieker, 2015)
(Lieberman et al., 2019)
(Lin et al., 2017)
(Lindhiem et al., 2011)
(Lloyd & Masur, 2014)
(Logsdon et al., 2014)
(Lowe et al., 2017)
(Lucassen et al., 2011)
(Maas et al., 2013)
(Maas et al., 2016)
(MacTurk et al., 1993)
(Mah et al., 2017)
(Masur et al., 2005)
(McElwain & Booth-
LaForce, 2006)
(McMahon & Gibson,
2002)
(McMahon & Newey,
2018)
(McNally et al., 2020)
(Meins et al., 2001)
(Parade et al., 2019)
(Park et al., 1997)
(Pearson et al., 2011)
(Pederson et al., 1990)
(Pederson et al., 1998)
(Pedroso & Gubert, 2021)
(Pianta et al., 1989)
(Popp et al., 2008)
(Puura et al., 2019)
(Raby et al., 2012)
(Ransone et al., 2018)
(Ravn et al., 2011)
(Rifkin-Graboi et al.,
2018)
(Rifkin-Graboi et al.,
2021)
(Rosenblum et al., 2020)
(Ruggiero et al., 2020)
(Salo et al., 2010)
(Sansavini et al., 2015)
(Schlansker, 1980)
(Smith & Pederson, 1988)
(Smith et al., 1996)
(Smith et al., 2007)
(Spangler et al., 2009)
(Spangler, 2013)
(Spinrad et al., 2007)
(Stacks et al., 2014)
(Stein et al., 2012)
(Steiner et al., 2018)
(Stiles, 2004)
(Talbott et al., 2016)
(Tétreault et al., 2017)
(Teramoto et al., 2010)
(Tharner et al., 2012)
(Væver et al., 2022)
(van den Boom, 1994)
(van Vliet et al., 2022)
(Wan et al., 2012)
(Wasser et al., 2017)
(Woodhouse et al., 2020)
(Worobey et al., 2009)
(Wu et al., 2016)

43

(Haltigan et al., 2014)
(Harker et al., 2016)
(Mermelshtine & Barnes,
2016)
Verbal
Communication
(n=123; 26.6%)
(Abraham et al., 2016)
(Alston & St. James-Roberts,
2005)
(Alvarenga et al., 2020)
(Ambrose, 2016)
(Athari et al., 2021)
(Aubuchon-Endsley et al.,
2020)
(Aureli & Presaghi, 2010)
(Banerjee et al., 2022)
(Barrera & Vella, 1987)
(Behrendt et al., 2019)
(Behrens et al., 2012)
(Belsky, 1980)
(Berkel et al., 2015)
(Berlin et al., 2018)
(Bigelow et al., 2004)
(Bigelow et al., 2010)
(Blizzard et al., 2018)
(Brandes-Aitken et al., 2020)
(Brundin et al., 1988)
(Boin Choi et al., 2020)
(Cooper et al., 2009)
(Crockenberg & Leerkes,
2003)
(Dàu et al., 2019)
(Shruti Dave et al., 2018)
(Donovan & Leavitt, 1978)
(Doom et al., 2020)
(Early et al., 2002)
(Eggum et al., 2009)
(Elmlinger et al., 2019)
(Ereky-Stevens 2008)
(Evans et al., 1999)
(Fagan & Doveikis, 2019)
(Favez et al., 2016)
(Feldman & Eidelman, 2005)
(Feldman et al., 2009)
(Feldman, 2010)
(Ferber et al., 2008)
(Flynn & Masur, 2007)
(Fourment et al., 2021)
(Goldberg et al., 2002)
(Gordon et al., 2010)
(Ha et al., 2002)
(Halford & Petch, 2010)
(Harker et al., 2016)
(Hazell Raine et al.,
2019)
(Hepworth et al., 2021)
(Hintermair et al., 2017)
(Hofer et al., 2008)
(Gillani et al., 2021)
(Ispa et al., 2017)
(Jeukens-Visser et al.,
2021)
(Kaitz et al., 2010)
(Kaitz et al., 2010)
(Karasik et al., 2014)
(A. M. Kellerman et al.,
2020)
(Kinard et al., 2017)
(King et al., 2016)
(Kuzava et al., 2019)
(Landry et al., 1997)
(Landry et al., 2003)
(Landry et al., 2006)
(Lee et al., 2022)
(Leerkes et al., 2004)
(Leerkes, 2011)
(Leezenbaum et al.,
2014)
(Legerstee et al., 2007)
(Level et al., 2021)
(Lieberman et al., 2019)
(Lin et al., 2017)
(Little et al., 2019)
(Lloyd & Masur, 2014)
(McMahon & Newey,
2018)
(Mermelshtine & Barnes,
2016)
(Michl-Petzing et al.,
2019)
(Moore et al., 2006)
(Moreno-Núñez et al.,
2021)
(Munz et al., 2010)
(Northrup & Iverson,
2015)
(Northrup & Iverson,
2020)
(Nozadi et al., 2013)
(Oosterom et al., 2020)
(Otomo, 2001)
(Out et al., 2009)
(Padilla‐Walker et al.,
2020)
(Pallewaththa et al., 2021)
(Popp et al., 2008)
(Pratt et al., 2019)
(Ransone et al., 2018)
(Ravn et al., 2011)
(Ruffman et al., 2020)
(Sansavini et al., 2015)
(Schofield & Weaver,
2016)
(Shai & Belsky, 2017)
(Smith & Pederson, 1988)
(Smith et al., 1996)
(Smith et al., 2018)
(Snijders et al., 2020)
(Sosa, 2016)
(Stacks et al., 2014)
(Stein et al., 2012)
(Talbott et al., 2016)
(Tamis‐LeMonda et al.,
2001)
(Tarabeh et al., 2019)
(Tétreault et al., 2017)
(Tereno et al., 2019)
(Tester‐Jones et al., 2017)
(Væver et al., 2022)
(van Bakel & Riksen‐
Walraven, 2008)
(Van den Boom, 1994)
(Vanormelingen et al.,
2015)
(Vazir et al., 2013)
(Vernon-Feagans et al.,
2016)
(Watson et al., 2017)

44

(Granat et al., 2017)
(Grant et al., 2010)
(Gros-Louis & Wu, 2012)
(Guzell & Vernon-Feagans,
2004)
(Natsuaki et al., 2010)
(Network, 2001)
(Nicholson et al., 2016)
(Wu & Gros-Louis, 2015)
(Wu et al., 2016)
Developmental
Appropriateness
(n=120; 25.9%)
(Abel et al., 2018)
(Adams et al., 2018)
(Alston & St. James-Roberts,
2005)
(Anzman-Frasca et al., 2018)
(Aytuglu & Brown, 2022)
(Baker et al., 2010)
(Banerjee et al., 2022)
(Barnett et al., 2008)
(Beckwith, Howard, et al.,
1999)
(Bedford et al., 2017)
(Behrens et al., 2012)
(Beijersbergen et al., 2012)
(Berry et al., 2017)
(Bilgin & Wolke, 2020)
(Biringen et al., 2000)
(Bliznashka et al., 2022)
(Brandes-Aitken et al., 2020)
(Braungart-Rieker et al.,
2010)
(Brooks-Gunn et al., 2002)
(Brown et al., 2012)
(Brown et al., 2017)
(Brown & Cox, 2020)
(Caldera & Lindsey, 2006)
(Daniels et al., 2012)
(Dàu et al., 2019)
(S. Dave et al., 2018)
(Degnan et al., 2015)
(Din et al., 2009)
(DiSantis et al., 2011)
(DiSantis et al., 2013)
(Early et al., 2002)
(Eggum et al., 2009)
(Elmadih et al., 2014)
(Ensink et al., 2017)
(Ereky-Stevens 2008)
(Feldman et al., 2004)
(Finegood et al., 2016)
(Gartstein et al., 2008)
(Hohman et al., 2017)
(Holditch-Davis et al.,
2011)
(Huang et al., 2012)
(Huffmeijer et al., 2020)
(Gillani et al., 2021)
(Hurley et al., 2008)
(Ispa et al., 2017)
(Iverson et al., 2020)
(Jaffari-Bimmel et al.,
2006)
(Jeukens‐Visser et al.,
2021)
(Juffer et al., 2005)
(Kaplan et al., 2009)
(Karrass & Braungart-
Rieker, 2003)
(Khalsa et al., 2019)
(Kivijärvi et al., 2004)
(Kochanska 1998)
(Rianne Kok et al., 2013)
(Kopystynska et al.,
2016)
(Landau et al., 2009)
(Landry et al., 1997)
(Lecuyer-Maus, 2000)
(Madigan et al., 2015)
(Mills-Koonce, Propper,
et al., 2007)
(Moore et al., 2009)
(Murray & Hornbaker,
1997)
(Neumann et al., 2020)
(Nozadi et al., 2013)
(Nuttall et al., 2012)
(Ojo et al., 2021)
(Out et al., 2009)
(Page et al., 2010)
(Pallewaththa et al.,
2021)
(Paul et al., 2019)
(Riddell et al., 2011)
(Pridham et al., 2001)
(Propper et al., 2008)
(Pungello et al., 2009)
(Quan et al., 2017)
(Quigley et al., 2017)
(Ravn et al., 2011)
(Rifkin‐Graboi et al.,
2018)
(Rifkin-Graboi et al.,
2021)
(Rodrigues et al., 2021)
(Ruggiero et al., 2020)
(Sall et al., 2020)
(Savage et al., 2018)
(Schofield & Weaver,
2016)
(Short et al., 2020)
(Smith et al., 1996)
(Smith et al., 2005)
(Smith et al., 2007)
(Smith et al., 2018)
(Stacks et al., 2019)
(Stams et al., 2002)
(Stein et al., 2012)
(Suchman et al., 2010)
(Talbott et al., 2016)
(Teramoto et al., 2010)
(Tereno et al., 2019)
(Tester‐Jones et al., 2017)
(Thomas et al., 2017)
(van Bakel & Riksen‐
Walraven, 2008)
(Vazir et al., 2013)
(Vernon-Feagans et al.,
2016)
(Wade et al., 2015)
(Wagner et al., 2019)
(Wallace et al., 1998)
(Wan et al., 2012)
(Wasser et al., 2017)

45

(Globus et al., 2019)
(Goodman et al., 2017)
(Halford & Petch, 2010)
(Harris et al., 2020)
(Hibel et al., 2011)
(Hintermair et al., 2017)
(Pedroso & Gubert,
2021)
(Perone & Gartstein,
2019)
(Perone et al., 2020)
(Watson et al., 2017)
(Willoughby et al., 2013)
(Wu, 2021)
(Zajac et al., 2019)
Transactional
(n=107; 23.1%)
(Aboud et al., 2008)
(Aubuchon-Endsley et al.,
2020)
(Augustine & Leerkes, 2019)
(Aureli & Presaghi, 2010)
(Aureli et al., 2018)
(Aytuglu & Brown, 2022)
(Azak & Raeder, 2013)
(Barrera & Vella, 1987)
(Barry et al., 2008)
(Behrens et al., 2012)
(Bernier et al., 2018)
(Bigelow et al., 2004)
(Biringen et al., 1997)
(Bosquet Enlow et al., 2014)
(Braungart-Rieker et al.,
2010)
(Brown & Cox, 2020)
(Clark et al., 2000)
(Coe et al., 2021)
(Dàu et al., 2019)
(Doiron & Stack, 2017)
(Ereky-Stevens 2008)
(Eriko & Yasue, 2013)
(Evans & Porter, 2009)
(Favez et al., 2016)
(Feldman & Eidelman, 2005)
(Feldman, 2007)
(Forman et al., 2007)
(Góngora & Farkas, 2009)
(Gartstein et al., 2008)
(Gibson et al., 2000)
(Goodman et al., 2017)
(Grant et al., 2010)
(Gunnar & Donahue, 1980)
(Guzell & Vernon-Feagans,
2004)
(Høivik et al., 2018)
(Isabella & Belsky,
1991)
(Isabella, 1993)
(Iverson et al., 2020)
(Jeukens-Visser et al.,
2021)
(Jonsson et al., 2001)
(Juffer et al., 2005)
(Kaitz et al., 2010)
(Kaitz et al., 2010)
(Karasik et al., 2014)
(Karrass & Braungart-
Rieker, 2003)
(A. M. Kellerman et al.,
2020)
(Kim & Kochanska,
2012)
(Kinard et al., 2017)
(King et al., 2016)
(Kivijärvi et al., 2004)
(Kochanska & Coy,
2002)
(Kochanska et al., 2005)
(Kochanska et al., 2008)
(Kochanska et al., 2015)
(Kretchmar & Jacobvitz,
2002)
(Leclère et al., 2014)
(Leerkes & Wong, 2012)
(Leerkes, Buehler, et al.,
2020)
(Level et al., 2021)
(Lowe et al., 2017)
(MacTurk et al., 1993)
(Matvienko-Sikar et al.,
2018)
(McMahon & Gibson,
2002)
(Mesman et al., 2016)
(Miller et al., 2019)
(Montirosso et al., 2010)
(Moore et al., 2006)
(Neumann et al., 2020)
(Newland et al., 2016)
(Nicholson et al., 2016)
(Northrup & Iverson,
2015)
(Oosterom et al., 2020)
(Otomo, 2001)
(Paradis & Koester, 2015)
(Park et al., 1997)
(Pedroso & Gubert, 2021)
(Perone & Gartstein, 2019)
(Perone et al., 2020)
(Planalp et al., 2019)
(Pratt et al., 2019)
(Pridham et al., 2001)
(Robertson et al., 2011)
(Ruggiero et al., 2020)
(Sakkalou et al., 2021)
(Sansavini et al., 2015)
(Sarfi et al., 2011)
(Spencer & Meadow‐
Orlans, 1996)
(Stacks et al., 2014)
(Szajnberg et al., 1989)
(Tester‐Jones et al., 2017)
(Tharner et al., 2012)
(Thompson et al., 2015)
(Tronick & Cohn, 1989)
(van Dijk et al., 2018)
(Vanormelingen et al.,
2015)
(Wade et al., 2015)
(Warren et al., 2003)
(Watson et al., 2017)
(Yatziv et al., 2018)
(Zajac et al., 2019)

46

(Mingo & Easterbrooks,
2015)
Accurate
Interpretation
(n=83; 17.9%)
(Aboud et al., 2008)
(Augustine et al., 2018)
(Bai et al., 2020)
(Bakermans-Kranenburg &
van Ijzendoorn, 2006)
(Bisceglia et al., 2012)
(Bliznashka et al., 2022)
(Bosquet Enlow et al., 2014)
(Bouvette-Turcot et al.,
2017)
(Braungart-Rieker et al.,
2010)
(Braungart-Rieker et al.,
2014)
(Bretherton, 2013)
(Brown et al., 2012)
(Coe et al., 2021)
(Colonnesi et al., 2019)
(Din et al., 2009)
(Doiron & Stack, 2017)
(Ereky-Stevens 2008)
(Farkas et al., 2017)
(Farkas et al., 2020)
(Farrell et al., 2019)
(Fearon et al., 2006)
(Finet et al., 2021)
(Forman et al., 2007)
(Foss, 2001)
(Fourment et al., 2021)
(Freitag et al., 1996)
(Frick et al., 2018)
(Haltigan et al., 2014)
(Herbers et al., 2020)
(Hintermair et al., 2017)
(Hofer et al., 2008)
(Holditch-Davis et al., 2011)
(Fuchs et al., 2017)
(Fuertes et al., 2020)
(Gartstein et al., 2008)
(Gedaly & Leerkes,
2016)
(Grant et al., 2010)
(Hakanen et al., 2019)
(Hallers-Haalboom et al.,
2017)
(Hodges et al., 2008)
(Horodynski et al., 2015)
(Isabella, 1993)
(Jacobvitz et al., 2006)
(Joosen et al., 2012)
(Juffer et al., 2005)
(Kalinauskiene et al.,
2009)
(Kiang et al., 2004)
(King et al., 2016)
(Klein Velderman et al.,
2006)
(Kretchmar & Jacobvitz,
2002)
(Li et al., 2022)
(Lickenbrock &
Braungart-Rieker, 2015)
(Lloyd & Masur, 2014)
(Logsdon et al., 2014)
(Lucassen et al., 2011)
(McMahon & Newey,
2018)
(Mingo & Easterbrooks,
2015)
(Neumann et al., 2020)
(Nicol-Harper et al.,
2007)
(Page et al., 2010)
(Parade et al., 2018)
(Parade et al., 2019)
(Pauli-Pott et al., 2004)
(Perone et al., 2020)
(Riddell et al., 2011)
(Quan et al., 2017)
(Raby et al., 2012)
(Rifkin-Graboi et al.,
2015)
(Schlansker, 1980)
(Schoppe-Sullivan et al.,
2006)
(Spangler, 2013)
(Stacks et al., 2014)
(Stiles, 2004)
(Eriko & Yasue, 2013)
(Tarabeh et al., 2019)
(Tarullo et al., 2020)
(Tétreault et al., 2017)
(Tharner et al., 2012)
(Vaccaro et al., 2021)
(van Vliet et al., 2022)
(Wan et al., 2012)
(Warren et al., 2003)
(Waters et al., 2015)
(Whitt & Casey, 1982)
(Woodhouse et al., 2020)
(Xing et al., 2016)
(Zajac et al., 2019)
(Zeegers et al., 2018)
Physical Touch
and Proximity
(n=72; 15.6%)
(Abraham et al., 2016)
(Aubuchon-Endsley et al.,
2020)
(Augustine & Leerkes, 2019)
(Aureli & Presaghi, 2010)
(Barnett et al., 2008)
(Barrera & Vella, 1987)
(Ha et al., 2002)
(Harrison & Ungerer,
2002)
(Hazell Raine et al.,
2019)
(Hepworth et al., 2021a)
(Hepworth et al., 2021b)
(Network, 2001)
(Out et al., 2009)
(Padilla‐Walker et al.,
2020)
(Pearson et al., 2011)
(Pearson et al., 2012)
(Pratt et al., 2019)

