The parenting of future parents: The effects of experienced maternal love withdrawal and competing demands on sensitive care giving

The parenting of future parents:

The effects of experienced maternal love withdrawal

and competing demands on sensitive care giving

Lianne W. Brock Teijlingerlaan 11 2171CB Sassenheim S0817589

Child and Family Studies, 2012-2013 l.w.brock@umail.leidenuniv.nl

Begeleiders:

Sandra Voorthuis, MSc Pieter de la Court gebouw Wassenaarseweg 52 2333 AK Leiden 071-527 4070

voorthuisa@fsw.leidenuniv.nl

Dr. Rixt van der Veen Pieter de la Court gebouw Wassenaarseweg 52 2333 AK Leiden 071-527 1431

Munier, E. (n.d.). Maternal Affection [Painting]. Retrieved from http://annacatharina.centerblog.net/rub-emile-munier-art-.html

Acknowledgements

Before you, you may find the final result of years of hard work and although it wasn’t always an easy charge, the process through which it has lead me, has resulted in a greater understanding of the importance and impact that science may have on society. Throughout the last five years studying has played a central role in my life and I truly believe it has benefited me greatly. It is somewhat bewildering, but with a sense of pride that I am now on the verge of graduating. As is due, I wish to make acknowledgements to all those who have guided and supported me in the writing of this final chapter. First, I wish to thank Sandra Voorthuis, MSc, whose guidance has been an incredible aid during the past year. Her willingness to answer my questions, her ability to coax me in the right direction and her trust in my

knowledge and ability, has definitely helped me accomplish what I had not thought possible. Secondly, I would like to thank Dr. Rixt van der Veen, whose critical view has undoubtedly helped raise the level of my writing and research. In addition to the pleasant conversations we’ve had during practical work, she, too, has significantly helped guide this process and brought it to its successful conclusion.

Naturally I am deeply thankful to my loving family for their support and encouragement, not just during this previous year, but throughout all my endeavours. I

especially wish to thank both my parents, who have always supported me unconditionally and whose confidence in me never faltered. Mum, Dad, for this I will always be deeply grateful to you.

Table of Contents Abstract ... 7 Method ... 12 Sample ... 12 Procedure ... 12 Measurements ... 13 Data Analysis ... 15 Results ... 16

Descriptive Statistics and Study Variables ... 16

Love Withdrawal Scores and Sensitivity ... 17

Competing Demand and Sensitivity ... 18

Love Withdrawal Moderation of Competing Demands Effect on Sensitivity ... 18

Discussion ... 19

References ... 23

Appendix 1: Samenvatting ... 27

Appendix 2: Dankwoord ... 29

Onderzoeksverslag. BabyCARE: Gehechtheid, kindermishandeling en reacties op huilen... 31

Abstract

Experiencing harsh parenting strategies has been shown to be detrimental to later outcomes and through intergenerational transference this parenting behaviour can lead to negative parenting across generations. However, there is a lack of research examining these early experiences in a controlled environment. Therefore the objective of this study was to examine the potential effects of early experienced love withdrawal on the sensitive care giving of an infant simulator. Furthermore, due to a possible change in sensitive parenting behaviour when experiencing multiple demands, we examined the possible effects of

competing demands on sensitivity. We hypothesized that more experienced love withdrawal would decrease sensitivity, as would competing demands and that love withdrawal would influence a possible relation between demanding tasks and sensitive behaviour. Our sample consisted of 90 female students, who had no children. Participants completed questionnaires concerning early childhood experiences, including the Love Withdrawal scale. They cared for an infant simulator during two consecutive evenings and were invited to a lab session where they were observed in their sensitive care giving, whilst performing free play and two demanding tasks, with the infant simulator. These observations were coded on sensitivity, using the Ainsworth Sensitivity Scale (Ainsworth, Bell & Stayton, 1974). We found that more experienced love withdrawal as a child was linked to less sensitive behaviour later. The experience of a demanding task, also decreased sensitive behaviour during care giving. The experience of love withdrawal, however, did not moderate the effect of competing demand on sensitivity. These results underline the importance of discouraging the use of negative

parenting strategies as this can lead to possible negative outcomes. Our findings also point to the potential negative impact that a demanding environment can have on sensitive care giving.

A baby’s cry is hard to ignore, which, from an evolutionary perspective, is a most useful feat. It is an important survival factor, as it encourages proximity to the parent in moments of stress or danger (Bowlby, 1969). For an infant, crying is the most important signal and both parents and non-parents show signs of arousal through increased cardiac reactivity and skin

conductance, when hearing this inescapable sound (Frodi, Lamb, Leavitt & Donovan, 1978; Groh & Roisman, 2009; Out, Pieper, Bakermans-Kranenburg & van IJzendoorn, 2010). Unfortunately, when an infant cries excessively it may also lead to child maltreatment, possibly resulting in infant death. At 6 months, approximately 5% of all parents in the

Netherlands has manhandled their baby through slapping, smothering or shaking due to what they believed to be the infant’s excessive crying (Barr, Trent & Cross, 2006; Reijneveld, van der Wal, Brugman, Hira Sing &Verloove-Vanhorick, 2004). Taken together these results point to infant crying as an important cue for examining parents’ responsiveness to their children’s signals.

Sensitivity is a very significant aspect of responding in parenting and can be extremely influential in a child’s life as it affects many child outcomes. High sensitivity implies that the parent accurately perceives a child’s signal, such as crying, and responds to it in a both prompt and adequate manner (Ainsworth, Blehar, Waters & Wall, 1978). The child will experience feelings of being heard and understood, which promotes a secure attachment (Ainsworth et al.,1974). It can also positively affect self-regulation skills and child

compliance (Bowlby, 1969). It is the manner in which parents react sensitively when the child is in (high) distress that encompasses the development of a secure attachment (Goldberg, Grusec & Jenkins, 1999). This means that when the child is ill, frightened or in any other way emotionally upset, the sensitive response of the parent greatly affects the secure attachment of the child, which in turn promotes a healthy child development. Securely attached children also exhibit greater social competence with peers due to their understanding of emotions, their conscience development is greater and they have better problem-solving skills in social situations (Thompson, 2008).