47

(Berlin et al., 2018)
(Bigelow et al., 2004)
(Blandon & Scrimgeour,
2015)
(Blunden et al., 2022)
(Cerezo et al., 2008)
(Cooper et al., 2009)
(Crockenberg & Leerkes,
2003)
(Dàu et al., 2019)
(Donovan & Leavitt, 1978)
(Doom et al., 2020)
(Early et al., 2002)
(Ensink et al., 2017)
(Favez et al., 2016)
(Feldman, 2010)
(Fourment et al., 2021)
(Globus et al., 2019)
(Granat et al., 2017)
(Grant et al., 2010)
(Gunnar et al., 1996)
(Guzell & Vernon-Feagans,
2004)
(Herbers et al., 2020)
(Hofer et al., 2008)
(Gillani et al., 2021)
(Kaitz et al., 2010)
(Kaitz et al., 2010)
(Karl, 1995)
(Kiel et al., 2011)
(Kinard et al., 2017)
(King et al., 2016)
(Kuzava et al., 2019)
(Landry et al., 1997)
(Landry et al., 2003)
(Leerkes et al., 2004)
(Leerkes, 2011)
(MacTurk et al., 1993)
(McMahon & Gibson,
2002)
(Meins et al., 2001)
(Mermelshtine & Barnes,
2016)
(Mills-Koonce, Propper,
et al., 2007)
(Munz et al., 2010)
(Pungello et al., 2009)
(Robertson et al., 2011)
(Sansavini et al., 2015)
(Schofield & Weaver,
2016)
(Shai & Belsky, 2017)
(Smith & Pederson, 1988)
(Smith et al., 1996)
(Stacks et al., 2014)
(Suchman et al., 2010)
(Teramoto et al., 2010)
(Tester‐Jones et al., 2017)
(Van den Boom, 1994)
(Vazir et al., 2013)
(Watson et al., 2017)
(Wu & Gros-Louis, 2015)
Effective
Conflict
Resolution
(n=65; 14.0%)
(Baker et al., 2010)
(Banerjee et al., 2022)
(Behrendt et al., 2019)
(Behrens et al., 2012)
(Mariëlle D Beijersbergen et
al., 2012)
(Berkel et al., 2015)
(Braungart-Rieker et al.,
2014)
(Campbell & Johnston,
2009)
(Conway & McDonough,
2006)
(Dàu et al., 2017)
(Dayton et al., 2016)
(Dubois-Comtois et al.,
2017)
(Ensink et al., 2017)
(Feldman & Eidelman, 2005)
(Feldman, 2010)
(Ferber et al., 2008)
(Flemington et al., 2015)
(Forcada-Guex et al., 2006)
(Globus et al., 2019)
(Gunnar et al., 1996)
(Høivik et al., 2018)
(Hammer et al., 2019)
(Harrison & Ungerer,
2002)
(Holdsworth & Schell,
2017)
(Ispa et al., 2017)
(Jaffari-Bimmel et al.,
2006)
(Kaplan et al., 2009)
(Kiang et al., 2004)
(Kinard et al., 2017)
(Kochanska et al., 2015)
(Koren-Karie et al.,
2002)
(Kuzava et al., 2019)
(Landry et al., 2006)
(Laxman et al., 2015)
(Lecuyer-Maus, 2000)
(Leerkes et al., 2004)
(Lindhiem et al., 2011)
(Mingo & Easterbrooks,
2015)
(Out et al., 2009)
(Page et al., 2010)
(Paradis & Koester, 2015)
(Pearson et al., 2011)
(Pickles et al., 2013)
(Riddell et al., 2011)
(Pratt et al., 2019)
(Provenzi et al., 2020)
(Quan et al., 2017)
(Ransone et al., 2018)
(Rifkin‐Graboi et al.,
2018)
(Robertson et al., 2011)
(Shai & Belsky, 2017)
(Spangler et al., 2009)
(Stams et al., 2002)
(Tarullo et al., 2020)
(Thomas et al., 2017)
(van Bakel & Riksen‐
Walraven, 2008)

48

(Frankel et al., 2015)
(Fuchs et al., 2017)
(Gerlach et al., 2022)
(Gibson et al., 2000)
(Maas et al., 2013)
(McElwain & Booth-
LaForce, 2006)
(Miller et al., 2019)
(von der Lippe et al.,
2010)
(Yatziv et al., 2018)
Consistency
(n=40; 8.6%)
(Anderson et al., 2012)
(Berlin et al., 2018)
(Bohr et al., 2010)
(Farkas et al., 2020)
(Feldman & Eidelman, 2005)
(Feldman et al., 2009)
(Feldman, 2010)
(Ferber et al., 2008)
(Gartstein et al., 2008)
(Goodman et al., 2017)
(Gordon et al., 2010)
(Hepworth et al., 2021)
(Huffmeijer et al., 2020)
(Iverson et al., 2020)
(Kachadourian et al.,
2009)
(King et al., 2016)
(Kochanska et al., 2015)
(Legerstee et al., 2007)
(Maas et al., 2013)
(Matvienko-Sikar et al.,
2018)
(McElwain & Booth-
LaForce, 2006)
(McNally et al., 2020)
(Meijssen et al., 2010)
(Meins, 2013)
(Neumann et al., 2020)
(Network, 2001)
(Nover et al., 1984)
(Out et al., 2009)
(Pallewaththa et al., 2021)
(Parade et al., 2019)
(Pederson et al., 1998)
(Perone & Gartstein, 2019)
(Sakkalou et al., 2021)
(Sansavini et al., 2015)
(Spangler et al., 2009)
(Spencer & Meadow‐
Orlans, 1996)
(Towe-Goodman et al.,
2014)
(van Dijk et al., 2018)
(Wallace et al., 1998)
(Waters et al., 2015)
Being Present
(n=26; 5.6%)
(Akai et al., 2008)
(Barry et al., 2008)
(Bedford et al., 2015)
(Berlin et al., 2018)
(Bernier et al., 2018)
(Clark et al., 2000)
(Colonnesi et al., 2019)
(Dayton et al., 2016)
(Góngora & Farkas, 2009)
(Hazell Raine et al., 2019)
(Iverson et al., 2020)
(Kim & Kochanska,
2012)
(Kochanska & Coy,
2002)
(Kretchmar & Jacobvitz,
2002)
(Leerkes et al., 2004)
(Lin et al., 2017)
(Logsdon et al., 2015)
(Miller et al., 2019)
(Montirosso et al., 2010)
(Oosterom et al., 2020)
(Page et al., 2010)
(Pratt et al., 2019)
(Snijders et al., 2020)
(Stacks et al., 2014)
(Tétreault et al., 2017)
(van Bakel & Riksen‐
Walraven, 2008)
Mirroring,
Reflecting, or
Imitating
(n=24; 5.2%)
(Alvarenga et al., 2020)
(Athari et al., 2021)
(Bakermans-Kranenburg &
van Ijzendoorn, 2006)
(Bigelow et al., 2010)
(Blizzard et al., 2018)
(Ereky-Stevens 2008)
(Feldman & Eidelman, 2005)
(Feldman, 2007)
(Glanemann et al., 2013)
(Kaitz et al., 2010)
(Kivijärvi et al., 2004)
(Kuzava et al., 2019)
(Lee et al., 2022)
(Leerkes et al., 2004)
(Lowe et al., 2017)
(Otomo, 2001)
(Pearson et al., 2012)
(Provenzi et al., 2020)
(Reichmuth et al., 2013)
(Talbott et al., 2016)
(Tamis‐LeMonda et al.,
2001)
(Væver et al., 2022)
(Weinberg et al., 1999)
(Wu et al., 2016)
Effective
(n=19; 4.1%)
(Augustine & Leerkes, 2019)
(Beijersbergen et al., 2012)
(Egotubov et al., 2020)
(Gartstein et al., 2008)
(Karl, 1995)
(Kiang et al., 2004)
(Lin et al., 2017)
(Mah et al., 2017)
(Masur et al., 2005)
(Neumann et al., 2020)
(Oosterom et al., 2020)
(Perone, 2019)
(Schoenmaker et al., 2015)
(Snijders et al., 2020)
(Stams et al., 2002)
(Væver et al., 2022)
(Yatziv et al., 2018)

49

(Kuzava et al., 2019) (Pridham et al., 2001)

Discussion
The purpose of this study was to develop a comprehensive, multidimensional, literature-
grounded definition of parent responsiveness. The resulting definition included a wide variety of
behaviors and characteristics of interaction that comprise parent responsiveness. This definition
contributes to the existing parent responsiveness literature by integrating and summarizing the
array of conceptualizations of this construct in order to provide a unifying framework for future
research.
One commonly cited definition of parent responsiveness is Ainsworth’s
conceptualization, which included sensitivity (“response to the infant’s signals and
communications” [p. 19]), acceptance-rejection (“balance between positive and negative feelings
about her baby” [p. 19]), cooperation-interference (degree of respect and imposition), and
accessibility (“attention is nearly always tuned-in to the baby” [p. 19]) (Ainsworth, 1969). The
definition of parent responsiveness established in this study reflects Ainsworth’s
conceptualization in the following dimensions: contingent responses (reflective of Ainsworth’s
sensitivity dimension), following the child’s lead (reflective of Ainsworth’s acceptance-
rejection), transactional nature of parent responsiveness (reflective of Ainsworth’s cooperation-
interference), and attention to the infant (reflective of Ainsworth’s accessibility). The definition
in this study also expands upon Ainsworth’s seminal work by including several new dimensions
drawn from other literature: being present, consistency of interaction, mirroring the infant’s
behavior, verbal communication, physicality of responsive behavior, effective conflict
resolution, and developmental appropriateness. These distinctions reflect the evolving nature of
the study of parent responsiveness over decades of research.

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Much of the extant literature focused primarily on parent responsiveness to verbal and
preverbal infant cues (Edmunds et al., 2019; Leezenbaum et al., 2014; Wu & Gros-Louis, 2015).
The comprehensive definition presented in this study reflects the importance of verbal
communication. Additionally, in this study we extracted important components of
responsiveness that can be applied both to verbal and preverbal cues as well as to infant cues in
other domains, such as sensory reactivity and regulation. That is, this study served to expand the
conceptualization of parent responsiveness to a broader set of qualities and types of parent
behavior that is not bound to only infants’ communicative cues.
Limitations
The results of this systematic review must be considered in light of a few limitations.
First, the review was limited to articles published in English, due to lack of availability of study
personnel fluent in other languages. While this may have limited the cultural diversity present in
articles’ definitions of parent responsiveness, results included participants from 37 countries,
which may have reduced the impact of this limitation. Finally, some articles used certain terms
interchangeably, while others used the same terms distinctly. For example, many articles used
“sensitivity” as the term referring to their responsiveness construct. However, other articles used
both “sensitivity” and “responsiveness” to describe slightly different constructs. In the former
case, the definition of “sensitivity” was included in analyses. In the latter case, the definition of
“responsiveness” was included. This limitation demonstrated the complex nature of this
construct in the literature.
Implications and Future Directions
The definition of parent responsiveness derived from the literature in this study can serve
as an organizing framework for studying parent responsiveness. That is, due to the complex

51

nature of parent responsiveness and wide array of conceptualizations used to study it, the field
has been yet unable to cohesively examine the “key ingredients” of this construct for optimal
child development. Additionally, it is yet unclear how much and what components of parent
responsiveness contribute most to developmental variability across domains. Future research
should include development of a valid, reliable measure to assess parent responsiveness;
comparison of the outcomes of responsive behavior across dimensions; and expansion of this
definition of parent responsiveness beyond infancy and early toddlerhood.

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Chapter 3: Measurement Development for Parent Responsiveness to
Sensory Reactivity and Regulation Cues
Abstract
Infants constantly take in sensory information that allows them to interact with and
experience the environment around them. These early sensory experiences, which are supported
by immense neuroplasticity in infancy and toddlerhood, may affect later preferences for certain
types of sensory experiences. Additionally, infants’ exploration of their environments and early
communication provides parents with intentional and unintentional cues about those preferences.
The manner in which parents respond to infant cues in order to scaffold the infant’s experiences
with sensory information in the environment may be important for supporting healthy
development across domains. Parent responsiveness to sensory reactivity and regulation (SRR)
cues relies on both the infant’s existing sensory processing skills and the parent’s own ability to
recognize and respond effectively to the infant’s cues. No tool currently exists in the literature to
measure parent responsiveness in this domain across populations of parent-infant dyads in which
there is elevated likelihood of suboptimal infant development due to SDH or early behavioral
signs. The purpose of this study was to employ the results of the systematic review of the
literature in Study 1 to further develop and refine an existing unpublished measure of parent
responsiveness to infant SRR cues. Measure development will serve to yield a more
comprehensive tool to measure parent responsiveness to SRR cues.
Background and Introduction
Infants constantly experience sensory input, both familiar and novel, from their
environments throughout their daily routines, facilitated by parents. As a result of these daily
sensory experiences, infants’ sensory systems develop throughout early life (Corbetta & Snapp-

53

Childs, 2009; Marshall, 2011). As sensory systems develop, infants and children learn to attend
to salient sensory input, “tune out” irrelevant sensory input, gain more of the sensory input that
they enjoy, and use information from multiple sensory systems to learn about and interact with
their environment. These processes are referred to here as sensory reactivity and regulation
(SRR). Individuals vary in the manner in which they are able to effectively manage the sensory
information in their environment, as well as their preferences for different types of sensory input.
An infant’s SRR may fall outside the range of typical sensory experiences, which manifest in
various behavioral patterns of response, which may include sensory hyporeactivity; sensory
hyperreactivity; and sensory interests, repetitions, and seeking (SIRS) behaviors (Baranek et al.,
2006; Ben-Sasson et al., 2009; Liss et al., 2006). Sensory hyporeactivity refers to a delayed or
lack of response to sensory input; for example, an infant demonstrating sensory hyporeactivity
may not turn toward his parent calling his name. Sensory hyperreactivity refers to an aversive or
defensive response to sensory input; for example, an infant demonstrating sensory
hyperreactivity may cover her ears or become upset when her parent activates a noisy toy. SIRS
refers to an intense desire for or seeking of certain sensory input. For example, an infant
demonstrating SIRS may hold toys that make sounds very close to their ears for long periods of
time or repeatedly rub objects with preferred textures.
Across sensory preferences and levels of sensory hyporeactivity, hyperreactivity, or
SIRS, all infants display intentional and unintentional cues about the current state of their SRR,
and parents may recognize these cues and respond by altering or perpetuating the infant’s
sensory experiences accordingly. While parent responsiveness to infant attention and verbal cues
has been widely studied (Edmunds et al., 2019; Kinard et al., 2017; Wan et al., 2019), literature
on parent responsiveness to SRR-specific infant cues is lacking. This type of parent

54

responsiveness may rely both on infant sensory features and on a parent’s own ability to manage
sensory input in addition to providing the sensitive and timely responses that characterize any
type of parent responsiveness (Donovan et al., 2007; Jaegermann & Klein, 2010; Kinard et al.,
2017; Wan et al., 2012). Research to elucidate levels of parent responsiveness to SRR and factors
that contribute to a parent’s ability to respond to cues in this area will require a comprehensive,
efficient, psychometrically sound measure of parent responsiveness to SRR cues.
Potential Barriers to Parent Responsiveness to SRR across Populations
Because parent responsiveness is dependent upon both the parent’s behavior and their
infants’ cues, several barriers to high quality parent responsiveness may exist within each dyad.
In dyads where the infant is at elevated likelihood of autism, some of the barriers to parent
responsiveness may be contingent upon the early signs of autism, including sensory reactivity
and regulation differences. Research shows that some infants at elevated likelihood of autism
show differences in sensory reactivity and regulation (e.g., intense interest in a specific part of a
toy, lack of apparent interest in interaction due to sensory hyporeactivity) (Germani et al., 2014;
Sacrey et al., 2015), ambiguous cues about their preferences and interests (Leezenbaum et al.,
2014; Warlaumont et al., 2014), or sensory experiences rapidly shifting from sensory
hyporeactivity to sensory hyperreactivity. These varying infant SRR cues may reduce clear
opportunities for parents to respond to infants in a manner that promotes dyadic interaction and
interaction with toys or objects without eliciting aversive, defensive, or withdrawn behavior from
the infant.
For dyads in which parents have histories of foster care and associated trauma around
parental relationships (e.g., abuse experiences, limited opportunities to experience positive
parenting), parents’ own sensory preferences and parenting skills may present barriers to

55

responsive behavior. For example, anxiety, depression, and post-traumatic stress, all of which are
more common in young adults with histories of foster care, have been associated with an
increased likelihood of sensory processing difficulties, especially sensory hyperreactivity (Engel-
Yeger & Dunn, 2011; Leal et al., 2022; Liss et al., 2005). Thus, it is possible that parental
sensory hyperreactivity, if paired with an infant with preferences for intense sensory input, may
yield mismatched parent and infant needs. This mismatch could present a barrier to the parent’s
ability to behave in a highly responsive manner. Additionally, research suggests that young
parents with histories of foster care may hold developmentally inappropriate expectations for
emotional reciprocity from their infants and lack knowledge of developmentally appropriate
infant behavior (Connolly et al., 2012; Schelbe & Geiger, 2017). Such expectations and limited
knowledge may yield parenting behavior that is not appropriately matched to their infants’
developmental level, thereby appearing less responsive than parent behavior that is appropriate
for their infants’ stage of development.
Purpose
The purpose of this study was two-fold. First, the dimensions of parent responsiveness
uncovered during Study 1 were discussed in expert interviews with young parents with histories
of foster care, clinicians who work with former foster youth who are parenting, and researchers
with demonstrated research experience in this area in order to confirm the extent to which the
literature-derived definition of parent responsiveness is relevant to this unique population.
Second, information from the systematic review in Study 1 and the stakeholder interviews was
used to adapt an existing measure of parent responsiveness to SRR cues (Lee et al., 2017) into a
more comprehensive measure.

56

Method
This qualitative semi-structured interview study was conducted for the purpose of further
developing a measure of parent responsiveness to infant SRR cues. Expert interviews occurred
first in small groups or individually with stakeholders with clinical, research, and experiential
perspectives. Results of the expert interviews were combined with the systematic review results
from Study 1 to adapt the measure.
Experts were a key component in the early development of this measurement tool in
order to ensure relevance, appropriateness, and comprehensiveness of dimensions of parent
responsiveness in this new population (Baranek et al., 2021; Phipps et al., 2016). Expert
interviews drew from three separate pools of participants: clinicians, researchers, and experts by
experience. Expert engagement occurred in the form of audio-recorded individual or small group
interviews, depending on the scheduling availability of group members. Clinicians were
interviewed in a single group (n=3). Researchers were interviewed in one group of two and one
individual interview. Experts by experience (n=3) were each interviewed individually. Interviews
and groups lasted 60-90 minutes each and were structured based on the type of expertise
represented in each group or interview. The clinician group emphasized a discussion of parent
responsiveness structured around clinicians’ own experiences and observations in the field. The
researcher interviews were designed to first elicit concrete experiences and observations,
followed by a more conceptual discussion of parent responsiveness as a construct, guided by the
dimensional definition of parent responsiveness from Study 1. The expert by experience
interviews focused on the personal experiences of each participant in coming to know and
understand their children during infancy and early toddlerhood. All interviews and groups
opened with a question designed to elicit a story about an interaction between a parent and

57

infant. The clinician and researcher groups/interviews continued with a discussion of elements of
responsive interactions between parent and child, and the researcher group included direct
discussion of the dimensional definition from Study 1. The expert by experience interviews
focused on the parent’s perception of their infant’s manner of communicating, in addition to
discussion of how the parent came to know about their infant’s preferences and personality. All
groups concluded with the question, “is there anything you were expecting me to ask that I did
not bring up?” The interviewer tailored the reading level of language used in each interview
guide to the expected education level of participants in each group. Existing dimensions of
parent responsiveness (identified in Study 1) that were supported by discussions in any of the
interviews were retained for use in the scale. New dimensions that emerged out of rapid analysis
coding of the interviews were considered for addition to the scale as part of an original
dimension or as an additional behavior for measurement only if those dimensions arose across all
3 expert samples. All study procedures were approved by the University of Southern California
Institutional Review Board, and participants completed informed consent forms prior to
engaging in study activities.
Participants
Each expert group was represented by three participants to allow for discussion of
specific individual experiences and to capture diverse perspectives (Onwuegbuzie et al., 2009).
All nine participants had sufficient English proficiency to participate in the interview or group,
conducted in English. Participants in the clinician group must have had at least one year of full-
time experience working with 18-35-year-old parents with histories of foster care in a
professional capacity. Each participant in the clinician group had different clinical or
professional training and worked in different settings to represent a broad range of clinical

58

perspectives. Experts by experience had at least one year of personal experience in the child
welfare system before age 18, had a child prior to age 35, and had custody of at least one child
while the child was between 6 and 18 months old. Inclusion criteria for the researcher group
consisted of experience (e.g., publications, active or past grants) studying parenting in young
adults with histories of foster care.
Data Analyses
Interview and focus group data were analyzed through rapid analysis procedures
completed by two trained study personnel who listened back to audio recordings in order to
complete rapid analysis templates, and differences were reconciled via consensus discussions.
Rapid analysis was an appropriate analytical method for this study due to the level of experience
of the research personnel, the highly targeted purpose of the interviews, and the time frame in
which analysis needed to occur (Hamilton & Finley, 2019). Rapid analysis procedures included
use of an analysis template to integrate participants’ words into primarily pre-set categories,
called domains in the rapid analysis literature, developed from the questions asked during the
focus group or interview (Hamilton & Finley, 2019). From this point forward, the term
“dimension” will be used instead of “domain,” because the topics used to organize the interviews
and rapid analysis procedures were the dimensions of parent responsiveness that were identified
during Study 1. Additional dimensions were added if a participant’s comment did not relate to an
existing literature-derived dimension of parent responsiveness. Each of the two trained study
personnel independently filled out an analysis template for each interview or focus group. One
researcher (EC) integrated analysis templates into a summary matrix integrating expert voices
from all three backgrounds. The two study personnel then met to discuss the matrix to reconcile
different interpretations of interviewee comments. Results under each dimension of parent

59

responsiveness in the summary matrix were used to determine any needed changes to the
dimensions to be included in the measure.
Existing Parent Responsiveness Measure
The scale that was adapted in this study was originally developed to measure parent
responsiveness to SRR cues in infants and toddlers (9-30 months) at elevated likelihood of
autism (Lee et al., 2017). The scale yielded a single score from 1 (extremely unresponsive) to 7
(extremely responsive) for each of 4 contexts for behavioral observation: free play with a
standard set of developmentally appropriate toys, an anticipatory game, snack, and clean-up.
Parent responsiveness scores were determined based on the quality and frequency of the parent’s
response behaviors and the impact of those behaviors on parent-child engagement throughout 1-5
minutes of recorded time for each context.
Results
Expert Interviews and Focus Groups
Perspectives on Literature-Derived Dimensions. The literature-derived definition of
parent responsiveness examined during the interviews and focus groups was: parent
responsiveness is timely, appropriate, predictable, transactional parent behavior that includes (a)
attention to and being present with the infant, (b) contingent responses, (c) verbal and physical
interaction, (d) effective conflict resolution, and (e) following the infant’s lead. Results are
reported in three categories:
1. Dimensions that were largely supported across expert perspectives.
2. Dimensions that were partially supported.

60

3. Dimensions that were not mentioned or only mentioned after the facilitator shared the
literature-derived definition of parent responsiveness listed at the beginning of this
paragraph.
The majority of the dimensions were supported by expert perspectives across groups
before the facilitator shared the literature-derived definition of parent responsiveness with the
participants. Attending to the infant was reported as an important aspect of responsiveness,
especially by researchers and one expert by experience, who stated “I watched [my child] the
whole time.” Researchers discussed that shifting attention between demands of the environment
and meeting the needs of the infant was an important aspect of parent responsiveness, stating that
“dividing his time and paying attention to the little girl [during a parenting class]” was an
example of high parent responsiveness. Contingent responsiveness was illustrated through
insights shared across groups, especially with regard to soothing an upset infant and responding
to distress cues, such as crying. Developmental appropriateness of parent behavior was strongly
supported across groups, including insights regarding the “impact of the dyad on the child’s
development” [clinician perspective], degree to which “parents weren’t interpreting the cues in a
developmentally appropriate lens” [researcher perspective], and the manner in which “we’re
building their brains up by letting them have those exploratory experiences” [expert by
experience perspective]. Verbal communication, including “cooing back to a child who’s
cooing” [researcher perspective] and explaining reasoning behind boundaries [expert by
experience perspective], was mentioned with regard to responsiveness. Additionally, researchers
and clinicians reported that negative or excessive verbal communication (e.g., over-promising
that “nothing bad will ever happen” again after the child trips and falls) and harsh or “non-
nurturing language” were sometimes used by parents due to a response to their own traumatic

61

childhood experiences. Experts by experience also shared the importance of verbal
communication to set boundaries with their infants, such as by “explaining to him why he
couldn’t do what he was doing.” The transactional (or cyclical) nature of parent responsiveness
was highlighted across all three expert perspectives. Clinicians reported that parent
responsiveness was “a process, a learning curve that is constantly changing throughout the
child’s whole life.” Researchers reported that responsive parent-child interactions were
“bidirectional [and directed] from the child but also directed from the parent,” while one expert
by experience stated that, when her daughter was learning to speak, “she would repeat or imitate
or she would give it a whole other word. I’m like ok we have a word for it,” suggesting the
manner in which the infant’s behavior impacted the parent’s own behavior reciprocally through
imitation, such that the parent used a made-up word for an object in order to support the infant’s
developing skills. Another expert by experience summarized the manner in which experiences
are shared transactionally between parents and their children when she stated that, “you just deal
with the emotional outburst in the moment, but I realized that was making both of us very upset.”
Appropriate control was reflected by researchers who stated that “the parent needs to set the
floor, set the foundation of safety,” while one expert by experience believed that “[her daughter]
knows [she’s] going to let her try things, but has to have boundaries too.” Clinicians and experts
by experience believed that parents were sometimes over-protective, or exerted more control
than necessary, as a result of pressure to perform well and fear of system involvement for their
own children. All of the experts believed that following the infant’s lead was important for
responsiveness. One expert by experience shared that each of her two children required different
levels of support for daily tasks and that she adjusted her own behavior based on each child’s
desire for independence versus close proximity and support, demonstrating the manner in which

62

she followed each child’s lead in daily interactions. Clinicians stated that parent behaviors should
be personalized to the individual infant. Researchers felt that following the infant’s lead was
important and very difficult to teach, as “[parents were] directing [their infants] and really
missing the concept.” Experts across groups believed in the importance of “parenting the kid you
have,” which speaks to the wide variety of potential parenting behavior and the degree to which
responsiveness must be dependent on the individual infant’s needs, wants, skills, and personality.
Some literature-derived dimensions were partially supported by expert perspectives but
included additional caveats to the behavior reported in the literature. Being present with the
infant was endorsed by all three experts by experience, but was not mentioned by researchers or
clinicians. One expert by experience shared that “the days are long, especially the hard days, but
you look back and the years are so short. You don’t get this time back,” indicating the
importance of cherishing moments with her child. Similarly, another expert by experience
reported that, “it was really sweet seeing [her son] take off and be adventurous.” Affect, while
supported by expert perspectives as a dimension of parent responsiveness, included the
importance of avoiding negative affective reactions, while the literature primarily emphasized
the use of positive affect as a tool to enhance parent-infant interactions. For example, clinicians
felt that parents aging out of foster care often had difficulty recognizing loving behavior from
their infants, so clinicians needed to assure their clients that “that baby really loves you, look at
how your baby looks at you.” Similarly, researchers had observed “things that kids were doing
that were not bothering me [the researcher] were really upsetting to [the parent].” One expert by
experience felt that it was immensely important to mask her own anxiety and stress in order to
protect her infant from her own negative affect, while another felt that it was important to “show
every emotion” in front of her child. These opposite perspectives may be related to the unique

63

and personal nature of parenting and the manner in which early experiences shape later beliefs
about parenting. Another expert by experience felt that her son’s affective expressions were key
for getting to know him and his preferences. The physicality of parent responsiveness was
discussed in the researcher interviews but was only briefly mentioned by the experts by
experience and clinicians. Researchers and clinicians felt that gentle touch was important for
parent responsiveness but that the extensive trauma histories that former foster youth often carry
may interfere with the parent’s desire to engage in affective physical touch. Additionally,
researchers expressed that “we don’t emphasize touch, which is such a huge part of parenting
and such a huge part of responsiveness,” and that parents were often taught about instrumental
touch (e.g., diapering and feeding) but not about affective touch (e.g., holding, physical
proximity). One expert by experience noted the importance of adjusting physical contact to her
son’s preferences, especially when the infant was upset. Researchers mentioned conflict
resolution in that ineffective conflict resolution, such as using punishment instead of rewards or
using inappropriate discipline, was influential upon the degree to which parents were responsive.
The experts by experience primarily endorsed that responding appropriately to infant distress
was important for parenting but did not mention other aspects of conflict resolution.
Predictability was endorsed as important by the experts by experience, especially during nap and
bedtime routines that they prioritized with their children, beginning in the newborn stage and
continuing throughout infancy, toddlerhood, and early childhood. Researchers stated that
consistency may be a more appropriate term, because “predictability could be negative, like
always blowing up during this time, but consistency better captures the positive,” or routine,
aspects of interaction. Researchers also felt that “the whole day of [positive] routine interactions
build up to something that allows you to repair from the more difficult moments,” highlighting

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the importance of consistency during interactions in order to build the foundation of a positive
parent-infant relationship.
A few of the literature-derived dimensions were only endorsed indirectly or after the
facilitator shared the definition. Timing, for example, was mentioned by one expert by
experience in that as an infant her child “wanted what she wanted right now.” Researchers
agreed that timing was important after viewing the literature-derived definition of parent
responsiveness. Ignoring as the opposite of parent responsiveness was only endorsed in a
researcher interview and one of the expert by experience interviews. With the exception of
timing and ignoring, the literature-derived dimensions of parent responsiveness were supported
across expert perspectives.
Expert-Derived Dimensions. One dimension of parent responsiveness that was not
explicitly present in the literature emerged from the expert interviews and focus groups: setting
up the environment. This dimension was endorsed by researchers and experts by experience.
Researchers shared that highly responsive parents were those who “[made] sure the child was in
an environment where they would be successful, so thinking about a child who may be
overwhelmed with uh sensory, making sure it’s not a loud chaotic environment.” Similarly, one
expert by experience shared that her child needed a “sensory area where he would go lay on a
soft pillow to calm down.” Interestingly, this was the only dimension in the literature and expert
perspectives in which sensory reactivity and regulation was mentioned.
Several additional themes emerged from the expert by experience interviews and focus
groups. These additional themes are reported in Appendix C, as they were not directly related to
the measure development process.

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Measure Adaptation
The protocol and coding scheme for measuring parent responsiveness from which the
new measure was adapted included several strengths and challenges, which are summarized in
Table 3.1, along with solutions to address these challenges in the new measure that resulted from
this study. Scoring using the new measure yields an additive total score for parent responsiveness
in each segment that includes both the quality and type of responsive or non-responsive
behavior. Scoring will be completed using a spreadsheet to first document infant SRR cues,
followed by noting each parent behavior, then determining the degree to which the parent’s
response to each SRR cue reflects each dimension of parent responsiveness. Dimensions that
emerged during Study 1 and the expert interviews that could not be reliably measured in a 5-
minute video clip were not included in the measure. Consistency was excluded from the measure
due to the lack of opportunity to observe the degree to which a parent behaves consistently
during a brief interaction. The transactional nature of parent-infant interactions was not included
in the measure, as transactions occur over time and based on past and present experiences.
Because past experiences cannot be considered when rating a five-minute video recording, the
transactional nature of the interaction was not explicitly rated in the measure. Being present was
also excluded from the measure, as presence reflects an internal state that cannot necessarily be
observed by an external rater. Additionally, the influences of internal and external pressures on
parents’ behavior were not included in the measure of parent responsiveness, as the purpose of
the measure was to rate moment-by-moment interactive behaviors, not the overall parenting
context. Finally, setting up the environment was not included in the new measure, as the
environment in which video recordings are collected is standardized as much as possible across

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participants, so parents did not have as many opportunities to engage in behavior related to
environmental set-up as they normally would in other daily contexts.
Table 3.1. Strengths and challenges of the existing measure of parent responsiveness and
solutions integrated in the new measure.
Existing Measure Solutions in the New Measure
Relevant
Strengths
Specific to SRR: a unique
perspective to the study of parent
responsiveness
Maintained these aspects of the existing measure
in the new measure.
Uses a 2-step scoring process to
arrive at a score in a systematic way
Areas for Development
Requires extensive note-taking
during the scoring process
Created an Excel template that required brief
notation of child behaviors followed by a
checklist of dimensions of the parent’s response
Single score may conceal important
sources of variability across dyads
Yielded individual dimensional scores in
addition to an overall responsiveness score
Was developed specifically for
dyads with neurodevelopmental
risk factors
Qualitative examination of the measure by
experts in other developmental risk groups
Variable length of parent-infant
interaction across situations
Included only free play and snack contexts,
duration of which can be controlled
Note: SRR = Sensory Reactivity and Regulation
The new coding scheme consisted of a list of infant cues related to SRR with descriptions
of each cue and a list of the dimensions of parent responsiveness with descriptions of the types of
behavior that fell within each dimension. Dimensions of parent responsiveness were polar, in
that there was a more responsive and less responsive pole within each dimension. Scoring
reflected this polar nature by allowing for a score of positive one for each parent behavior that
was within the more responsive pole, a score of negative one for each parent behavior that was
within the less responsive pole, and a score of zero if that particular dimension was not relevant
to the interaction that was observed. Each dimension was scored with regard to the parent’s
response to each infant behavior that was deemed an SRR cue. See Appendix D for the complete
text of the coding manual.