Thus, how sensitively a parent responds to a child’s signals has widespread

consequences in later life. Low quality sensitivity can influence a child’s life negatively and the same applies to parents using more love withdrawal when disciplining. By practicing love withdrawal the parent withholds any form of affection following unwanted or undesirable behaviour of the child. Though this is not directly harmful, when used in excess it can be defined as child maltreatment (Euser,Van IJzendoorn, Prinzie & Bakermans-Kranenburg, 2010). The effects that love withdrawal (especially maternal love withdrawal) can have on a

child’s life have been examined and this disciplining strategy shows associations with some unwanted child outcomes like lowered self esteem, fear of failure and a lower emotional happiness (Assor, Roth and Deci, 2004; Huffmeijer, Tops, Alink, Bakermans-Kranenburg & Van IJzendoorn, 2011). Experiencing this form of harsh and rejecting parenting during

childhood also relates to an unsecure attachment in adults and it is thought that the conditional aspect of this parenting strategy is very harmful (Swanson & Mallinckrodt, 2001).This type of parenting can be detrimental to the child’s development and may have long-term effects. How a child experiences their upbringing can contribute to how they parent their own children. Many studies have shown that the parenting that children experience is

intergenerational, meaning that it elicits the same type of parenting in these children when they are parents themselves (Belsky, Conger & Capaldi, 2009; Capaldi, Pears, Patterson, & Owen, 2003; Neppl, Conger, Scaramella & Ontai, 2009). This could be ascribed to internal working models, which implies that adults have models based on what they perceived and experienced around them in their childhood (Bowlby, 1969). This is the case for harsh, aggressive and insensitive parenting. Evidence shows that children develop a certain social competence in their childhood, which they convey in their own parenting when adults (Belsky et al., 2009). Fortunately, internal working models also apply to positive, consistent and sensitive parenting. Children experiencing this kind of parenting have been found to raise their children by similar means (Chen & Kaplan, 2001). Taking internal working models into consideration, parents using more love withdrawal may have less regard for signals from their child and through their care giving could be expected to raise children who themselves are less concerned with signals from others. It is therefore our aim to investigate whether

experienced love withdrawal as a child affects the levels of sensitive responsiveness cued by infant crying.

To be deemed sensitive, parents need to respond to their child’s signals effectively. For infants, crying is a way of eliciting care giving from their parent. Baby cries therefore seems an adequate means for the evaluation of sensitivity, as it elicits care giving. Added to that, some studies point to the effectiveness of maternal sensitivity on attachment security only when the infant is distressed (Leerkes, Weaver & O’Brien, 2012; McElwain & Booth-LaForce, 2006) or during distressing tasks (Leerkes, 2011). Infants displaying excessive crying can be deemed highly distressed by parents, so a sensitive response is in place. However, we know that depressed mothers often respond less sensitively (Campbell, Matestic, von Stauffenberg, Mohan & Kirchner, 2007; Donovan, Leavitt & Walsh, 1997; Lovejoy, Graczyk, O’Hare & Neuman, 2000). This also applies to mothers who experience

high parenting stress, through which they feel unable to provide the resources that care giving demands of them (Pereira, Vickers, Atkinson, Gonzalez, Wekerle & Levitan, 2012).

Likewise, mothers experiencing high stress through environmental factors or from the child self also show lower levels of sensitivity compared to mothers who feel supported (Pianta, Sroufe & Egeland, 1989). Consequently, the level of maternal sensitivity may also depend on external factors like a demanding task. Therefore, we will also be looking at the effects that a task may have on a sensitive response to infant crying, as during a demanding task a mother must choose whether to react to their child’s signals or to complete the task at hand.

In recent studies a new manner of eliciting a response from participants has been introduced, proving to be an excellent alternative. The use of a life-like doll with crying sounds has been used and verified to be a valid method of examining adults reactions (van Anders, Tolma & Volling, 2012; Gustafson & Harris, 1990). Compared to having participants listening to audio tracks, it ensures a more ecologically valid situation as the participants take care of the life-like baby doll (Bruning & McMahon, 2009). This, contrary to using real babies, allows for randomized control settings as every participant receives the same stimuli. In one study the use of the doll not only led to significant hormonal changes, it provided these changes after only 10 minutes of interaction with non-fathers (van Anders et al., 2012). Aside from obvious ethical reasons, the advantage of using a doll is that the amount of crying that participants are exposed to can be standardized leading to more valid and comparable data (St. James-Roberts, 2001).

Quality of parenting is important as it can have many implications concerning the child and its own parenting later on. Good parenting, defined as consistent and sensitive, has a pronounced effect on a child’s later life. Since love withdrawal is neither sensitive nor

consistent it is important to study the extent to which adults have experienced love withdrawal in their youth and what its effects can be on later parental sensitivity (Chen & Kaplan, 2001). We have examined this potential effect by observing parental sensitivity with the Maternal Sensitivity Scale (Ainsworth et al., 1974) during the care giving of an infant simulator. We expected to find that having experienced more love withdrawal as a child would negatively affect sensitivity levels in response to infant crying. It is conceivable that mothers do not always respond to their infants signals promptly or adequately, but it is interesting to asses if an infant’s distressed crying can be overruled by another external factor like stress or a task. Therefore, our second research question was aimed at understanding the influences that doing a task may have on maternal sensitivity during care giving. One study researched this specific subject and results showed that professional care givers have

significantly lower sensitivity when confronted with a task during care giving, compared to free one-on-one play (Goossens & Melhuish, 2000). This lead us to speculate that the

presence of a competing demand may negatively affect sensitivity scores, as a task leaves less room for sensitive responding.

Arising from these hypotheses came further interest in the effect that love withdrawal might have on sensitivity during the three demanding tasks. As we expected to find that both experienced love withdrawal and competing demands influenced sensitivity, we proposed that love withdrawal may moderate the potential competing demands effect on sensitivity.

Method

To test the above mentioned hypotheses we have looked at sensitivity as coded by the Ainsworth Sensitivity vs. Insensitivity Scale (Ainsworth et al., 1974) and the measure of love withdrawal by means of an 11 item 5-point-scale, based on the extended Children’s Report of Parental Behaviour Inventory (CRPBI, Schludermann & Schludermann, 1988) and adapted by Huffmeijer et al. (2011). Our data was taken from the BabyCARE study which, amongst other things, examines people’s reactions to infant crying. Below a short description is given of the methods, procedure and data analysis we have used to examine the main questions.

Sample

For the BabyCARE research 353 students took part in the first phase of the study, where they filled out online questionnaires. Ten male students and five mothers had to be left out as both gender and the experience in parenting may influence outcomes. Also, due to some random responses one other participant was left out. In continuing to the second phase of the study the remaining 337 participants were invited to attend; 186 students were willing to partake in this phase. The remaining 53% did not significantly differ on demographic factors (all p > .05) from the students not participating. For the present study a sample of 90 participants were randomly selected. The sample thus comprised of 90 females, of which 98% was born in the Netherlands, with an average age of 19.79 (SD = 1.48), who had no children. They were attending Leiden University and were mainly students of Pedagogy (72 %). For their participation, all students received either monetary reward, credits or both.

Procedure

At the start of our research participants were asked to complete an online questionnaire on experienced care giving and some demographic details. After completing these, the

participants received information about the possibility to take care of the infant simulator for two evenings lasting five hours at home and during a lab session. For each instance, the

participants were asked to take care of the doll as if it was a real baby. Following the second evening, participants were asked to fill out a questionnaire on the realism of the care giving. For the subsequent lab session, the laboratory had been decorated as homely as possible with the help of a dresser with a changing mat, a table and chairs, a baby cot, pictures of the baby, baby books and some toys.

The lab session itself was structured as follows. Participants were introduced to the examiner and accompanied to the lab room. The participants were given a short description of the lab session and were told that they would be filmed. They also received an explanation about the doll-session in which they were told that the session would be different from their home experiences, that they might use anything in the room and that they would not be wearing the sensor this time. The examiner then collected the doll and introduced her to the respondent, after which the doll was carefully handed over. The doll was named, comparable as to the home-sessions, to make care giving as realistic as possible and the examiner

mentioned the possibility of talking, reading or singing to the doll to comfort it. During the first session the participant only had to look after the doll. In the second doll-sequence, the participant was asked to fill out a questionnaire whilst still taking care of the doll. In the third session the participant performed a computer task; The Tower of London. Participants were informed that those who ended the task quickest would receive an extra monetary bonus. All lab sessions were filmed and coded for sensitivity.

Measurements

RealCare doll. All participants took care of a RealCare baby doll (Realityworks, Inc.,

Virtual Parenting, Coffs Harbour, NSW 2013) during three separate instances; twice in their own home and once in a lab. This real-life doll had the appearance and weight of a 6 week-old baby. The doll’s neck allowed for head-movement, which meant that participants needed to support it, or the child would give a cry of pain. The cry sounds were recorded from real infants.

Supplied with the doll were feeding bottles, nappies with coloured markers, so that the baby could be properly changed, and baby clothing. The doll could be programmed to cry at set times and when participants had identified themselves through the means of an ID-tag, they could try to sooth the baby by feeding it, changing it, rocking it or burping it with the help of similar sensors placed in the bottles, diapers and within the doll itself. The doll could also just be fussy and just like with real baby’s, the participant had to find out what the doll required so as to comfort it and stop the crying.

The crying of the doll varied in pitch and intensity and when at home, could be stopped by providing its needs. We programmed the doll as being difficult in all three instances, which meant its crying was similar to that of a difficult or colic baby. For both evenings and the lab session the crying had been programmed differently so that participants had no prior knowledge of when the doll would start crying and what it needed. Thus, before the lab session the participant had been able to practice care giving with the RealCare baby doll.

Sensitivity. For coding the level of sensitivity of the participants we have used the

Sensitivity Scale (Ainsworth et al.,1974). This scale ranged from a score of 1 to 9, where a higher score equalled higher sensitivity. Though the scale provided descriptions of the scores 1, 3, 5, 7 and 9, between scores and halves could also be assigned.

Sensitivity was coded based on the recorded sessions, each of which was ten to twelve minutes, in which participants could interact with the RealCare baby doll. Each of the

previously mentioned care giving sessions were coded independently. The coding has been done by the research staff of the BabyCare study at the University of Leiden, who received training from an expert in reliable coding of sensitivity. The staff consisted of nine trained coders and their intercoder-reliability was r = .85

Love withdrawal. To measure the extent of participant experience with love

withdrawal we have used an adapted Dutch scale for Maternal Love Withdrawal (Huffmeijer et al., 2011). Participants filled in for 11 items whether or not it was relevant to their mother’s behaviour on an 5-point scale with answers ranging from not applicable (1) to fully applicable (5). These scores were based on the mother’s conduct during the first sixteen years of the participants life. High scores on this scale equalled more experience of love withdrawal. One item stated: “My mother is less friendly to me, when I don’t see things her way” (Huffmeijer et al., 2011). Concerning one of the items; several participants were able to fill it in properly, but the majority could not due to a technical error. Therefore the scores for this particular item were replaced with the mean scores of the remaining items on the Love Withdrawal scale. We conducted our analysis with the total mean scores on the Love Withdrawal Scale. The internal consistency of the Love Withdrawal scale was α = .90

Realism of care giving. Through the means of a 5-item questionnaire, participants

filled out their experiences of caring for the doll. Questions concerned how participants had cared for the doll, the realism of caring for the doll and how the care giving might have

effected participants view on caring for children in the future. Items were scored on a 10-point-scale. For this study we made use of the ‘realism-of-care-giving’ item (Item 1).

Data Analysis

Before starting our analyses we controlled all variables for normality, missing values and outliers. Participants with missing scores concerning the measured sensitivity were omitted from analysis. We inspected the relation of the background variables with the dependent variable sensitivity. By means of correlation we inspected the relation between sensitivity and the variables age and realism of the care giving. We also performed independent t-tests to inspect potential differences in sensitivity for psychiatric illness or disorders, the presence of siblings, previous care for children younger than two years and whether participants lived with both their biological parents until the age of 16.