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Discussion
The purpose of this study was to integrate the literature-derived definition of parent
responsiveness with perspectives from experts on parenting in former foster youth in order to
adapt a measure of parent responsiveness to infant sensory reactivity and regulation cues. The
purpose of the new measure is to reliably and sensitively rate parent responsiveness across
developmental risk groups, including infants at elevated likelihood of autism and those at
elevated likelihood of suboptimal development due to SDH. The revised definition of parent
responsiveness based on the results of the interviews was: parent responsiveness is
developmentally appropriate, consistent, transactional, prompt parent behavior that includes: (a)
attention to and being present with the infant; (b) contingent responses; (c) positive, gentle verbal
and physical interaction; (d) effective conflict resolution; and (e) following the infant’s lead
within a safe and appropriate structure. Changes to the literature-derived definition include (a) a
decreased emphasis on timing of responses due to the limited discussion of this dimension in
interviews despite its prominence in the literature, (b) reframing of verbal and physical
interaction as gentle and positive, (c) change of the word “predictable” to “consistent,” and
including the caveat that following the infant’s lead should only occur within the context of a
safe and appropriate environment.
Measure adaptation relied on the dimensions of parent responsiveness that were
ultimately included in the definition above. The new measure allows for each of these
dimensions to be examined both individually and as a composite rating of parent responsiveness
composed of responses to each infant behavior. That is, the new measure will allow for
comparison of parenting behavior within each of the dimensions of parent responsiveness, in

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addition to examination of the degree of parent responsiveness that is “good enough” to yield
more optimal child developmental outcomes.
Additional Parenting Context
The broad parenting context for former foster youth that is well-documented in the
literature was also supported specifically with regard to its relationship to parent responsiveness
in the expert interviews and focus groups. Specifically, parents who were raised in the foster care
system commonly report immense pressure to “do better” than their own parents did in raising
them (Geiger & Schelbe, 2014; Holtrop et al., 2015; Pryce & Samuels, 2010; Radey et al., 2016;
Schelbe & Geiger, 2017). Additionally, these parents are frequently under pressure to prove their
competence as parents, which leads to a sense of not being allowed to ask for support where
needed (Connolly et al., 2012). Finally, parents with foster system histories tend to lack the
necessary social support and role modeling that all parents need (Radey et al., 2016; Schelbe &
Geiger, 2017; Shenk et al., 2017). Each of these concepts that are apparent in the literature
regarding parenting in former foster youth were upheld strongly within the interviews conducted
for this study (see Appendix C), even though these interviews were focused specifically on
parent responsiveness: just one aspect of parenting behavior. The connection between the
contextual themes emerging in these interviews and the existing literature on parenting in former
foster youth suggests that parent responsiveness exists not only in the transactional, mutually
engaging interaction between parent and infant, but as a construct that is situated in the larger
systemic and social context. That is, while parent responsiveness is important to understand at a
granular, individual level in order to examine associations with developmental outcomes and
parent and infant characteristics, future research must also include the influences of the broader
context on the degree to which parents can be responsive.

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Limitations
There were several limitations to consider when interpreting the results of this study.
First, the study was originally designed to consist of a focus group to represent each of the three
expert perspectives, which would promote discussion and sharing of ideas around the parent
responsiveness construct. However, due to scheduling limitations, some of the interviews
occurred individually. Additionally, the researcher and clinician participants shared their
expertise from interactions with parents who were either participating in research or accessing
services, which is a subset of former foster youth who have access to these networks and
supports. Similarly, the convenience sample of experts by experience may represent particularly
well-connected and proactive parents who are comfortable with and interested in sharing their
experiences. Thus, the results of this study only represent these specific perspectives on parent
responsiveness and cannot be assumed to generalize to the broader population of former foster
youth who are parenting.
Implications
This study produced a relevant and preliminarily reliable measure of parent
responsiveness to SRR cues. Because the measure was developed from both an existing measure
of parent responsiveness to SRR cues in infants at elevated likelihood of autism and expert input
from those associated with the child welfare system, the resulting measure is applicable to both
populations. This measure will be useful for comparison across groups in order to understand
common and disparate features of parent responsiveness across groups. Additionally, this
measure will yield scores that are sensitive enough to the spectrum of responsive parenting
behavior to examine the amount of parent responsiveness that is “good enough” to promote
positive child developmental outcomes across contexts.

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Chapter 4: Validating the New Measure of Parent Responsiveness
Abstract
Parent responsiveness to infant cues may be an important developmental protective factor
for infants at various levels and types of risk for suboptimal developmental outcomes. However,
several important gaps exist in the literature surrounding this construct. Parent responsiveness,
specifically to infant cues related to sensory reactivity and regulation (SRR), has not been
examined, despite infant SRR being an important foundation for other developmental skills,
especially in those at elevated likelihood of autism or suboptimal development due to social
determinants of health. In addition, a comprehensive measure that captures the multidimensional
nature of parent responsiveness has not been used to test this construct across developmental risk
groups. The purpose of this study was three-fold. First, this study aimed to pilot test a new
measure of parent responsiveness to SRR cues in parents with foster care histories. Second, this
study tested the reliability and validity of the measure. Finally, examine nuanced differences in
parent responsiveness across groups through a matched case study design. Outcomes of this
study will serve as a foundation for further scale development and refined understanding of the
influence of parent responsiveness to SRR cues on later developmental outcomes.
Background and Introduction
Parent responsiveness refers to the manner in which parents recognize and respond to
their infants’ cues regarding interest, attention, and affect, among other areas. Because of the
major role parents play in infant development across domains (Booth et al., 2002; Kotila et al.,
2013; Marshall, 2011), parent responsiveness may be a protective factor across developmental
risk groups. In fact, parent responsiveness and its associations with social communication
outcomes has been commonly studied in infants at elevated likelihood of autism and other
neurodevelopmental diagnoses (Edmunds et al., 2019; Kellerman et al., 2020; Wan et al., 2019).

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Infants at elevated likelihood of autism are known to provide more ambiguous cues
(Leezenbaum et al., 2014; Warlaumont et al., 2014) and less reciprocal interactive behavior
(Kellerman et al., 2020; Wan et al., 2012) to which their parents can respond, thereby yielding
different parent responsiveness behavior than that which is evident in parents of infants without
developmental risk factors. More specifically, parents of infants with early signs of autism tend
to use more play acts, more bids for attention, and more demanding behavior while interacting
with their infants (Kinard et al., 2017; Srinivasan & Bhat, 2020; Steiner et al., 2018; Wan et al.,
2012). However, parent behaviors that follow the child’s lead and natural focus of attention are
more strongly associated with positive child developmental outcomes (Leezenbaum et al., 2014).
Thus, it is important to understand how different types of parent responsiveness are related to
infant abilities and outcomes. In addition, despite the known high prevalence of SRR differences
in infants at elevated likelihood of autism (Baranek, 1999; Sacrey et al., 2015; Zwaigenbaum et
al., 2015), there is limited coverage in the literature regarding parent responsiveness to cues in
this domain of development.
Another group for whom parent responsiveness may be especially important is children
born to parents with histories of foster care and associated childhood trauma. Parents with
histories of foster care may lack accurate knowledge about children’s needs and child
development, which can lead these parents to expect their children to demonstrate
developmentally inappropriate levels of behavior regulation or independence (Radey et al., 2016;
Schelbe & Geiger, 2017). Misinterpretations of an infant’s behavior may trigger inappropriate
attempts by the parent to punish or otherwise change behavior that might be more appropriately
navigated in the presence of increased knowledge of children’s developmental capacities at
various stages of infancy, toddlerhood, and childhood. Additionally, instability in family

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placements and relationships, as well as the maltreatment or traumatic experience(s) that
precipitated child welfare system involvement, result in a lack of good parenting role models and
mentors for many parents transitioning out of the child welfare system (Geiger & Schelbe, 2014;
Pryce & Samuels, 2010; Radey et al., 2016; Schelbe & Geiger, 2017). Traumatic experiences,
such as intimate partner violence, which is experienced by up to two thirds of adolescent former
foster youth (PettyJohn et al., 2021), increase parents’ likelihood of experiencing elevated
parenting stress, exhibiting poor self-regulation skills, and demonstrating low responsiveness to
their child’s cues and needs (Sypher et al., 2021). Finally, parents with decreased arousal
regulation, which can be related to childhood trauma experiences (Sypher et al., 2021), tend to
demonstrate less responsive behavior than parents with better regulated levels of arousal
(Leerkes et al., 2023). Taken together, all of these barriers to development of positive parenting
skills may also serve to reduce parent responsiveness in parents of infants at elevated likelihood
of suboptimal development due to SDH. However, limited research exists on parent
responsiveness in parents with foster care histories.
Comparing Parent Responsiveness across Groups
While infants at elevated likelihood of autism and elevated likelihood of suboptimal
development due to SDH are very different groups in many ways, parent responsiveness may
still play comparable roles in development for these two groups. That is, we know that parent
responsiveness is important for attachment, social-emotional, and communication development,
areas that pose shared difficulties for both developmental risk groups (Edmunds et al., 2019;
Finger et al., 2009; George et al., 2010; Raval et al., 2001). Additionally, parents of infants at
elevated likelihood of autism and parents with histories of foster care tend to experience elevated
parenting stress (Holtrop et al., 2015; Lange et al., 2019; Shenk et al., 2017; Steiner et al., 2018),

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which may affect the degree to which they are able to engage in responsive behavior (Steiner et
al., 2018; Wan et al., 2012). Developing a measurement tool that is reliable and valid for
measuring parent responsiveness in both of these groups is a foundational step toward
understanding similarities and differences across groups and examining the nuances of parent
responsiveness and the manner and amount of responsiveness that is most supportive of optimal
child developmental outcomes in groups with developmental risk factors.
Parent Responsiveness to Sensory Reactivity and Regulation
SRR refers to the manner in which individuals take in sensory information and use that
information, which supports learning and development across domains. SRR can include sensory
response patterns that differ from others (e.g., sensory hyperreactivity, sensory hyporeactivity),
which can be indicative of developmental challenges, or simply sensory preferences. All infants,
therefore, provide intentional and unintentional cues about their sensory experiences: sensory
input they enjoy, sensory input that is too intense, or sensory input that has not yet attracted their
attention. Thus, SRR is an area of infant development to which parents can respond in daily
routines, which are rich with sensory input. However, there is limited literature to date that has
examined parent responsiveness to SRR cues.
Purpose and Hypotheses
The primary purpose of this study was to examine the reliability and validity of a new
parent responsiveness scale. The internal consistency and inter-rater reliability are expected to be
>0.70, and the correlation between the new scale and a gold standard measure of general parent
responsiveness is expected to be moderate due to the focused nature of the new scale on SRR
cues only. The secondary purpose of this study was to pilot-test the new measure in parents with
histories of foster care. The pilot participants were hypothesized to rate study procedures as

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acceptable and feasible, and average coding time using the new measure was expected to be
between 30 and 45 minutes for each 10-minute video recording. The tertiary purpose of this
study was to explore profiles of parent responsiveness, parenting stress, and infant sensory
features across risk groups and dyads with typically developing infants.
Method
This study was a cross-sectional validation study of a novel measure of parent
responsiveness to infant SRR cues. Additionally, case studies are presented to demonstrate the
utility of the new measure across participants at elevated likelihood of autism, elevated
likelihood of suboptimal development due to SDH, and typical development.
Participants
Participants for this study were drawn from two extant samples and a newly recruited
sample. The extant samples included data from time 1 assessments in two longitudinal studies:
the Parents and Infants Engaged (PIE) study and the Sensory and Social Communication
Development in Infants and Toddlers (SASI) study. Data from these samples will comprise the
elevated likelihood of autism group (n=40) and the group with no known developmental risk
factors (n=40), hereafter denoted as typically developing (TD). The sample (n=3) of infants at
elevated likelihood of suboptimal development due to SDH (i.e., whose parents have histories of
foster care) was collected for the purposes of this study. To be included, parents across groups
had an infant between the ages of 6 and 18 months. For those at elevated likelihood of
suboptimal development due to SDH, the participating parent was between 18 and 35 years of
age. See Table 4.1 for participant demographics. Though the average age of parents whose
infants were at elevated likelihood of suboptimal development due to SDH was expected to be
lower than that of the elevated likelihood of autism and TD groups, years of parenting experience

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were expected to be comparable, given the likelihood of former foster youth to bare multiple
children at an early age (Courtney et al., 2007; Dworsky & DeCoursey, 2009). The elevated
likelihood of autism and TD group membership was determined in the previous studies using a
screening tool for autism: the First Years Inventory-version 3.1 (SASI) (Turner-Brown et al.,
2013) or -version 3.1b-Lite (PIE) (Baranek et al., 2014). Exclusion criteria for all groups were:
infant developmental or genetic diagnoses, major physical impairments, neurological differences,
or sensory loss.
Table 4.1. Descriptive data on demographic and clinical characteristics of the sample.
TD (N=40) EL-A (N=40) EL-SDH (N=3) Total (N=83)
Demographic Characteristics
Child’s age (mo) M(SD) 13.6 (3.0) 14.0 (1.7) 13.3 (2.3) 13.8 (2.4)
Child’s sex n (% male) 25 (62.5%) 27 (67.5%) 2 (66.7%) 54 (65.1%)
Parent race n (%)
AmIn/Alaska Native
Asian
Black
White
Multiple
Unknown

0 (0%)
3 (7.5%)
1 (2.5%)
34 (85%)
1 (2.5%)
1 (2.5%)

1 (2.5%)
2 (5.0%)
3 (7.5%)
21 (52.5%)
2 (5.0%)
11 (27.5%)

0 (0%)
0 (0%)
0 (0%)
3 (100%)
0 (0%)
0 (0%)

1 (1.2%)
5 (6.0%)
4 (4.8%)
58 (69.9%)
3 (3.6%)
12 (14.5%)
Parent ethnicity n (% Hispanic) 1 (2.5%) 3 (7.5%) 1 (33.3%) 5 (6.0%)
Parent education n (%)
HS/GED
Some College
College Degree
Master’s
Professional

1 (2.5%)
1 (2.5%)
17 (42.5%)
13 (32.5%)
7 (17.5%)

4 (10.0%)
6 (15.0%)
14 (35.0%)
8 (20.0%)
1 (2.5%)

1 (33.3%)
0 (0%)
2 (66.7%)
0 (0%)
0 (0%)

6 (7.2%)
7 (8.3%)
33 (39.8%)
21 (25.3%)
8 (9.6%)
Clinical Characteristics
SEQ Hypo 1.5 (.3) 2.1 (.6) 1.6 (.5) 1.7 (.6)
SEQ Hyper 1.7 (.3) 1.9 (.3) 1.6 (.4) 1.8 (.3)
SEQ SIRS 2.6 (.6) 2.5 (.5) 2.9 (.4) 2.5 (.6)
Cognition 105.3 (24.1) 83.8 (16.3) 107.3 (9.3) 94.9 (22.8)
Parental Stress 34.4 (6.7) 41.1 (9.8) 43.3 (5.7) 38.1 (9.0)
Note: TD = typically developing; EL-A = elevated likelihood of autism; EL-SDH = elevated likelihood of
suboptimal development due to social determinants of health; AmIn = American Indian; HS/GED = high
school/General Educational Development; SEQ = Sensory Experiences Questionnaire, version 2.1; Hypo = sensory
hyporeactivity; Hyper = sensory hyperreactivity; SIRS = sensory interests, repetitions, and seeking

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Recruitment
Initial recruitment efforts took place through a partner organization that serves young
mothers aging out of foster care. Due to low enrollment, recruitment efforts were later expanded
to include social media, a wide variety of community organizations that may serve former foster
youth, and community locations (e.g., recreational centers and public libraries). Additionally,
recruitment criteria were expanded to include families who had experienced homelessness,
including couch surfing, shelter dwelling, street dwelling, or serious risk of losing housing, since
the birth of the target child.
Procedures
All parent participants across samples provided informed consent for participation, and
all studies were approved by the University of Southern California (SASI study, current study) or
University of North Carolina-Chapel Hill (PIE study; R21HD091547; MPIs Watson and
Baranek) Institutional Review Boards. Informed consent appointments and study visits for the
newly recruited sample were conducted via Zoom due to the national catchment area for
participants. Informed consent visits were combined with the assessment visit whenever possible
to mitigate problems associated with retaining participants with histories of foster care in
research studies (Holtrop et al., 2018). The assessment visit consisted of a 10-minute recording
of parent-child interaction in free play and snack, administration of a measure of cognitive
development, and time for the parent to complete parent questionnaires with the research
personnel available to troubleshoot any challenges with the online questionnaire format.
Observational and parent questionnaire measures were limited to reduce participant burden.
Additionally, the primary purpose of this study was to examine the reliability and validity of the
new parent responsiveness measure, so collection of a traditional battery of assessments across

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developmental domains was not critical to achieve study aims. Each participant in the newly
collected sample completed an acceptability questionnaire at the end of the study procedures.
Questions determined the degree to which participants were comfortable with, enjoyed, and
would recommend study participation to others. Feasibility was measured by tracking the
amount of time needed for training procedures and applying the coding scheme to each video.
Measures
Parent Responsiveness to Sensory Reactivity and Regulation. The parent
responsiveness to SRR measure used in this study was developed in Studies 1 and 2. This
measure was applied to video recordings of parent-child interaction during 5-minute free play
and 5-minute snack activities. The measure consisted of moment-by-moment behavioral coding
in three steps. On the first pass through the video, the coder recorded child sensory reactivity and
regulation cues, including approach/avoidance behavior, sensory seeking behavior, orientation,
changes in arousal level, and affective cues. Then, on the second pass through the video, the
parental response that occurred within 5 seconds of each of the SRR cues recorded in the first
pass was noted. The third step included rating each parental response as negative one, zero, or
one on each of the dimensions of parent responsiveness. A score of negative one indicated that
the parent’s behavior fell on the less responsive pole of that dimension. A score of zero indicated
that that dimension was not relevant to the situation. A score of one indicated that the parent’s
behavior fell on the more responsive pole of that dimension, or met criteria for that dimension.
See Appendix D for the coding manual. The measure yielded proportional scores for each
dimension of parent responsiveness, which represented the average of all ratings within that
dimension. Proportional scores for each dimension were averaged to yield a total proportional
score. Additionally, a complexity of responses score was the average of the total number of