We used an independent t-test for analyzing the possible mean differences in sensitivity between those with more and those with less experienced love withdrawal. For sensitivity we used the mean scores of the three sessions combined. Scores on the Love Withdrawal scale were divided by means of a median split resulting in two groups, one of which represented participants with less experience of love withdrawal (N = 42) and one which represented those with more experience of love withdrawal (N = 48).

For our second question concerning the influence that performing a task with increasing competing demand may have on maternal sensitivity during care giving we have used a one-way repeated measures ANOVA, where measured sensitivity in the 3 parts of the session was the within-subjects factor. For post hoc analysis we have made use of the

Bonferroni correction.

We analyzed whether the experience of love withdrawal might influence the

participant’s change in sensitive behaviour over the three levels of the demanding tasks. We used a mixed between-within subjects analysis of variance, with mean sensitivity during the three sessions as the within-subjects factor and high and low experienced love withdrawal as the between-subjects factor to analyze a possible interaction effect, as well as the two main effects previously analyzed.

We performed statistical analyses with the use of the SPSS 19 software and for all statistical tests we used an alpha level of .05.

Results Descriptive Statistics and Study Variables

Before starting our analysis we performed data-inspection on the variables in question. The dependent variable sensitivity showed normality, with a standardized skewness of -0.54 and a standardized kurtosis of -1.04, no outliers or missing values. Across the three observed tasks, sensitivity ranged from 1.00 to 8.50 on a scale from 1 to 9. For our first analysis concerning the influence that experienced love withdrawal might have on sensitivity, we made use of mean sensitivity scores (Table 1.) which were calculated by averaging the summed scores for the three separate sensitivity observations. The mean sensitivity scores over all three sessions was 5.28, meaning that participants scored average on sensitive behaviour. The scores on the Love Withdrawal scale ranged from 1.0 to 4.1 with a relatively low mean (M = 1.65, SD = .637) and did not approach normality as they were positively skewed. We therefore decided to log transform these scores leading to acceptable normality, which were then used for further analysis.

Table 1

Range of Sensitivity Scores for All Three Tasks (N=90)

Minimum Maximum Range M SD Sensitivity for doll during free

play (A) 2.00 8.50 6.50 6.32 1.55

Sensitivity for doll during

questionnaire (B) 1.50 8.00 6.50 5.11 1.58

Sensitivity for doll during

computer task (C) 1.00 8.00 7.00 4.39 1.93

Mean score sensitivity (ABC) 2.17 7.83 5.67 5.28 1.33

On average, the realism of care giving was rated as a realistic experience (Table 2). Of the participants, 79% lived with both biological parents until the age of sixteen, 31% of the participants had no prior experience in the care for a child aged two or younger, 97% had one or more siblings and 8% of the participants sustained a chronic illness or disorder (such as asthma, ADHD and hearing impairment). The distribution of the age of the participants and the experienced realism of care giving is given in Table 2.

When taking sensitivity into consideration, there were no significant differences between participants who lived with their biological parents and those who did not (t(88) =

-1.28, p = .20) and between those who had previous experience in caring for a child younger than two years of age and those who had not (t(88) = .16, p = .87). There were also no

differences between those who had siblings and those who didn’t (t (88) = 1.11, p = .27) and neither was there between participants who had a chronic illness or disorder and those who didn’t (t(88) = .07, p = .95). Correlations showed that there were no relations between sensitivity and participants age (r = .12, p = .25) and between sensitivity and realism of the care giving (r = .11, p = .29).

Table 2

Participant Characteristics

N Minimum Maximum M SD

Age of participants 90 17.89 24.84 19.79 1.48

Realism of care giving 89 2 9 6.36 1.64

Love Withdrawal Scores and Sensitivity

For the purpose of analysing sensitivity in a group with high versus low scores on Love Withdrawal, we performed a median-split, resulting in low and high experienced love withdrawal. We found that there was a marginally significant effect of love withdrawal on sensitivity t(89) = 1.974 , p = .052, with the group who experienced more love withdrawal (M

= 5.02, SD = 1.36) showing lower sensitivity than the group with less experiences of love

withdrawal (M = 5.57, SD = 1.25) (Figure 1). These results had a medium effect-size of d = 0.42

Figure 1. The scores of observed sensitivity during the care giving of an infant simulator, for both more and less experienced love withdrawal, show a marginally significant difference

Competing Demand and Sensitivity

Concerning our second question, we wished to examine the effects that the

performance of a task might have on sensitivity. All assumptions, including normality and sphericity (χ²(2) = 4.38, p = .11), were met. Mean sensitivity scores significantly differed for the increasing competing demands (F (2,89) = 51,60, p < .001). Through post-hoc analysis we found a significant decrease of sensitivity between the first and second task (p < .001) and the second and third task (p < .01), as was there between the first and third task (p < .001) (Figure 2).

Figure 2. The observed sensitive care giving of the infant simulator during the three successive tasks including free play and two competing demand tasks shows an overall significant decrease. *** p < .001 compared to free play, ## p < .001 compared to competing demand 1.

Love Withdrawal Moderation of Competing Demands Effect on Sensitivity

To examine whether love withdrawal influenced the effect of a task on sensitivity during the course of the three separate tasks, we made use of a mixed between-within subjects analysis of variance. Besides the main effects for love withdrawal (F(1,88) = 3.88, p = .052) and competing demands (F(1,88) = 1462.10, p <.001) previously mentioned, we found no significant interaction of love withdrawal and sensitivity during the three tasks (F(1,88) = .334, p = .72) (Figure 3).

Figure 3. Observed sensitivity during the care for an infant simulator with participants’ more or less experienced love withdrawal and the three successive tasks. There was no moderation of experienced love withdrawal on the effects of free play and competing demands on changes in observed sensitive care giving for an infant simulator.

Discussion

The aim of this study was to examine whether the experience of love withdrawal as a child could affect later parental sensitive care giving cued by infant crying and whether competing demands could also affect sensitivity. Our results showed that participants who experienced more love withdrawal as a child were less sensitive care givers then those who experienced less love withdrawal. We also concluded that experiencing competing demands during care giving led to a decrease of sensitive responding to infant crying during care giving. Our final results showed that the experience of love withdrawal, whether less or more, did not alter the relation between sensitive behaviour and the competing demands.

Our results suggest that children who experienced more love withdrawal in their youth could, when adults, come to provide less sensitive care whilst nurturing an infant, then do those who experienced less love withdrawal. These findings are in line with previous research as other studies have also shown that the effects of maternal love withdrawal can be

detrimental on a person’s life, both in childhood and adulthood. This, amongst others, is expressed through lowered self regard, fear of failure and a general lower emotional

happiness (Elliot & Thrash, 2004; Euser, Van IJzendoorn, Prinzie & Bakermans-Kranenburg, 2010; Goldstein & Heaven, 2000; Huffmeijer et al., 2011; Swanson & Mallinckrodt, 2001). Experience of love withdrawal examined in other studies also demonstrated it to be

unfavourable to later adult life, with outcomes such as attachment anxiety and avoidance and emotional problems (Goldstein & Heaven, 2000; Swanson & Mallinckrodt, 2001).

Harsh or insensitive parenting can be damaging to future parenting behaviour through intergenerational transmission and our research acknowledges the findings that love

withdrawal could lead to negative parenting outcomes across generations of families (Assor, Roth & Deci, 2004; Neppl, Conger, Scaramella, & Ontai, 2009). Experience of love

withdrawal may also negatively influence the future adult’s perception of infant crying signals, when combined with sensitive temperamental traits (Bhandari, Voorthuis, van der Veen, Out, Bakermans-Kranenburg & Marinus van IJzendoorn, 2013). The results of our study could add to the understanding of this, as it has been shown that those who experienced more harsh parenting responded less sensitive to infant crying themselves. Though our participants reported relatively less experienced love withdrawal, thereby possibly explaining the marginal significance, it may be expected that research with a more clinical sample would provide more robust outcomes.

We also found that the successive performance of a demanding task negatively

influences sensitive care for an infant. This is in line with previous research into the effects of a demanding task on sensitivity which showed similar outcomes; that sensitivity decreases with the increase of demanding task performance (Goosssens & Melhuish, 2000). These results indicate that stressful factors, including environmental demands, can overrule the need to give sensitive care to a crying baby. Our finding that a demanding task decreased sensitive behaviour adds to the knowledge that parenting stress could influence parental behaviour (Gutermuth, Anthony, Glanville, Naiman, Waanders & Shaffer, 2005; Pereira et al., 2012; Pianta, Sroufe & Egeland, 1989; Rogers, 1998). It is conceivable that participants experienced stress through these competing demands and sensitivity became less of a priority.

As noted before, research has also shown that love withdrawal may, under certain conditions, influence the way that parents perceive the crying of their infant (Bhandari et al., 2013). We must keep in mind that infant crying can also be a cause for stress, therefore health professionals should focus more on situations in which the crying of babies is the source of stress, which in turn can lead to decreased sensitive parenting or even abuse (Bruning and McMahon, 2009; Out, Pieper, Bakermans-Kranenburg, Sanford Zeskind, van IJzendoorn, 2010).

Our results showed that love withdrawal did not influence the relation between the demanding tasks and sensitivity. We may speculate that the experience of a competing demand already ruled out the probability of sensitive care, as even participants with higher sensitivity scores showed a decline in sensitive behavior at the increase of the competing demands task. Perhaps in a clinical sample results would have shown a moderation as it is feasible that those who have endured higher levels of love withdrawal cope differently with stress during care giving.

This study is the first that made use of an infant stimulator to assess sensitivity. Past research has not always favoured the use of the doll as a valid instrument (Bath, Cunningham & McIntosh, 2000) but as our study showed that sensitive care for the infant simulator

actually varied amongst those with more or less experienced love withdrawal as well as through the succession of a difficult task and based on participants’ experienced realism, it is safe to say that the use of an infant simulator has proven to be a valuable asset to research focussed on infant-parent interactions, as has been done in previous studies (Bhandari et al., 2013; Bruning & McMahon, 2009; Van Anders et al., 2012).

This study knows some limitations. First, the sample was of a homogeneous nature, consisting of only female students who had no clinical background, causing our results to be relevant to a smaller part of the population. However, given the innovative aspect of our research, we have chosen for this composition as our study is in its early stages and we first wished to examine effects on non-parents, followed by studying effects on parents, which is now in progress. A second limitation is the choice to only make use of the maternal Love Withdrawal scale and thereby omitting experienced paternal love withdrawal from this study. However, previous research found that especially the effects of maternal love withdrawal between mothers and their daughter’s later functioning were significant and so we decided on using both the maternal Love Withdrawal scale and female participants in our study (Renk, McKinney, Klein & Oliveros, 2006). Thirdly, we have only examined maternal love withdrawal as a possible unfavourable parenting factor. There are most likely other aspects concerning parents that may influence later sensitive behaviour such as maternal depression, parental relationships and parenting stress, which may need to be examined further (Assor, et al., 2004; Belsky et al., 2009; Campbell et al., 2007; Gutermuth Anthony et al., 2005). Added to that, our overall research has focused on other earlier experiences such as child abuse, which have not been incorporated in the present study.

Overall this study has come to new insights concerning sensitivity, through a combination of a novel instrument and the existing knowledge on sensitive parenting and

harsh discipline. Concerning the future, research should take into serious consideration the use of an infant simulator as it can provide standardized means of care giving measurements, aid observations of sensitive behavior and can evoke physiological changes, as has been shown in other studies. Subsequent studies should also examine the effects that stress can have on sensitivity as our findings indicate that competing demands on parents, something which is inevitable in busy households, can make them less sensitively responsive. The

possible detrimental and transgenerational effects of experienced love withdrawal on sensitive behavior found in this study should also evoke further research. From a practical stance, there should be more understanding about circumstances where parents enforce love withdrawal and more thoughts should go into communicating to parents the negative consequences of using love withdrawal as a disciplinary strategy, whilst at the same time the use of more sensitive, positive and consistent parenting should be encouraged due to its highly favorable outcomes. It is our hope that our substantial findings shall contribute to parenting as a whole.