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dimensions met per parental response. Scores were calculated for the free play segment, the
snack segment, and the total across free play and snack. Twenty percent of video recordings
were double-coded to examine inter-rater reliability.
Sensory Experiences Questionnaire-Version 2.1 (Baranek, 1999). The SEQv2.1 is a
10-15 minute parent questionnaire that can be used to examine sensory experiences across
modalities, social and nonsocial contexts, and sensory response patterns in children ages 5
months to 12 years (Baranek et al., 2006). Earlier versions of the SEQ have been used with
children with autism, developmental delays, and typical development (Baranek et al., 2006;
Little et al., 2011). This measure has demonstrated good internal consistency (α=.80) and test-
retest reliability (.92) across populations (Baranek et al., 2006; Little et al., 2011). Parents were
offered information about their infant’s sensory processing patterns after the assessment visit.
Maternal Behavior Rating Scale (MBRS) (Mahoney et al., 1986). The MBRS is a
common measure of parent responsiveness, which yields a separate 1-5 rating for responsivity
and sensitivity. Ratings are based on the approximate percentage of infant behaviors, including
shifts in attention and intentional bids for interaction, to which a parent responds appropriately.
The MBRS has 9 total subscales, but only responsivity and sensitivity were used in this study
due to the focus of the new scheme specifically on responsiveness to infant cues. Convergent
validity was tested separately between the new scheme and (a) the responsivity subscale of the
MBRS and (b) the sensitivity subscale of the MBRS.
Developmental Assessment of Young Children – Second Edition (DAYC-2) (Voress
& Maddox, 1998). The DAYC-2 is a measure of child development across domains from birth
to five years, 11 months. This measure was administered in a hybrid format, obtaining
information through observation, direct assessment, or parent interview. The DAYC-2

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demonstrates internal consistency of .89-.98 and test-retest reliability of .89 on the cognitive
domain (Swartzmiller, 2014). The cognitive subscale of the DAYC-2 was administered to the
those at elevated likelihood of suboptimal development due to SDH and the SASI study portion
of the TD and elevated likelihood of autism groups.
Mullen Scales of Early Learning (MSEL) (Mullen, 1995). The MSEL is a commonly
used measure of general child development from birth to 5 years, 8 months. The Early Learning
Composite (ELC) can be used as a measure of cognition (Bradley-Johnson, 2001). The ELC was
the cognitive measure used in the PIE study portion of the TD and elevated likelihood of autism
samples. Due to the extant nature of the data from this sample, the DAYC-2 could not be
administered. Therefore, the MSEL ELC was used to describe the current level of cognition for
this portion of the sample.
Parental Stress Scale (PSS) (Berry & Jones, 1995). The PSS is a validated self-report
measure of parenting-related stress levels. The PSS assesses parenting stress in the areas of
satisfaction in the parenting role, time and energy required for parenting, and feelings toward
children. The PSS has 18 items, with answer choices on a scale from strongly disagree to
strongly agree, such that a higher score indicates higher parenting stress. The total raw score on
all 18 items was used in this study as an estimate of overall level of parenting stress. The PSS
was collected for the majority of the extant sample (in the PIE study) and from the newly
collected sample.
Demographic Questionnaire. A brief demographic questionnaire was developed for this
study in order to collect data on race/ethnicity, education level, medical and developmental
history, marital status, parity, family income, parent and infant gender, parent and infant age, and

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basic information about the perinatal period (e.g., gestational age at birth, birth complications).
These data were used to characterize the sample.
Data Analysis
Data analyses were completed using SPSS version 29.0. Feasibility and acceptability
were examined based on the following criteria:
1. Average amount of time required to code each recording.
2. Amount of time spent training on the new scale.
3. Participant experiences during the parent-child interaction protocol as reported on the
brief acceptability survey following participation in pilot data collection.
Descriptive analyses were performed in order to characterize the sample and examine the
distributions of data across variables. Percentages were calculated for categorical demographic
variables (e.g., race/ethnicity, gender), and means and standard deviations were calculated for
continuous demographic and background variables (e.g., age, cognition). Means, standard
deviations, and ranges were calculated for the continuous variables prior to conducting main
analyses: total parenting stress, infant sensory processing patterns, and overall parent
responsiveness.
Reliability and validity analyses included inter-rater reliability, internal consistency, and
convergent validity. Inter-rater reliability was measured by two-way, mixed-effects, single rater,
absolute agreement intraclass correlation coefficients (ICCs), which were calculated on 20% of
the full sample between ratings independently assigned by the primary and reliability raters.
Additional exploratory analysis was conducted on a subset of reliability videos coded most
recently to examine the influence of further training on ICC values. Internal consistency was
calculated using Cronbach’s alpha on the primary rater’s ratings for the full sample. Convergent

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validity was assessed by examining bivariate correlations of ratings obtained using the new scale
with ratings obtained using the MBRS (n=30).
Due to the uneven sample sizes across groups, the three participants at elevated
likelihood of suboptimal development due to SDH were matched with infants at elevated
likelihood of autism and TD infants on infant chronological age, race, and sex for detailed
qualitative comparison of parent responsiveness across these developmental contexts. Case study
profiles included description of infant sensory reactivity and cognition, parenting stress, and
examination of each dimension of parent responsiveness to demonstrate the potential utility of
the new scale to provide a measure of the relative strengths and weaknesses of parents’
responsiveness across groups.
Results
Acceptability and Feasibility
Among the three participants in the group at elevated likelihood of suboptimal
development due to SDH, study procedures were rated as highly acceptable. All three
participants reported that the study was not at all burdensome and that they would recommend
study participation to a friend. Participants found study participation to be “a little” (n=2) or “a
lot” (n=1) enjoyable. Participants felt neutral (n=1) or comfortable (n=2) with the study activities
(e.g., playing with their infants), but one participant felt uncomfortable with the study
questionnaires.
With regard to feasibility, videos took an average of 48 minutes (range = 28-65; SD = 8)
to code for the primary coder and 97 minutes (range = 80-130; SD = 15) for the reliability coder.
Coding training took approximately 12 hours for the reliability coder to achieve 80% absolute
agreement across dimensional codes for each behavior.

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Reliability and Validity
Internal consistency values within the free play, snack, and combined segments were all
>.7. See Table 4.2 for values. Correlations between the free play mean scores with the new
scheme and the free play sensitivity and responsivity subscales of the MBRS were moderate: .57
(p=.001) and .47 (p=.009), respectively.
Table 4.2. Internal consistency values across coded video segments.
Video Segment Cronbach’s α 95% Confidence Interval
Free Play .84 .78-.89
Snack .80 .73-.86
Combined (Free Play and Snack) .87 .82-.91

With regard to inter-rater reliability, ICCs varied by video segment, level of coding (i.e.,
sensory cues or dimensions of parent behavior), and amount of coder training. Within the full
sample of reliability-coded videos, complexity scores met criteria for adequate reliability (>.70)
in free play and combined segments, but not in snack. Relatively few dimensions met criteria for
adequate reliability in free play (four dimensions), snack (one dimension), and combined (three
dimensions). In the subset of most recently coded videos, complexity scores met criteria for
adequate reliability across free play, snack, and combined segments. The majority of dimensions
met criteria for adequate reliability in free play (five dimensions), snack (three dimensions), and
combined (six dimensions). Confidence intervals were broad for all ICCs, indicating a high
degree of variability within the inter-rater reliability across video recordings. See Table 4.3 for
ICCs.
Table 4.3. Inter-rater reliability by video segment.
Level of Coding
ICC (95% CI)
(N=17)
ICC (95% CI)
(n=8)
Free Play
Child Sensory Cues
Affect
Approach

.08 (-.13,.39)
.16 (-.07,.51)

.08 (-.31,.63)
.08 (-.10,.49)

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Arousal
Avoid
Orientation
Seeking
.77 (.48,.91)
.47 (.00,.77)
.48 (.03,.78)
.56 (-.09,.85)
-.31 (-.78,.44)
.45 (-.18,.85)
.26 (-.08,.74)
.70 (-.07,.94)
Dimensional Scores
Affect
Attention
Conflict Resolution
Contingency
Developmental Appropriateness
Following Child’s Lead
Mirroring
Physical Touch/Proximity
Verbal Communication

.80 (.53,.92)
.77 (.49,.91)
-.37 (-.71,.12)
.87 (.68,.95)
.54 (.12,.80)
.47 (.01,.77)
.68 (.28,.87)
.63 (.04,.87)
.70 (.33,.88)

.94 (.72,.99)
.95 (.66,.99)
-.22 (-.97,.58)
.96 (.55,.99)
.82 (.33,.96)
.61 (-.08,.91)
.38 (-.43,.84)
.56 (-.06,.89)
.82 (.32,.96)
Complexity Score .83 (.57,.94) .97 (.86,.99)
Snack
Child Sensory Cues
Affect
Approach
Arousal
Avoid
Orientation
Seeking

.62 (.23,.84)
.55 (-.06,.84)
.76 (.45,.91)
.73 (.35,.90)
.68 (.30,.87)
.28 (-.24,.66)

.36 (-.26,.82)
.35 (-.16,.80)
.44 (-.41,.86)
.79 (.26,.95)
.08 (-.78,.73)
.41 (-.46,.85)
Dimensional Scores
Affect
Attention
Conflict Resolution
Contingency
Developmental Appropriateness
Following Child’s Lead
Mirroring
Physical Touch/Proximity
Verbal Communication

.67 (.30,.86)
.09 (-.38,.53)
.30 (-.16,.67)
.67 (.30,.86)
-.21 (-.67,.32)
.62 (.23,.84)
.60 (.21,.83)
.24 (-.28,.64)
.87 (.68,.95)

.71 (.14,.93)
.18 (-.35,.73)
-.09 (-.87,.65)
.66 (-.06,.92)
.38 (-.25,.82)
.82 (.35-.96)
.51 (-.11,.87)
.24 (-.41,.77)
.95 (.19,.99)
Complexity Score .61 (.18,.84) .86 (.49,.97)
Combined
Child Sensory Cues
Affect
Approach
Arousal
Avoid
Orientation
Seeking

.29 (-.11,.65)
.40 (-.06,.79)
.73 (.40,.89)
.55 (-.01,.83)
.65 (.26,.86)
.39 (-.06,.72)

-.16 (-.43,.43)
.20 (-.09,.67)
.05 (-.68,.70)
.52 (-.11,.88)
.06 (-.25,.57)
.44 (-.14,.84)
Dimensional Scores
Affect
Attention
Conflict Resolution

.89 (.72,.96)
.60 (.20, .83)
.03 (-.36,.46)

.95 (.80,.99)
.80 (.20,.96)
-.23 (-.97,.57)

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Contingency
Developmental Appropriateness
Following Child’s Lead
Mirroring
Physical Touch/Proximity
Verbal Communication
.87 (.69,.95)
.28 (-.22,.66)
.54 (.07,.81)
.66 (.21,.87)
.41 (-.02,.73)
.84 (.62,.94)
.92 (.04,.99)
.78 (.29,.95)
.71 (-.06,.94)
.44 (-.14,.84)
.41 (-.16,.83)
.91 (.64,.98)
Complexity Score .82 (.58,.93) .97 (.87,.99)
Note: ICC = intraclass correlation coefficient; CI = confidence interval.

Case Studies
Triad A. Infants in this matched triad were 12-13 month-old white, non-Hispanic males.
Their mothers had bachelor’s (infants at elevated likelihood of autism and elevated likelihood of
suboptimal development due to SDH) or master’s (TD infant) degrees. The infant at elevated
likelihood of suboptimal development due to SDH demonstrated the highest SIRS and sensory
hyperreactivity scores, but the lowest sensory hyporeactivity scores. Parenting stress scores for
the mothers of the infants at elevated likelihood of autism and at elevated likelihood of
suboptimal development due to SDH were identical and 5 points higher than the TD infant’s
mother. The infant at elevated likelihood of suboptimal development due to SDH demonstrated
similar cognitive skills to the TD infant, while the infant at elevated likelihood of autism
demonstrated cognition at approximately 2 standard deviations below the other two infants. See
Table 4.4 for a summary of characteristics compared within Triad A.
Table 4.4. Comparison of characteristics of interest within Triad A.
EL-SDH EL-A TD
Clinical Characteristics
Sensory Hyporeactivity 1.17 1.33 1.67
Sensory Hyperreactivity 2.00 1.57 1.71
SIRS 3.23 1.92 3.15
Cognitive Scores 118 86 115
Parenting Stress 37 37 32
Total Dimensions of Parent Responsiveness (Proportions from -1 to 1)
Affect 0.29 0.15 0.35
Attention 1.00 0.82 0.97
Contingency 0.67 0.04 0.50

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Developmental Appropriateness 0.85 0.43 0.54
Effective Conflict Resolution 0.03 -0.07 0.04
Following Child’s Lead 0.31 -0.11 0.06
Mirroring 0.03 0.00 0.06
Physical Touch 0.16 0.00 0.04
Verbal Communication 0.64 0.16 0.52
Complexity of Parent Responsiveness (Mean across Behaviors)
Free Play 4.19 1.26 3.42
Snack 3.81 1.59 2.81
Total 3.98 1.43 3.09
Note: EL-SDH = elevated likelihood of suboptimal development due to social
determinants of health; EL-A = elevated likelihood of autism; TD = typically developing;
SIRS = sensory interests, repetitions, and seeking

Parent Responsiveness during Free Play. During free play, the infant at elevated
likelihood of autism demonstrated the highest number of sensory cues, followed by the TD
infant, then the infant at elevated likelihood of suboptimal development due to SDH. The mother
of the infant at elevated likelihood of suboptimal development due to SDH demonstrated the
highest complexity of responsiveness, averaging 4.2 dimensions of responsiveness met per infant
sensory cue. The TD infant’s mother met approximately 3.4 dimensions per infant sensory cue,
while the mother of the infant at elevated likelihood of autism met 1.3 dimensions per infant
sensory cue. The pattern of most often met to least often met dimension was similar across all
three mothers, with the exception of the mother of the infant at elevated likelihood of suboptimal
development due to SDH, who demonstrated a higher proportion of developmentally appropriate
responses compared to most other dimensions.
Parent Responsiveness during Snack. The TD infant and infant at elevated likelihood of
autism showed approximately 10 more sensory cues than the infant at elevated likelihood of
suboptimal development due to SDH during the snack activity. The mothers of the infant at
elevated likelihood of suboptimal development due to SDH and the TD infant showed slightly
lower complexity of responses during snack than during free play, meeting an average of 3.8 and

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2.8 dimensions per sensory cue, respectively. The mother of the infant at elevated likelihood of
autism showed slightly higher responsiveness during snack, meeting 1.6 dimensions per sensory
cue during this segment.
Triad B. Infants in this matched triad were 12-month-old white, Hispanic males. The
mothers of the infant at elevated likelihood of autism and the infant at elevated likelihood of
suboptimal development due to SDH had high school diplomas or GEDs, while the TD infant’s
mother had a bachelor’s degree. Of note, the infant at elevated likelihood of autism was born at
35 weeks’ gestation, while the other two infants were full term. The TD infant demonstrated the
highest SIRS and lowest sensory hypo- and hyperreactivity scores. The infant at elevated
likelihood of suboptimal development due to SDH had the highest sensory hyporeactivity and
had sensory hyperreactivity comparable to that of the TD infant. The mothers of the infants at
elevated likelihood of autism and at elevated likelihood of suboptimal development due to SDH
scored similarly to one another and approximately 10 points higher than the TD infant’s mother
on parenting stress. The TD infant had the highest cognitive score, followed by the infant
elevated likelihood of suboptimal development due to SDH (average, but ~1 standard deviation
below the TD infant), then the infant at elevated likelihood of autism (~2 standard deviations
below average). See Table 4.5 for a summary of characteristics compared within Triad B.
Table 4.5. Comparison of characteristics of interest within Triad B.
EL-SDH EL-A TD
Clinical Characteristics
Sensory Hyporeactivity 2.17 2.00 1.50
Sensory Hyperreactivity 1.57 1.71 1.50
SIRS 3.00 2.00 3.38
Cognitive Scores 103 67 118
Parenting Stress 45 44 33
Total Dimensions of Parent Responsiveness (Proportions from -1 to 1)
Affect 0.17 0.38 0.37
Attention 0.78 0.78 1.00
Contingency 0.20 0.62 0.60

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Developmental Appropriateness 0.57 0.62 0.72
Effective Conflict Resolution 0.02 0.04 0.10
Following Child’s Lead 0.10 0.15 0.15
Mirroring 0.07 0.11 0.03
Physical Touch 0.07 0.10 0.07
Verbal Communication 0.23 0.58 0.65
Complexity of Parent Responsiveness (Mean across Behaviors)
Free Play 2.53 3.31 4.14
Snack 1.87 3.42 3.26
Total 2.20 3.37 3.68
Note: EL-SDH = elevated likelihood of suboptimal development due to social determinants
of health; EL-A = elevated likelihood of autism; TD = typically developing; SIRS = sensory
interests, repetitions, and seeking

Parent Responsiveness during Free Play. All three infants in this triad showed ~30
sensory cues during the free play segment. The mother of the TD infant demonstrated the highest
complexity of responses (4.1 dimensions met per sensory cue), followed by the mother of the
infant at elevated likelihood of autism (3.3 dimensions met per sensory cue), then the mother of
the infant at elevated likelihood of suboptimal development due to SDH (2.5 dimensions met per
sensory cue). The mother of the infant at elevated likelihood of suboptimal development due to
SDH demonstrated relatively fewer contingent responses and relatively more developmentally
appropriate responses compared to her behavior in other dimensions. The mothers of the TD
infant and infant at elevated likelihood of autism demonstrated similar patterns of responsiveness
across dimensions, with attention and contingency of responses being the most frequently met
dimensions.
Parent Responsiveness during Snack. The TD infant and the infant at elevated
likelihood of suboptimal development due to SDH provided fewer sensory cues than the infant at
elevated likelihood of autism during the snack segment. The mothers of the TD infant and the
infant at elevated likelihood of suboptimal development due to SDH had lower complexity of
responses (3.3 and 1.9 dimensions per sensory cue, respectively) during snack compared to free