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Appendix 1: Samenvatting

Onderzoek heeft aangetoond dat harde disciplinering schadelijk kan zijn voor latere kinduitkomsten en dit opvoedingsgedrag kan intergenerationeel worden overgedragen wat leidt tot negatieve ouderschap in latere generaties. Er is echter een tekort aan onderzoeken naar deze vroegere ervaringen in een gecontroleerde setting. Daarom was het doel van deze studie om de mogelijke effecten van vroeg ervaren love withdrawal op sensitieve verzorging van een baby simulator te onderzoeken. Daarnaast onderzochten wij ook de mogelijke effecten van concurrerende eisen op sensitiviteit, daar eerder onderzoek uitwees dat het ervaren van meerdere eisen mogelijk kan leiden tot een verandering in sensitief ouderschap. We veronderstelden dat zowel meer ervaren love withdrawal als de aanwezigheid van concurrerende eisen zou leiden tot verminderde sensitiviteit en dat love withdrawal de potentiële relatie tussen stress en sensitiviteit zou beïnvloeden. Onze steekproef omvatte 90 kinderloze, vrouwelijke studenten. De participanten vulden vragenlijsten over vroege ervaringen in, waaronder ook de Love Withdrawal schaal. Zij zorgden voor twee

opeenvolgende avonden voor een baby simulator en werden uitgenodigd voor een labsessie waarin hun sensitieve zorg werd geobserveerd, tijdens vrij spel en twee veeleisende taken, met de baby simulator. Deze observaties werden gecodeerd aan de hand van de Ainsworth Sensitiviteit schaal (Ainsworth, Bell & Stayton, 1974). Wij vonden dat meer ervaring met love withdrawal leidde tot minder sensitief gedrag later. Het ervaren van een veeleisende taak leidde ook tot een afname van sensitief gedrag. De ervaren love withdrawal had echter geen invloed op de relatie tussen stress en sensitief gedrag. Deze resultaten onderstrepen het belang van de ontmoediging van het gebruik van negatieve opvoedingsstrategieën, omdat dit

mogelijk kan leiden tot negatieve kind uitkomsten. Onze bevindingen wijzen ook op de eventuele negatieve gevolgen die een veeleisende omgeving kan hebben op een sensitieve opvoeding.

Appendix 2: Dankwoord

Voor u treft u het eindresultaat van jaren hard werken en hoewel het niet altijd een

gemakkelijke opgave is geweest, heeft het proces voor mij geleid tot een beter begrip van het belang en de impact die de wetenschap kan hebben op de samenleving. Gedurende de laatste vijf jaar heeft studeren een centrale rol gespeeld in mijn leven en ik ben oprecht van mening dat het mij ten goede is gekomen. Het is ietwat overweldigend, maar met enige trots dat ik nu op het punt sta van afstuderen. Vanzelfsprekend wil ik mijn dank betuigen aan allen die mij hebben geadviseerd en ondersteund in het schrijven van dit laatste hoofdstuk.

Ten eerste, wil ik Sandra Voorthuis, MSc, bedanken, die met haar begeleiding een ongelooflijke steun is geweest tijdens het afgelopen jaar. Haar bereidheid om mijn vragen te beantwoorden, haar vermogen om mij in de juiste richting te navigeren en haar vertrouwen in mijn kennis en bekwaamheid, heeft mij zeker geholpen om te bereiken wat ik niet voor mogelijk had gehouden.

Ten tweede zou ik graag Dr. Rixt van der Veen bedanken, wiens kritische blik beslist heeft bijgedragen aan de totstandkoming van het niveau van mijn schrijven en onderzoek. Naast de plezierige gesprekken die wij gevoerd hebben tijdens het praktische werk, heeft ook zij een belangrijk aandeel gehad in het sturen van dit proces en de totstandkoming van het uiteindelijke eindresultaat.

Uiteraard ben ik mijn liefdevolle familie zeer dankbaar voor hun steun en

aanmoedigingen, niet enkel tijdens dit voorgaande jaar, maar gedurende al mijn inspanningen. Ik wil vooral mijn dank uitspreken aan mijn beide ouders, die mij altijd onvoorwaardelijk gesteund hebben en wiens vertrouwen in mij grenzeloos was. Mam, Pap, hiervoor zal ik jullie altijd diep dankbaar zijn.

BabyCARE:

Gehechtheid, kindermishandeling en reacties op

huilen

Het onderzoek

Het BabyCARE project onderzocht de emotionele en fysiologische reacties van vrouwen op het huilen van baby’s. Eerder onderzoek heeft aangetoond dat ouders en niet-ouders zowel middels de hartslag als de huidgeleiding reageren op het huilen van een baby (Out, Pieper, Bakermans-Kranenburg, Zeskind & van IJzendoorn, 2010) en dat het luisteren naar baby huilen in diverse situaties kan leiden tot een verhoging van de hartslag (Crowe & Zeskind, 1992; Frodi & Lamb, 1980). In ander onderzoek zijn naar aanleiding van baby huilen veranderingen in de hormonale reactiviteit waargenomen (Van Anders, Tolma en Volling, 2012), als ook een toename van negatief affect, angst en een negatieve perceptie van de huilende baby (Bruning en McMahon, 2009). Het BabyCARE onderzoek maakte gebruik van huilpoppen om de reactie van participanten op baby huilen te kunnen onderzoeken. Eerder onderzoek met deze simulatoren leverde veelbelovende resultaten op, omdat de simulator uitnodigde tot verzorgend gedrag (Gustafson & Harris, 1990) en het verzorgen van de pop leidde tot fysiologische en emotionele verandering bij de participanten (Van Anders et al., 2012). In onderzoek naar huilgeluiden is standaardisatie noodzakelijk maar niet altijd vanzelfsprekend (St. James-Roberts, 2001). Het gebruik van een simulator in plaats van echte baby’s komt dan ook ten goede aan de standaardisatie van dit onderzoek.