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play, while the mother of the infant at elevated likelihood of autism maintained complexity
across segments (3.4 dimensions per sensory cue). The patterns of more frequent and less
frequent dimensions met within each participant were similar to their patterns during free play.
Triad C. Infants in this triad were 16-month-old white, non-Hispanic females. Their
mothers had varying college degrees: bachelor’s (elevated likelihood of suboptimal development
due to SDH), associate (elevated likelihood of autism), and master’s (TD). The infant at elevated
likelihood of suboptimal development due to SDH demonstrated lower sensory hyperreactivity
than the other two infants, while her sensory hyporeactivity and SIRS scores were between the
other two infants. The infant at elevated likelihood of autism had the highest scores in sensory
hyporeactivity and SIRS and demonstrated equal sensory hyperreactivity to the TD infant. The
mother of the infant at elevated likelihood of suboptimal development due to SDH reported the
highest stress at 4 points above the mother of the infant at elevated likelihood of autism, who
scored 7 points above the TD infant’s mother. The TD infant and the infant at elevated likelihood
of suboptimal development due to SDH demonstrated average cognitive skills, while the infant at
elevated likelihood of autism demonstrated cognition >1 standard deviation below average. See
Table 4.6 for a summary of characteristics compared within Triad C.
Table 4.6. Comparison of characteristics of interest within Triad C.
EL-SDH EL-A TD
Clinical Characteristics
Sensory Hyporeactivity 1.33 1.83 1.00
Sensory Hyperreactivity 1.21 1.86 1.86
SIRS 2.38 2.62 2.08
Cognitive Scores 101 80 112
Parenting Stress 48 44 37
Total Dimensions of Parent Responsiveness (Proportions from -1 to 1)
Affect 0.32 0.33 0.28
Attention 0.94 1.00 1.00
Contingency 0.55 0.64 0.63
Developmental Appropriateness 0.68 0.79 0.68
Effective Conflict Resolution 0.07 0.02 0.08

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Following Child’s Lead 0.16 0.22 0.26
Mirroring 0.01 0.07 0.10
Physical Touch 0.09 0.21 0.06
Verbal Communication 0.63 0.50 0.54
Complexity of Parent Responsiveness (Mean across Behaviors)
Free Play 3.00 4.11 3.88
Snack 3.84 3.47 3.43
Total 3.45 3.78 3.63
Note: EL-SDH = elevated likelihood of suboptimal development due to social determinants
of health; EL-A = elevated likelihood of autism; TD = typically developing; SIRS =
sensory interests, repetitions, and seeking

Parent Responsiveness during Free Play. All three infants gave approximately 30
sensory cues during the free play activity. The mother of the infant at elevated likelihood of
autism demonstrated the highest complexity of responses (4.1 dimensions met per sensory cue),
followed by the mother of the TD infant (3.9 dimensions met per sensory cue), then the mother
of the infant at elevated likelihood of suboptimal development due to SDH (3.0 dimensions met
per sensory cue). Developmentally appropriate and verbal communication dimensions were
relatively high, while contingency was relatively low compared to other dimensions for the
mother of the infant at elevated likelihood of suboptimal development due to SDH. Contingency
and developmental appropriateness were relatively high compared to other dimensions for the
mothers of the TD infant and the infant at elevated likelihood of autism.
Parent Responsiveness during Snack. The TD infant showed the highest number of
sensory cues, followed by the infant at elevated likelihood of suboptimal development due to
SDH, then the infant at elevated likelihood of autism. The parent of the infant at elevated
likelihood of autism due to SDH showed the highest complexity of responses during snack (3.8
dimensions met per sensory cue), while the mothers of the infant at elevated likelihood of autism
and the TD infant showed similar complexity of responses at 3.5 and 3.4 dimensions met per
sensory cue, respectively. All three mothers had similar patterns of responsiveness to one another

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across dimensions during this activity. However, the mother of the infant at elevated likelihood
of suboptimal development due to SDH showed relatively higher use of verbal communication
than the other mothers in this activity.
Discussion
The purpose of this study was to validate a novel measure of parents’ responsiveness to
their infants’ sensory reactivity and regulation cues across developmental risk populations. The
novel tool was found to be valid and internally consistent, and case studies demonstrated
sensitivity to different types of parent behavior in parents of infants at elevated likelihood of
autism, at elevated likelihood of suboptimal development due to SDH, and with typical
development.
Convergent Validity
Moderate correlations between the new measure and the sensitivity and responsivity
subscales of the MBRS demonstrated that the new measure has convergent validity with this
well-validated measurement tool. Additionally, the new measure appears to have captured a
novel aspect of parent responsiveness that may be missed by the MBRS. The new scale uses a
more granular approach to capture the nuances of moment-by-moment parent responses to each
infant cue. The new scale also emphasizes sensory reactivity and regulation cues, thereby
excluding some potential opportunities for parents to respond that would be considered when
assigning an MBRS rating.
Inter-Rater Reliability
Inter-rater reliability was variable across dimensions, infant versus parent behavior
coding, video segments, and amount of training. There were three dimensions with low inter-
rater reliability in the subset of more recently coded videos: conflict resolution, mirroring, and

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physical touch and proximity. There were several possible reasons for this unreliability. First, the
relatively low frequency of behaviors that qualified for scoring on these dimensions limited the
variability of scores. A high proportion of variability within the intraclass correlation coefficient
calculations was due to rater differences, rather than true variability within the sample as a result
of the low frequencies. Low-frequency dimensions may need to be further specified or dropped
from future iterations of the coding scheme due to difficulty with reliability on these dimensions.
Second, subtlety and ambiguity of behaviors included within the low reliability dimensions,
especially physical touch and proximity, may have produced difficulties with inter-rater
reliability. For example, a parent shifting in their chair to get more comfortable may have
inadvertently moved closer to their child. Because “leaning in” toward the child is included in
the physical touch and proximity dimension, one coder may have scored this incidental leaning
in as meeting criteria for this dimension, while the other rater may have interpreted this behavior
as only related to the parent’s own comfort and not part of a response to the child.
Inter-rater reliability was notably lower when coding infant sensory cues compared to
parent responses to those cues. The unreliability in sensory cue coding resulted from several
sources. First, the reliability coder tended to note more sensory cues than the primary coder. That
is, the reliability coder often divided a series of similar behaviors into separate cues for coding,
while the primary coder often grouped similar behaviors together into a single cue. Second,
certain types of sensory cues, such as orientation, approach, and seeking behaviors may appear to
be similar or related. For example, a child must orient to an object before approaching it, so one
coder could label the same behavior as orienting or approach, especially since these cues tend to
occur in quick succession. Additionally, exploratory, or approach, behaviors in infancy are often
repetitive in nature, causing some behaviors to appear similar to sensory seeking (e.g., banging

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blocks repeatedly). Future iterations of the scale could yield better sensory cue inter-rater
reliability by simplifying categories into only approach or avoidance cues. Even with
unreliability of sensory cue coding, coding of parent behavior demonstrated acceptable reliability
across most dimensions, suggesting that the overall qualities of the parent behavior were not
dependent on the specific sensory cues to which the parent was responding. Additionally, the
stronger reliability of the final parent responsiveness scores suggests trustworthy ratings that can
be used in further analyses.
The substantial increase in inter-rater reliability in the later-coded half of the reliability
sample compared to the full sample suggests a training effect on inter-rater reliability. The
primary coder provided feedback on coding of the parent behaviors to the reliability coder
between each independently coded video, which may have served as additional training
throughout the reliability coding process. The increase in inter-rater reliability toward the end of
the coding process indicated that additional training and/or a more stringent training standard is
needed to promote acceptable inter-rater reliability in future studies using the new measure.
Case Studies
Case studies revealed several interesting differences among these triads of participants.
First, several factors outside of parent responsiveness were consistent across all three triads. The
cognitive skills of TD infants and infants at elevated likelihood of suboptimal development due
to SDH were comparable, while cognition of the infants at elevated likelihood of autism was
substantially lower, which is consistent with literature on broad developmental delays in young
children with autism (Miller et al., 2021). Additionally, parenting stress was comparable in
mothers of infants at elevated likelihood of autism and at elevated likelihood of suboptimal
development due to SDH but high compared to mothers of TD infants. This is consistent with

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existing literature that demonstrates elevated parenting stress in these developmental risk
populations (Holtrop et al., 2015; Shenk et al., 2017; Srinivasan & Bhat, 2020; Wan et al., 2012).
Additionally, it is possible that elevated stress related to parenting could influence parents’
ability to interact with their infants in a highly responsive manner.
With regard to parent responsiveness, parents with foster care histories across all three
triads demonstrated relatively lower scores in contingent responses, while this dimension was a
relative strength for parents with TD infants or infants at elevated likelihood of autism.
Developmental appropriateness was a relative strength for parents with foster care histories in
these triads, which is contrary to literature that suggests that parents with foster care histories
may place developmentally inappropriate expectations on their infants (Connolly et al., 2012).
Parents with foster care histories demonstrated variable degrees of responsiveness across triads,
with one parent showing the most responsiveness in her triad and one parent demonstrating the
least responsive behavior in her triad. This variability highlights the importance of understanding
each individual parent-infant dyad and examining strengths and challenges in light of each
family’s context but without assuming the presence or absence certain skillsets. The new
measurement tool developed in this dissertation has utility for closely examining parent
responsiveness and identifying specific strengths and challenges for each individual dyad.
Limitations and Future Directions
The results of this study must be considered in light of several limitations. First, it is
unknown whether or not any participants in the extant datasets had foster care histories, so there
may have been overlap in group membership. Additionally, there was limited racial and ethnic
diversity in the sample, despite the disproportionate number of individuals of minority races
impacted by child welfare system involvement. Two of the three former foster youth participants

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were also married and college educated, two outcomes that may be less common or less stable
among this population than their peers raised in more traditional family situations (Hook &
Courtney, 2011; Jones, 2013). Finally, the very small group of participants at elevated likelihood
of suboptimal development due to SDH limited the generalizability of comparisons across
groups.
Future directions for scale development include factor analysis to examine the underlying
latent structure of the scale and refinement of training procedures to optimize inter-rater
reliability. Additionally, testing of the scale’s sensitivity to change in parent responsiveness will
be important to advance the scale toward utility for measuring intervention outcomes. Finally,
the relevance of the dimensions included on this scale to different age groups and developmental
risk populations should be tested.
Implications
The main implication of this study is preliminary evidence for the reliability and validity
of a new measure of parent responsiveness to SRR. This new measure examines parent
responsiveness through a nuanced, granular coding system that allows for recognition of various
types of parent responsiveness as well as comparison of responsive behavior across dimensions
and across individuals. The new measure can be used to explore the relationships between
specific types and levels of parent responsiveness and later child developmental outcomes, which
will advance the study of this construct toward better understanding and individually-tailored
support for parents to develop responsive behaviors that are most important for child
developmental outcomes.

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Chapter 5: Conclusion
Parent responsiveness is a broad concept that has been widely studied with regard to its
associations with child development, the home environment, parent-child attachment, and
parental mental health. The purpose of this series of studies was to synthesize the body of
literature on parent responsiveness into a single comprehensive definition and use that definition
to develop an in-depth, multidimensional measure of parent responsiveness across
developmental risk groups. The resulting measure demonstrated promising internal consistency
and convergent validity, as well as important insight into the training needed to achieve inter-
rater reliability.
Research Implications
This series of studies filled several gaps in the existing parent responsiveness literature.
First, definitions of this construct varied widely across disciplines, time, and areas of study (e.g.,
Banerjee et al., 2022; Bell & Ainsworth, 1972; Kinard et al., 2017). These highly variable
definitions limit the degree to which results can be compared or synthesized across studies,
thereby limiting our knowledge of the function of these constructs for parental role development,
infant development, and overall family functioning. Study 1 was a foundational step toward
unifying research on this construct by systematically and comprehensively defining parent
responsiveness based on the definitions already available in the literature. Second, there are
myriad measures of parent responsiveness used in research, but most of these measures apply
broad or unidimensional rating systems. Given the complex, multidimensional nature of this
construct highlighted in Study 1, it is possible that existing rating scales for parent
responsiveness may be insufficient for capturing the nuances of parent-infant interaction
unfolding across time. Measure development and validation, which occurred in Studies 2 and 3,

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yielded a specific, in-depth, moment-by-moment coding scheme that is anchored in themes from
the literature. Third, previous measures of parent responsiveness have primarily been developed
either with typically developing research participants or for a specific group of parent-infant
dyads affected by certain developmental differences (e.g., Augustine & Leerkes, 2019;
Vanormelingen et al., 2015; Watson et al., 2017). The measure that resulted from this series of
studies was developed from an existing measure of parent responsiveness to SRR cues in parents
of infants at elevated likelihood of autism (Lee et al., 2017); anchored in the diverse body of
literature on parent responsiveness, which includes typically developing infants and those with a
variety of diagnoses; and evaluated by individuals with lived, research, and clinical expertise on
parenting with history of foster care. Thus, the new measure is broadly applicable across
populations with varying degrees and sources of potential developmental differences, which will
allow for comparison of parent responsiveness across a wide range of populations. Finally, there
is very little literature on validated measures of parent responsiveness specifically to infant
sensory reactivity and regulation (SRR), which is an area of development that may underlie
many other developmental processes (Baranek et al., 2018; Williams et al., 2018). The new
measure developed in these studies will serve as an important tool to better understand the role of
parent responsiveness in relationships among infant SRR and later child developmental
outcomes.
Conceptual Implications
Parenting is a major occupational role for many adults, and the transition to this role (e.g.,
during family planning, pregnancy, and the child’s infancy) is rich with changes in daily
routines, self-concept, primary roles, and meaning assigned to daily tasks (Horne et al., 2005;
Levin & Helfrich, 2004). Parenting role development occurs in a cyclical nature that is

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influenced by both infant and parent behavior, in addition to the family’s history and current
context. Parent responsiveness and the measurement thereof is situated within this period of
immense change and development for both the parent and the infant.
Meaning
Day-to-day parenting responsibilities and interactions are perceived as highly meaningful
for many parents (Horne et al., 2005). However, the experience of meaning within the parenting
role may vary across individuals due to personal history; parity; cultural context; socioeconomic
status; and health and well-being of parent and infant (Holditch‐Davis et al., 2011; Levin &
Helfrich, 2004; Schelbe & Geiger, 2017). Given the personal and context-specific nature of
parent responsiveness, each parent’s experience of the meaningfulness of a given interaction
with their infant may contribute to their degree of responsiveness. Additionally, the new measure
has so far been developed using naturalistic scenarios within a controlled environment (e.g.,
standardized toys and snack foods). This format, which may mimic typical parent-infant
interactions but has a different context, could change the meaning experienced within the
interaction. Thus, future research should examine the relationship between parents’ perceptions
of meaning during daily parenting and during recorded naturalistic scenarios and resulting parent
responsiveness.
Transactional Nature of Occupation
Occupation in general is broadly known as transactional – each individual or collective
experience of occupation is directly or indirectly affected by myriad variables related to personal
and social context, the physical environment, and values instilled through relationships and
experiences (Rosenberg & Johansson, 2013). In turn, each individual engaged in occupation
paves the way for future generations by contributing to these variables. Parent responsiveness is

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transactional both at the macro level described above and at the micro level within each moment
of parent-infant interaction. At the micro level, parents are directly influenced by their infants,
who are, in turn, directly influenced by their parents (Edmunds et al., 2019; Leezenbaum et al.,
2014; Warlaumont et al., 2014). Thus, parent-infant interaction is reciprocal in nature. The
measure developed in these studies takes into account the back-and-forth nature of parent
responsiveness by noting only the parent behavior that occurs as a result of an infant cue.
Dimensional scores, therefore, reflect the degree to which the parent took into account their
infant’s cues during interaction, thus capturing the transactional nature of this component of the
parenting role.
Future Directions
These studies laid the foundation for a program of research dedicated to better
understanding and supporting parent responsiveness for healthy child and family outcomes. Prior
to scaling up the use of the new measurement tool, further development is needed. First, a factor
analysis study is necessary to determine relationships among the literature-identified dimensions
of parent responsiveness and the degree to which there is a general latent characteristic that
underlies each dimension of this construct. Additionally, training procedures for use of the new
measure need to be refined to increase efficiency and effectiveness of training, which will
ultimately yield improved inter-rater reliability and reduce error in results of studies using this
measure.
After the measure is further refined and training is streamlined to improve inter-rater
reliability, there are several future directions to further the study of parent responsiveness. First,
the same dimensions of parent responsiveness that were applied to child SRR cues in these
studies should be examined with regard to infants’ social communication or other cues to

99

determine the extent to which parent responsiveness to SRR cues is distinct from responsiveness
to other types of infant behavior. Then, longitudinal studies are needed to track the role of parent
responsiveness for child development. The complexity of the new measure will support research
on the differential importance of each dimension or combinations of dimensions for different
developmental risk populations. Finally, this foundational knowledge about the specific types
and roles of parent responsiveness can be used to refine interventions and other supports for
parents to develop responsive behavior within specific dimensions that will best support the
evolving parent-child relationship and child outcomes.
Conclusion
This series of studies yielded a measure with promising reliability and validity for
measuring parent responsiveness to SRR cues across developmental groups. This measure has
novelty and value in its dimensionality and moment-by-moment scoring of parent behavior
specifically as it relates to infant SRR cues. The measure, with further refinement, lays the
foundation for future research that may be impactful for implementing a strengths-based
approach to enhance parent child-interaction and support child development within families with
a variety of contexts and histories.

100

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Appendix A: Study 1 Search Strategy
PubMed
("Mother-Child Relations"[Mesh] OR "Parent-Child Relations"[Mesh] OR "Father-Child
Relations"[Mesh] OR "dyadic synchrony"[tiab] OR "mother-infant interaction"[tiab] OR "father-
infant interaction"[tiab] OR "parent-infant interaction"[tiab] OR "Parenting"[Mesh] OR "parent
responsiveness"[tiab] OR "parent responsivity"[tiab] OR "parent response"[tiab] OR "parent
sensitivity"[tiab] OR "parent synchrony"[tiab] OR "parent verbal responsiveness"[tiab] OR
"parental responsiveness"[tiab] OR "parental responsivity"[tiab] OR "parental response"[tiab]
OR "parental sensitivity"[tiab] OR "parental synchrony"[tiab] OR "parental verbal
responsiveness"[tiab] OR "caregiver responsiveness"[tiab] OR "caregiver responsivity"[tiab] OR
"caregiver response"[tiab] OR "caregiver sensitivity"[tiab] OR "caregiver synchrony"[tiab] OR
"caregiver verbal responsiveness"[tiab] OR "maternal responsiveness"[tiab] OR "maternal
responsivity"[tiab] OR "maternal response"[tiab] OR "maternal sensitivity"[tiab] OR "maternal
synchrony"[tiab] OR "maternal verbal responsiveness"[tiab] OR "maternal interaction"[tiab] OR
"paternal responsiveness"[tiab] OR "paternal responsivity"[tiab] OR "paternal response"[tiab]
OR "paternal sensitivity"[tiab] OR "paternal synchrony"[tiab] OR "paternal verbal
responsiveness"[tiab] OR "paternal interaction"[tiab] OR "parent-child synchrony"[tiab] OR
"parent-child interaction"[tiab] OR "parent-infant synchrony"[tiab] OR "parent-infant
interaction"[tiab] OR ("Parents"[Mesh] AND "Social Behavior"[Mesh]) OR ("Parents"[Mesh]
AND "Nonverbal Communication"[Mesh]) OR ("Parents"[Mesh] AND "Facial
Expression"[Mesh]) OR ("Parents"[Mesh] AND "Verbal Behavior"[Mesh]) OR
("Parents"[Mesh] AND "Communication"[Mesh]) OR ("Fathers"[Mesh] AND "Social
Behavior"[Mesh]) OR ("Fathers"[Mesh] AND "Nonverbal Communication"[Mesh]) OR
("Fathers"[Mesh] AND "Facial Expression"[Mesh]) OR ("Fathers"[Mesh] AND "Verbal

153

Behavior"[Mesh]) OR ("Fathers"[Mesh] AND "Communication"[Mesh]) OR ("Adolescent
Fathers"[Mesh] AND "Social Behavior"[Mesh]) OR ("Adolescent Fathers"[Mesh] AND
"Nonverbal Communication"[Mesh]) OR ("Adolescent Fathers"[Mesh] AND "Facial
Expression"[Mesh]) OR ("Adolescent Fathers"[Mesh] AND "Verbal Behavior"[Mesh]) OR
("Adolescent Fathers"[Mesh] AND "Communication"[Mesh]) OR ("Mothers"[Mesh] AND
"Social Behavior"[Mesh]) OR ("Mothers"[Mesh] AND "Nonverbal Communication"[Mesh]) OR
("Mothers"[Mesh] AND "Facial Expression"[Mesh]) OR ("Mothers"[Mesh] AND "Verbal
Behavior"[Mesh]) OR ("Mothers"[Mesh] AND "Communication"[Mesh]) OR ("Adolescent
Mothers"[Mesh] AND "Social Behavior"[Mesh]) OR ("Adolescent Mothers"[Mesh] AND
"Nonverbal Communication"[Mesh]) OR ("Adolescent Mothers"[Mesh] AND "Facial
Expression"[Mesh]) OR ("Adolescent Mothers"[Mesh] AND "Verbal Behavior"[Mesh]) OR
("Adolescent Mothers"[Mesh] AND "Communication"[Mesh]) OR ("Single Parent"[Mesh] AND
"Social Behavior"[Mesh]) OR ("Single Parent"[Mesh] AND "Nonverbal
Communication"[Mesh]) OR ("Single Parent"[Mesh] AND "Facial Expression"[Mesh]) OR
("Single Parent"[Mesh] AND "Verbal Behavior"[Mesh]) OR ("Single Parent"[Mesh] AND
"Communication"[Mesh])) AND ("infancy"[tiab] OR "baby"[tiab] OR “babies”[tiab] OR
"infant"[tiab] OR “infants”[tiab] OR "first year"[tiab] OR "toddler"[tiab] OR “toddlers”[tiab] OR
"Infant"[Mesh] OR "Infant Behavior"[Mesh])
Filters applied: 1-23 months of age, humans, English language.
CINAHL
((MH "Mother-Infant Relations") OR (MH "Father-Infant Relations") OR (MH "Parent-Infant
Relations") OR "dyadic synchrony" OR "mother-infant interaction" OR "father-infant
interaction" OR "parent-infant interaction" OR (MH "Parenting") OR "parent responsiveness"

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OR "parent responsivity" OR "parent response" OR "parent sensitivity" OR "parent synchrony"
OR "parent verbal responsiveness" OR "parental responsiveness" OR "parental responsivity" OR
"parental response" OR "parental sensitivity" OR "parental synchrony" OR "parental verbal
responsiveness" OR "caregiver responsiveness" OR "caregiver responsivity" OR "caregiver
response" OR "caregiver sensitivity" OR "caregiver synchrony" OR "caregiver verbal
responsiveness" OR "maternal responsiveness" OR "maternal responsivity" OR "maternal
response" OR "maternal sensitivity" OR "maternal synchrony" OR "maternal verbal
responsiveness" OR "maternal interaction" OR "paternal responsiveness" OR "paternal
responsivity" OR "paternal response" OR "paternal sensitivity" OR "paternal synchrony" OR
"paternal verbal responsiveness" OR "paternal interaction" OR "parent-child synchrony" OR
"parent-child interaction" OR "parent-infant synchrony" OR "parent-infant interaction" OR
((MH "Parents") AND (MH "Social Behavior")) OR ((MH "Parents") AND (MH "Nonverbal
Communication")) OR ((MH "Parents") AND (MH "Facial Expression")) OR ((MH "Parents")
AND (MH "Verbal Behavior")) OR ((MH "Parents") AND (MH "Communication")) OR ((MH
"Fathers") AND (MH "Social Behavior")) OR ((MH "Fathers") AND (MH "Nonverbal
Communication")) OR ((MH "Fathers") AND (MH "Facial Expression")) OR ((MH "Fathers")
AND (MH "Verbal Behavior")) OR ((MH "Fathers") AND (MH "Communication")) OR ((MH
"Adolescent Fathers") AND (MH "Social Behavior")) OR ((MH "Adolescent Fathers") AND
(MH "Nonverbal Communication")) OR ((MH "Adolescent Fathers") AND (MH "Facial
Expression")) OR ((MH "Adolescent Fathers") AND (MH "Verbal Behavior")) OR ((MH
"Adolescent Fathers") AND (MH "Communication")) OR ((MH "Mothers") AND (MH "Social
Behavior")) OR ((MH "Mothers") AND (MH "Nonverbal Communication")) OR ((MH
"Mothers") AND (MH "Facial Expression")) OR ((MH "Mothers") AND (MH "Verbal

155

Behavior")) OR ((MH "Mothers") AND (MH "Communication")) OR ((MH "Adolescent
Mothers") AND (MH "Social Behavior")) OR ((MH "Adolescent Mothers") AND (MH
"Nonverbal Communication")) OR ((MH "Adolescent Mothers") AND (MH "Facial
Expression")) OR ((MH "Adolescent Mothers") AND (MH "Verbal Behavior")) OR ((MH
"Adolescent Mothers") AND (MH "Communication")) OR ((MH "Single Parent") AND (MH
"Social Behavior")) OR ((MH "Single Parent") AND (MH "Nonverbal Communication")) OR
((MH "Single Parent") AND (MH "Facial Expression")) OR ((MH "Single Parent") AND (MH
"Verbal Behavior")) OR ((MH "Single Parent") AND (MH "Communication"))) AND ("infancy"
OR "baby" OR “babies” OR "infant" OR “infants” OR "first year" OR "toddler" OR “toddlers”
OR (MH "Infant") OR (MH "Infant Behavior"))
Filters applied: 1-23 months of age, English language, academic journals as source of
publication.
ProQuest Nursing & Allied Health
(MESH(Mother-Child Relations) OR MESH(Parent-Child Relations) OR MESH(Father-Child
Relations) OR AB(dyadic synchrony) OR AB(mother-infant interaction) OR AB(father-infant
interaction) OR AB(parent-infant interaction) OR MESH(Parenting) OR AB(parent
responsiveness) OR AB(parent responsivity) OR AB(parent response) OR AB(parent sensitivity)
OR AB(parent synchrony) OR AB(parent verbal responsiveness) OR AB(parental
responsiveness) OR AB(parental responsivity) OR AB(parental response) OR AB(parental
sensitivity) OR AB(parental synchrony) OR AB(parental verbal responsiveness) OR
AB(caregiver responsiveness) OR AB(caregiver responsivity) OR AB(caregiver response) OR
AB(caregiver sensitivity) OR AB(caregiver synchrony) OR AB(caregiver verbal responsiveness)
OR AB(maternal responsiveness) OR AB(maternal responsivity) OR AB(maternal response) OR

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AB(maternal sensitivity) OR AB(maternal synchrony) OR AB(maternal verbal responsiveness)
OR AB(maternal interaction) OR AB(paternal responsiveness) OR AB(paternal responsivity)
OR AB(paternal response) OR AB(paternal sensitivity) OR AB(paternal synchrony) OR
AB(paternal verbal responsiveness) OR AB(paternal interaction) OR AB(parent-child
synchrony) OR AB(parent-child interaction) OR AB(parent-infant synchrony) OR AB(parent-
infant interaction) OR (MESH(Parents) AND MESH(Social Behavior)) OR (MESH(Parents)
AND "Nonverbal Communication"[Mesh]) OR (MESH(Parents) AND MESH(Facial
Expression)) OR (MESH(Parents) AND "Verbal Behavior"[Mesh]) OR (MESH(Parents) AND
MESH(Communication)) OR (MESH(Fathers) AND MESH(Social Behavior)) OR
(MESH(Fathers) AND MESH(Nonverbal Communication)) OR (MESH(Fathers) AND
MESH(Facial Expression)) OR (MESH(Fathers) AND MESH(Verbal Behavior)) OR
(MESH(Fathers) AND MESH(Communication)) OR (MESH(Adolescent Fathers) AND
MESH(Social Behavior)) OR (MESH(Adolescent Fathers) AND MESH(Nonverbal
Communication)) OR (MESH(Adolescent Fathers) AND MESH(Facial Expression)) OR
(MESH(Adolescent Fathers) AND MESH(Verbal Behavior)) OR (MESH(Adolescent Fathers)
AND MESH(Communication)) OR (MESH(Mothers) AND MESH(Social Behavior)) OR
(MESH(Mothers) AND MESH(Nonverbal Communication)) OR (MESH(Mothers) AND
MESH(Facial Expression)) OR (MESH(Mothers) AND MESH(Verbal Behavior)) OR
(MESH(Mothers) AND MESH(Communication)) OR (MESH(Adolescent Mothers) AND
MESH(Social Behavior)) OR (MESH(Adolescent Mothers) AND MESH(Nonverbal
Communication)) OR (MESH(Adolescent Mothers) AND MESH(Facial Expression)) OR
(MESH(Adolescent Mothers) AND MESH(Verbal Behavior)) OR (MESH(Adolescent Mothers)
AND MESH(Communication)) OR (MESH(Single Parent) AND MESH(Social Behavior)) OR

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(MESH(Single Parent) AND MESH(Nonverbal Communication)) OR (MESH(Single Parent)
AND MESH(Facial Expression)) OR (MESH(Single Parent) AND MESH(Verbal Behavior))
OR (MESH(Single Parent) AND MESH(Communication))) AND (AB(infancy) OR AB(baby)
OR AB(babies) OR AB(infant) OR AB(infants) OR AB(first year) OR AB(toddler) OR
AB(toddlers) OR MESH(Infant) OR MESH(Infant Behavior))
Filters applied: Scholarly Journals, humans, infant, infants, mother-child relations, parenting,
maternal behavior, and English language.

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Appendix B: Study 1 Full-Text Screening Decision Guide
1. Is there a full-text version of the article available online via open access or through USC
libraries?
a. If no, mark “Exclude” with the reason “no full text available.”
b. If yes, move on to question 2.
2. Is this article a peer-reviewed study?
a. If the article is a dissertation, mark “Exclude” with the reason “not a peer
reviewed article.”
b. If the article is an opinion piece, letter to the editor, erratum from a previous
publication, or not published in an academic journal, mark “Exclude” with the
reason “not a peer reviewed article.”
c. If neither a nor b apply, move on to question 3.
3. Is the age noted in the abstract?
a. If no, check the participants section, the first paragraph of the results section
and/or Table 1 for the age group.
i. If the mean age is between 6 and 18 months, move to question 4.
ii. If the mean age is outside 6 and 18 months, mark “Exclude” with the
reason “wrong age.”
iii. If age is unclear, mark “Exclude” with the reason “wrong age.”
iv. If the article is a systematic review, look for the large table of all the
articles included. These tables will usually have an age listed for each
article. If the majority of articles included have a mean age of infant
participants from 6-18 months, then move to question 4. If the majority of

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articles have participants with a mean age outside of 6-18 months, mark
“Exclude” with the reason “wrong age.”
b. If yes, confirm that the age was accurately screened during title/abstract screening
and move onto question 4.
4. Find the terms used in the abstract that refer to parent responsiveness (e.g., sensitivity,
contingent behavior, etc.). Search for this term in the article.
a. If it only comes up a few times (<1x per page) and is not mentioned in the
aims/purpose (typically the last paragraph of the introduction), scan through to see
if there is another term used throughout the article. If not, mark “Exclude” with
the reason “not primarily focused on parent responsiveness.”
b. If it comes up many times (≥1x per page), click through to see if any of those
mentions includes a definition of parent responsiveness (typically in the
introduction or measures sections).
i. If no definition is present, mark “Exclude” with the reason “insufficient or
missing definition of parent responsiveness.”
ii. If a definition is present, move on to question 5.
5. Is the definition sufficiently in-depth for inclusion in the thematic analysis?
a. If the definition is less than a sentence long or primarily relies on our key terms
(e.g., “maternal sensitivity was defined as sensitive responding to infant cues”),
mark “Exclude” with the reason “insufficient or missing definition of parent
responsiveness.”
b. If the definition is at least a full sentence with detail about the types of behaviors
that were considered parent responsiveness, mark “Include.”

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Appendix C: Additional Themes Emerging from Expert Interviews
Parenting Context
Across groups and interviews, several key elements of the parenting context for former
foster youth emerged unprompted as inextricably linked to parenting behavior for this
population. That is, researchers, clinicians, and experts by experience all stated that parenting
pressures, expectations from society, and role models influence confidence in parenting
decisions and behaviors for this population. While these contextual influences cannot be directly
measured through brief observations of parent-child interactions, it is important to consider that
parenting behavior for former foster youth is situated in a complex network of internal and
external influences.
Parenting Under Surveillance. Researchers, clinicians, and experts by experience alike
discussed that the pressure on parents aging out of foster care is exponentially greater than the
pressure experienced by parents who were raised in more stable households. That is, according to
researchers, parents aging out of foster care have difficulty “feeling confident in the way
[they’re] interacting with [their] child, which is impacted by the level of stress and threat from
the constant surveillance” by the child welfare system. That is, these parents are parenting "under
the gaze of the system that may or may not define responsiveness in the same way," which had
the potential to unduly influence their parenting decisions and behaviors. Similarly, clinicians
noted that “a lot of people have told [former foster youth] that [they’re] not doing this right” with
regard to parenting. Clinicians shared that "if [former foster youth] ask for help they think that
someone's going to report them, they're not good enough, and they'll have their children taken
away." The experts by experience endorsed this idea by stating that parenting was colored by “a
fear that they’re going to come and take your baby, which is a real fear” or “a huge pressure to

161

do things right.” Therefore, these parents’ confidence may be negatively impacted by the
surveillance and pressures of the system into which they were forced due to their experiences of
abuse or neglect as children.
Sociocultural Expectations of Parenting. Across expert by experience and researcher
groups, the impact of gender and race on perceptions of parenting became clear and was
emphasized as important for consideration when measuring parent responsiveness. While experts
believed that the same behaviors would be considered responsive regardless of the gender of the
parent, they highlighted the differences in expectations on mothers and fathers. For example, one
expert by experience shared that her husband was applauded for “being such a good dad” while
allowing his daughter to ride in the large portion of the shopping cart, while the mother
(interview participant) was criticized on the same day in the same store for “buckling the seatbelt
wrong even though [she] had it buckled.” This story emphasizes the degree to which mothers
may experience even more parenting pressures than fathers. Additionally, one researcher shared
that “some of those things are culturally situated,” those things being parenting language and
behavior. Thus, it is important to acknowledge the potential differences in perspectives held by
study participants in video recordings and researchers responsible for coding parent
responsiveness.
Parenting as Modeled Behavior. Participants stated that parenting behaviors were
learned from others and that former foster youth were at a disadvantage with regard to
trustworthy role models for parenting skills. One expert by experience shared that, while “being
a mother is innate,” and she had a broad network of siblings and supportive foster parents, “that's
totally unnormal for my peer group – they have maybe 1 or 2 people who could even babysit
their child for them.” Another expert by experience mentioned receiving criticism and a lack of

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support from her family. Additionally, a lack of trustworthy sources of parenting advice can
yield misinformed parenting decisions, as stated by one researcher: "I cannot stress enough the
lack of information some parents have…we're talking about something that medically is like
wrong… the information was just factually so wrong." This lack of support and lack of
trustworthy information about parenting may contribute to decreased confidence for parents
aging out of foster care when interacting with their own children.
“Good Enough” Parenting.
Despite the lack of parenting support and modeling and the pressures of constant
surveillance, “these kids in the system are so driven to give their kids a better life.” This drive
may sometimes play out as further pressure and desire to do everything “right.” When discussing
parent responsiveness, it is important to note that “if you're there in a good enough kind of way
then it's gonna work out – getting it right often enough is good enough parenting.” This caveat to
the discussion of parent responsiveness – that “there is no way you’re going to get this 100% of
the time” – is vital to acknowledge when discussing parent responsiveness in order to avoid
adding to the immense pressures experienced by former foster youth who are parenting.