In het BabyCARE onderzoek zijn fysiologische metingen (met de hartslag en

speeksel) verricht, vragenlijsten over de kindertijd en de huidige gemoedstoestand ingevuld en is sensitiviteit door middel van de Ainsworth schalen geobserveerd en gecodeerd

(Ainsworth, Bell & Stayton, 1974).

Het eerste gedeelte van het onderzoek betrof de werving van studenten die digitale vragenlijsten invulden met betrekking tot demografische gegevens, het temperament van de participanten, de ervaren opvoeding en eventuele ervaren kindermishandeling.

Onder andere vernieuwend aan deze studie was het meten van sensitief gedrag naar aanleiding van het huilen van de RealCare babypoppen in het tweede deel van het onderzoek (Realityworks, Inc., Virtual Parenting, Coffs Harbour, NSW 2013). Deze poppen hebben een levensecht uiterlijk, produceren babygeluiden opgenomen van echte baby’s en signaleren zodoende ook om verzorging, waaronder bijvoorbeeld voeden, verschonen, wiegen en boeren. Om de verzorging nog realistischer te maken werd de pop geleverd met kleding, een flesje en luiers waarin sensors zaten, waardoor de pop de verzorging door de participant, na

aanmelding met een ID, waar kon nemen. De signalen werden in een intern systeem opgenomen, wat later in een computerprogramma als een samengevat verslag door de onderzoeker geraadpleegd kon worden. Het huilen van de pop kon, met betrekking tot het

moment van huilen, de frequentie en duur daarvan, worden geprogrammeerd. In het huidige onderzoek werd gekozen voor een moeilijke baby, welke veel en langdurig huilde, om zo de realistische reactie van participanten op het huilen van een baby te kunnen waarnemen.

Thuissessies. De participanten zorgden zowel thuis als in het laboratorium voor de

huilpop. Voorafgaand aan de thuissessies, welke van 17:00 tot 22:00 duurde, kregen de participanten een korte toelichting, waarbij ze informatie over het onderzoek nogmaals

doorlazen en een toestemmingsformulier tekenden. Hierna werd er toelichting gegeven op hoe men de pop kon verzorgen en dat het ID gebruikt moest worden. Voor meting van de hartslag, door middel van ECG en ICG, werd een hartslagmonitor (AMS) aangesloten. De VU-AMS bepaalde de hartslag aan de hand van enkele geleidende plakkers die op diverse plekken op de borst en rug bevestigd werden. In het onderzoek is bekeken of de hartslag naar

aanleiding van het huilen van de pop veranderde. Participanten vulden ook na elk

troostmoment een vragenlijst in op een PDA, waarin werd gevraagd naar de gemoedstoestand van de participant, de gebruikte troostmethode, middelengebruik en aanwezigheid van derden. Na het terugbrengen van de materialen haalden de medewerkers de data van zowel de PDA, de VU-AMS en de pop af, als van de microfoon welke ter controle van de huilschema in de pop was geplaatst. Voor de tweede avond volgde een beknoptere uitleg, waarna de participant de pop weer mee naar huis nam. De pop had een aangepast huilschema en ook nu werd de VU-AMS en de PDA gebruikt. De volgende dag beoordeelde de participant aan de hand van een vragenlijst hoe realistisch het zorgen voor de pop was.

De thuissessies werden door de medewerkers van het onderzoek voorbereid en afgerond. Zo moest voor de pop het juiste huilschema ingesteld worden, moest het microfoontje geplaatst worden en moest een tas met alle materialen voor de participant worden klaargelegd. Zowel voor het aanbrengen van de VU-AMS, het filmen van de labsessies, als voor het meegeven van de pop werden de medewerkers vooraf getraind.

Labsessies. Participanten werden voor de labsessie door een medewerker opgehaald

en begeleid naar de labruimte waar zij een korte beschrijving van de labsessie kregen en op de hoogte gebracht werden van het feit dat zij gefilmd werden. Vervolgens werd de VU-AMS aangebracht en volgde het oefenen met het verzamelen van speeksel, waaruit salivary α-amylase (sAA) en Cortisol gemeten zou worden. Hierna volgde een rustperiode, waarin participanten eerst een kwartier lang vooraf bepaalde tijdschriften lazen. Daarna vulden zij de PANAS in, welke informeerde naar de gemoedstoestand van de participanten, gevolgd door het lezen en voorlezen van een tekst en het lopen door de ruimte ter controle van de hartslag tijdens het zorgen voor de pop. Hierna werd wederom speeksel verzameld, ten behoeve van

een baseline meting. Wanneer dit voltooid was volgde de uitleg over de popsessie, waarbij werd benadrukt dat de participanten de pop als een echte baby dienden te behandelen, dat alles in de ruimte gebruikt mocht worden en dat de ID deze keer niet gebruikt zou worden. De medewerker haalde vervolgens de pop, stelde haar voor en overhandigde haar aan de

participant. Het zorgen voor de pop bestond uit drie sessies van 10 minuten waarin de pop als huilbaby werd geprogrammeerd, maar niet getroost kon worden. In de eerste sessie hadden de studenten enkel de pop omhanden. In de tweede sessie werden zij gevraagd om enkele

vragenlijsten in te vullen. In de derde zorgsessie moesten de participanten zo snel mogelijk een computertaak (Tower of London) maken, waarbij de snelste studenten een geldbonus kregen. Deze drie sessies vormden vrij spel en twee maal een competing demand, waarbij gekeken werd hoe een competing demand het sensitieve gedrag van de participanten kon beïnvloeden. Wanneer de sessies waren voltooid werd de pop teruggebracht en vulden de participanten nogmaals de PAN-AS in, waarmee bekeken kon worden of de gemoedstoestand van de participant veranderd was na het zorgen voor de pop. Dit werd gevolgd door een speekselverzameling en een rust periode waarin na 15 minuten en na 30 minuten speeksel verzameld werd. Na verwijdering van de VU-AMS werden participanten gevraagd een fysiologie vragenlijst in te vullen, zodat de voorgaande fysiologische metingen correct geïnterpreteerd konden worden. Aansluitend moesten de participanten het huilparadigma (Out et al., 2010) voltooien waarin zij enkele vragen beantwoorden over de geprojecteerde huilgeluiden. Na afronding hiervan volgde een nabespreking waarin de onderzoeker

informeerde naar het welzijn van de participant en deze eventueel geruststelde, uitleg gaf over het onderzoek en toestemming vroeg voor het gebruik van de filmfragmenten voor

onderwijskundige doeleinden.