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Appendix D: New Scheme Coding Manual
Measuring Parent Responsiveness to Infant Sensory Reactivity and Regulation Cues
Manual Draft: 04/18/2023
Section 1: Infant Behavioral Cues Indicative of Sensory Reactivity and Regulation
Every individual experiences a constant flow of sensory input throughout our daily lives. With
this constant flow of input comes individual preferences and levels of reactivity. The behaviors
listed below are cues that any infant might demonstrate that give an observer or interactive
partner insight into that individual’s sensory experiences, preferences, and reactivity. The
behaviors listed are not necessarily indicators of atypical development nor sensory reactivity
problems. During the first watch of each section recording (free play and snack), note the child’s
sensory behaviors in the left hand column of the score sheet, organized in 30-second time blocks.
Approach/Exploratory Behaviors
Approach behaviors are a sign of tolerance or enjoyment of a sensory experience. Approach
behaviors include voluntarily interacting with an object or food, exploring it, or prolonging
interaction with it. Approach behaviors are another way of observing sensory preferences.
Aversion, Defensiveness, Avoidance
Aversion, defensiveness, and avoidance are various intensities of behavior that indicates dislike
of a sensory experience and/or sensory hyperreactivity. Observable behaviors in this category
include turning head away, pushing an object away, moving across the room, and/or actively
ignoring or avoiding a toy. Intense behaviors in this category may include crying, tantrums, or
aggressive behaviors.

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Change in Arousal
Arousal refers to the degree of alertness a person experiences. Arousal levels fluctuate
throughout the day for many reasons, including sensory stimuli. A sharp increase in arousal may
be indicative of sensory hyperreactivity, and very low arousal may be indicative of sensory
hyporeactivity. Observable behaviors related to high arousal include increased vocal pitch or
pitch of giggling/squealing, disorganized movements, or hypervigilance. Observable behaviors
related to low arousal include slumping posture, appearing sleepy, or moving slowly.
Orienting
Orienting behavior is a clear, observable sign that a child has registered the presence of a
stimulus. While it is possible for neurological registration of a stimulus to occur without a
behavioral signal, behavioral signals are the only way for an outside observer to recognize
registration. Behavioral orienting includes turning the eyes or head toward a stimulus. A lack of
orienting behavior may be a sign of sensory hyporeactivity to that stimulus.
Preferences and Change in Affect
Affect refers to an individual’s expression of emotions. Affect can be a sign of an individual’s
preferences: what they enjoy or do not enjoy. With regard to sensory reactivity, a person’s
preferences may be related to the sensory properties of a toy or food. Positive affect (smiles,
giggling, happy vocalizations, “mmm” sounds during snack) may indicate that the individual
enjoys that sensory experience. Negative affect (frown, furrowed brow, whining or other
negative vocalizations) may indicate that the individual is not enjoying that sensory experience.
Seeking

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Sensory seeking behavior can occur in any sensory modality. Sensory seeking of tactile input
may include rubbing toys, surfaces, or foods. Children who are seeking oral tactile input may
mouth or lick non-food objects to a degree that is beyond typical oral exploratory behavior.
Sensory seeking of proprioceptive input may include repeatedly banging toys; pushing very hard
on utensils, tools, or toys; tensing full body; and selecting crunchy or chewy foods. Children who
are seeking vestibular input may jump, spin, run, or bounce. Children who are seeking auditory
input may repeatedly activate toys that make noise or hold such toys close to their ears. Children
who are seeking visual input may demonstrate similar behaviors with light-up or moving toys.
Children who are seeking gustatory input may repeatedly smell objects.
Section 2: Dimensions of Parent Responsiveness
Each dimension of parent responsiveness was identified from a combination of systematic
literature review and focus group interviews with researchers, clinicians, and experts by
experience as former foster youth who are parenting. Dimensions are polar, in that the left most
behavior below is considered responsive, and the rightmost behavior is considered unresponsive.
In the coding scheme, a behavior should be marked with a 1 if it falls into the responsive
category, a -1 if it falls into the unresponsive category, and a 0 if that dimension was not
reflected in/relevant to the behavior demonstrated by the parent (e.g., if a response to the child’s
behavior is not necessary, every dimension would be marked with a 0 for that behavior).
Descriptions of behaviors consistent with each dimension are listed below. During the second
watch of each recording (free play and snack), note the parents’ behavior in the 5 seconds
following the child’s cue in the second column on the score sheet. By restricting rating of parent
behavior to the 5 seconds following the child cue, the “timing” dimension of parent
responsiveness is inherently built into the coding process, so is not separately scored. After

166

watching, rate each parent response on each dimension of parent responsiveness. Note that
scoring is simply a way of categorizing parent behavior, and does not indicate either “good” or
“bad” parenting. See Table D.1 for a summary of scores across dimensions.
Appropriate Affect
The affective dimension of parent responsiveness refers to use of positive affect and warmth
toward the child, as well as matching affect to the child’s needs. A parent who scores a 1 on this
dimension would demonstrate positive affect (laughing, smiling, positive tone of voice) when the
child’s affect is positive or neutral, and would demonstrate calm, neutral affect when the child is
demonstrating negative affect (e.g., frustration, crying). A parent who scores a -1 on this
dimension would demonstrate negative affect or harshness toward the child. A parent would
score a 0 on this dimension if the child is not demonstrating affect-related cues and the parent
remains neutral (e.g., no positive or negative affect).
Attention to Child
A parent who scores a 1 on this dimension may direct gaze to the child, position themselves
within the child’s visual field or contacting the child, and use body language that demonstrates
attention (e.g., leaning in, mirroring the child). A parent who scores a -1 on this dimension may
look away from their child (e.g., down at their cell phone or smart watch), position themselves at
a distance from the child, or demonstrate disengaged body language (sitting back, sighing, closed
off). A score of 0 would apply here if the parent is engaged with the same toys or activity as the
child, but not directly attending to the child. In this case, the parent is not ignoring the child due
to engagement in an activity together, but they are also not directly demonstrating attention to the
child.

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Contingent Responses
Response to immediate cues refers to the degree to which the parent’s behavior is contingent
upon the child’s cues, well-matched to the child’s needs or desires, and timed within a few
seconds of the child’s cue. A parent who scores a 1 on this dimension demonstrates an
appropriate response (e.g., seems to be related to the child’s signal) to the child’s cue. A parent
who scores a -1 on this dimension either demonstrates an inappropriate or unrelated response or
demonstrates no response. A score of 0 would apply here if the parent appears to be allowing the
child to explore or experience toys in their own way prior to jumping in with a response. In this
case, the parent is not immediately responding, but is not being unresponsive either. For
example, if a child is using her fingers to explore the texture of the pudding during snack time,
and the parent observes for a few seconds before commenting or directing the child, they would
receive a 0 on this dimension.
Developmentally Appropriate
Developmental appropriateness refers to parent behavior that takes into account the child’s
current capacities, including the level of independence with which the child engages in activities,
the types of play actions that the child can engage in, maintaining safety awareness, and allowing
the child to lead the interaction within appropriate structure/control. A parent who scores a 1 on
this dimension would suggest appropriate play ideas (e.g., container play for a 12-month-old),
speak in language that is matched to the child’s level of communication skill, prevent the child
from engaging in unsafe behavior, and follow the child’s interest or type of play within safe
boundaries. A developmentally appropriate response to sensory avoidance or aversion may be to
provide co-regulation through calming verbal input, deep pressure, or slow/rhythmic vestibular
input. A parent who scores a -1 on this dimension may suggest play ideas or use language that is

168

too advanced for the child or too basic for the child, such that the child gets frustrated or bored.
A parent scoring a -1 may also allow the child to engage in clearly unsafe behavior or fail to
provide needed co-regulation in response to the child’s aversive reaction to sensory input. A
score of 0 on this dimension indicates that the parent’s behavior would be appropriate or
applicable regardless of developmental level and/or there is no response, so developmental
appropriateness cannot be assessed.
Effective Conflict Resolution
A parent should score a 1 on this dimension if they are able to effectively navigate their child’s
needs and desires in the context of the activity. That is, if the parent must redirect the child due
to safety or a desire to engage in activities together, a parent who scores a 1 on this dimension
would redirect to an activity that provides similar sensory input to the child’s choice of activity
(e.g., if the child is running circles around the room, the parent might pick them up and swing
them around). A parent should score a -1 on this dimension if they engage in power struggles
with the child or demonstrate any repeated behavior that seems to provoke or frustrate the child.
A parent should score 0 on this dimension if there is not a need for conflict resolution in response
to a given cue from the child.
Follow Child’s Lead
A parent should score a 1 on this dimension if the parent’s behavior appears to follow the child’s
agenda for the interaction. For example, a parent who joins the child in their activity, expands the
child’s activity, or comments on the child’s activity would receive a 1. A parent should score a -1
on this dimension if they redirect the child to a new activity or are overly controlling of the

169

interaction. A parent should score a 0 on this dimension if they are neither following nor
redirecting the child (e.g., if they are observing the child’s activity).
Mirroring, Reflecting, Imitating
A parent should score a 1 on this dimension if they mirror, reflect, or imitate their child’s
behavior. For example, if the parent repeats the child’s vocalization, facial expression, or
physical movement back to the child, a score of 1 on this dimension would be appropriate. If a
parent does not engage in this behavior, they should score a 0 on this dimension. There is no
score of -1 on this dimension, as mirroring and reflecting is a low-incidence behavior.
Positive Physical Touch
Physical touch is sometimes a part of responsive parenting, though it is not always necessary
during every activity. A parent would score a 1 on this dimension if the child demonstrated a
need for or enjoyment of physical touch (e.g., the child’s arousal is very high due to an aversive
sensory experience; the child appears to seek touch, such as tickling or deep pressure; the child
does not orient to a salient stimulus, so the parent adds a tactile cue) and the parent provided
positive touch in response. Additionally, a parent would score a 1 if they position themselves in
close physical proximity to the child. A parent would score a -1 on this dimension for any
instance of negative, harsh, or aggressive physical touch or if the parent continued providing
physical touch that the child appeared to dislike (e.g., the child demonstrated an aversive or
avoidant response to the tactile input from the parent and the parent continues providing the
same input). If the parent demonstrates no physical touch and the child does not appear to need
physical touch (for co-regulation or to provide preferred touch), the parent should score a 0 on
this dimension.

170

Verbal Communication
Verbal communication is a part of most interactions and can either add to or take away from the
nature of the interaction. A parent should score a 1 on this dimension if their verbal
communication is well-matched to the child’s current focus of attention and/or relevant to the
child’s current sensory experience. A parent should score a -1 on this dimension if their verbal
communication is excessive or unrelated to the current shared experience. A parent should score
a 0 on this dimension if they do not demonstrate verbal communication.

Table D.1 Parent behavior scoring summary
Dimension Score of 1 Score of 0 Score of -1
Affect
Positive parent affect
when child’s affect is
positive; neutral or
positive parent affect
when child’s affect is
negative
Neutral parent affect
when child is not
displaying affective
cues
Negative parent affect
or harshness
Attention
Gaze toward child Engaged in same
activity as child but not
oriented to child
Sitting back, looking
elsewhere (e.g., cell
phone, different toy)
Contingent Response
Response is related to
child’s cue
Observing before
responding (e.g.,
delaying response)
Inappropriate,
unrelated, or no
response
Developmentally
Appropriate
Appropriate play ideas,
matching child’s level
of development,
allowing independence
Parent behavior is
applicable regardless of
developmental level,
response is not related
to developmental level
Allowing child to
engage in unsafe
behavior, too advanced
or too basic in language
or play ideas
Effective Conflict
Resolution
Navigate child’s needs
and respond well to
distress
No distress/conflict Power struggles or
repeated frustrating
behavior
Following Child’s Lead
Child’s agenda, joins or
expands child’s activity
Neither following nor
redirecting (e.g.,
observing)
Redirecting child to a
new activity in the
absence of a safety
concern
Mirroring, Reflecting,
Imitating
Imitates or repeats the
child’s action
Does not imitate or
repeat the child’s action
N/A

171

Positive Physical Touch
Child needed/wanted
touch, parent provided.
OR parent adjusts to
improve physical
proximity to child
Child did not need/want
touch
Child avoided touch,
parent provided touch.
OR parent increased
distance between self
and child (or positioned
out of child’s view)
Verbal Communication
Matched to child’s
focus of attention or
current sensory
experience
No verbal
communication
Excessive or unrelated

Section 3: Score Calculation
Mean scores for each dimension are computed by averaging all of the points on that dimension
across the total number of child cues in order to reduce the impact of recording length and
number of child cues on parent responsiveness scores. A total mean score is calculated by
averaging the dimensional scores. Finally, a complexity score is calculated by averaging the
number of dimensions met for each parent response.

Abstract (if available)

Abstract Parents are widely known to be primary caregivers and important attachment figures for their children, thereby substantially influencing their children’s development, especially during infancy and toddlerhood when children are completely dependent upon adult care for all daily occupations. Parent responsiveness to their infants’ cues is an important component of parenting behavior, given that infants and toddlers learn pragmatic and social-emotional skills as a result of back-and-forth interactions with their parents. Additionally, parent responsiveness is known to promote some positive developmental outcomes. There are several important sources of developmental risk for which parent responsiveness may be a resilience factor. First, infants at elevated likelihood of autism may benefit from parent behavior that is responsive to potentially ambiguous or less frequent cues resulting from the early signs of autism. Second, infants whose parents lacked good parenting role models, such as those with foster system history, could benefit from parenting behavior that promotes social-emotional development through responsiveness. However, this construct has been less studied in populations at such elevated likelihood of suboptimal infant development due to social determinants of health (SDH). Given potentially similar presentations among infants at elevated likelihood autism and those with social-emotional challenges due to SDH, certain parent responsiveness behaviors may be similar across these populations. However, no study to date has examined similarities and differences in parenting behavior in parents of infants at elevated likelihood of autism versus suboptimal development due to SDH. The purpose of these dissertation studies was three-fold:
1. To establish a comprehensive definition of parent responsiveness across existing literature.
2. To adapt a measure of parent responsiveness for applicability across populations.
3. To test the new measure.
Study 1 was a systematic review of the literature on parent responsiveness to their infants’ cues when infants were 6-18 months old. Articles were identified from several relevant databases using search terms related to parent responsiveness and infant age. The initial search returned 18,978 unique articles, 463 of which were included in the final review. Definitions of parent responsiveness used in each article were extracted and thematically coded to yield a comprehensive, multidimensional definition of this important construct.
Study 2 included (a) focus groups and individual interviews based on the definition identified in Study 1 and (b) measure adaptation. Focus groups or interviews were conducted with three distinct groups of experts:
1. Researchers with demonstrated experience researching with parents who are former foster youth.
2. Clinicians with at least one year of experience working with this population.
3. Experts by experience who themselves were parents and spent time in foster care as children.
Interviews determined that many of the dimensions of parent responsiveness identified in Study 1 were relevant to this unique population and that there were a few additional dimensions to consider.
Study 3 included pilot testing of the new measure with former foster youth (n=3) and reliability and validity testing of the new measure with an extant dataset collected from (a) parents of infants at elevated likelihood of autism and (b) parents of children with no known developmental risk. Additionally, case studies were presented to compare profiles of parent responsiveness, parent stress, infant sensory reactivity, and infant cognition across groups. The development of a measurement tool for examining the key dimensions of parent responsiveness is useful for research in the areas of infant development with elevated likelihood of autism or suboptimal development due to SDH. These studies contributed to understandings of parent responsiveness in various developmental risk groups. The measure developed through these studies lays the foundation for examining parent responsiveness in a nuanced way across the groups studied and others. Most importantly, there are growing bodies of literature on parenting interventions for infants at elevated likelihood of autism and infants whose parents have foster system histories. The new measurement tool that resulted from these studies will serve as a foundation for examining commonalities and differences in parent responsiveness across groups and identifying predictors of positive outcomes with implications for intervention targets, thereby promoting interdisciplinary sharing of knowledge to ultimately strengthen the body of research around supporting parents of infants at risk of suboptimal developmental outcomes.

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Asset Metadata

Creator Campi, Emily (author)

Core Title Examining parent responsiveness to sensory reactivity and regulation cues of infants with developmental risk factors

School School of Dentistry

Degree Doctor of Philosophy

Degree Program Occupational Science

Degree Conferral Date 2023-08

Publication Date 06/27/2023

Defense Date 06/12/2023

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag former foster youth,OAI-PMH Harvest,parent responsiveness,sensory reactivity

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Baranek, Grace T. (committee chair), Lawlor, Mary (committee member), Sideris, John (committee member), Traube, Dorian (committee member), Watson, Linda R. (committee member)

Creator Email campi@usc.edu,ecampi15@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113259707

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