sAA. De speekselverzameling diende voor de meting van sAA welke de activiteit van

het sympathische zenuwstelsel aangeeft en veelal stijgt bij zowel fysieke als psychologische stress. In eerder onderzoek lieten vooral ouders met een risico op kindermishandeling of harde disciplinering een verhoging zien van sAA wanneer zij herhaaldelijk naar het huilen van baby’s luisterden (Out, Bakermans-Kranenburg, van Pelt & van IJzendoorn, 2012). In het huidige onderzoek werd sAA gemeten voorafgaand aan het verzorgen van de pop als baseline en na het verzorgen nog driemaal om de ervaren stress te meten. Ook het stresshormoon Cortisol, wat bij waarneming van stress geproduceerd wordt door de HPA-as, werd uit de speekselverzamelingen gemeten.

Sensitiviteit. Een ander onderdeel van het onderzoek betrof de sensitiviteit-training,

ouderschap aan de hand van de Ainsworth Sensitivity vs. Insensitivity schale (1974). Deze schaal had een scorebereik van 1 tot 9, waarbij een lagere score gerelateerd was aan lagere sensitiviteit. De scores konden binnen het gehele bereik vallen en bij iedere score stond een beschrijving met betrekking tot het gedrag dat bij de ouder geobserveerd was. De training omvatte enkele bijeenkomsten gegeven door Prof. Marian Bakermans-Kranenberg en mevr. Voorthuis, waarin fragmenten werden beoordeeld en besproken en waarbij advies werd gegeven over herkenbare gedragingen, typerend voor (on-)sensitief gedrag. De medewerkers moesten buiten de bijeenkomsten om 40 fragmenten als oefening coderen. De training werd afgesloten met een betrouwbaarheidsset van 20 filmpjes welke naar behoren moest zijn gecodeerd.

Technische werkzaamheden. Het BabyCARE project omvatte ook andere

werkzaamheden. Zo heb ik onder andere aan de sensitiviteit-fragmenten van de labsessies gewerkt en middels het bewerken van de originelen veel verschillende soorten sensitief gedrag voorbij zien komen Daarnaast heb ik werkzaamheden verricht welke niet altijd direct met de theoretische pedagogiek te maken hadden maar desalniettemin een nuttige kijk gaven op het onderzoek aan de Universiteit. Een voorbeeld hiervan was het traceren van het VU-AMS signaal in de labsessies. Het signaal gaf een piek in het hartslag patroon, wat de

berekening van de hartslag als reactie op huilen van de pop mogelijk maakte. Een soortgelijke activiteit was het vinden en aangeven van de huilmomenten van de thuissessies. Het

verwerkingsprogramma gaf de frequentie van het geluid aan, waardoor huilpatronen zichtbaar werden. Via beide werkzaamheden heb ik kennis kunnen maken met de technische elementen van onderzoek, een mogelijkheid die in het dagelijkse onderwijs niet mogelijk was.

Op administratief gebied heb ik ook enkele werkzaamheden uitgevoerd waardoor ik verschillende materialen betreffende het onderzoek in heb kunnen zien, waaronder één van de vragenlijsten die ik zelf in mijn onderzoek heb gebruikt, als mede ook de data van de

participanten aangaande de verzorging van de pop, thuis en in de labsessie.

Literatuurbijeenkomsten. Binnen het project werden ook literatuurbijeenkomsten

georganiseerd, waarin medewerkers samen met de begeleiders artikelen voorbereidde, presenteerde en bediscussieerde. Hierdoor kwam men in aanraking met de kennis al bekend op het gebied van onder andere huilbaby’s en de fysiologische reacties daarop, het gebruik van de huilpoppen, oxytocine en hartslagmetingen. Ook werd een kritische blik geworpen op de uitvoering van onderzoek weergegeven in de artikelen. De presentaties hadden als doel om de visie van een ander op het beschreven onderzoek te leren kennen en het verduidelijken van onderzoeken die van een gecompliceerde aard waren.

Dit onderdeel heb ik zeer kunnen waarderen, daar er doormiddel van het inlezen en bespreken van de artikelen een grondigere reflectie op het eigen schrijven en onderzoeken ontstond. Deze vaardigheden zijn, vooral in de Bachelor, amper aan de orde gekomen en daardoor miste men kennis bij het schrijven van belangrijke papers.

Eigen ervaringen/conclusie. Over het geheel genomen heb ik diverse positieve en

leerzame ervaringen binnen het BabyCare project opgedaan. Het is fijn geweest om met zoveel professionals te hebben gewerkt en door hen met bepaalde expertises kennis te hebben gemaakt. Ook het grote gemis aan een stage binnen de opleiding werd deels gecompenseerd door deze internship. Het contact met de participanten vond ik leuk; zij waren zelf meestal erg enthousiast over het onderzoek. Om het onderzoek niet te comprimeren mochten

medewerkers uiteraard niet te veel informatie vrijgegeven tijdens de sessies en mede hierdoor was het soms lastig om vragen van participanten te beantwoorden. De labsessies waren

weleens spannend omdat een goed verloop jouw verantwoordelijkheid binnen het project was. Hierdoor werd je wel geoefend in het snel en overwogen keuzes maken. Ook de instructie van participanten omtrent de thuis- en labsessies creëerde een leermoment, daar er strak aan het draaiboek gehouden moest worden, om niet te veel informatie weg te geven en voor de standaardisatie van de sessies. Ik had geen moeite om participanten te woord te staan maar merkte dat ik soms te veel woorden gebruikte voor een simpele uitleg en ik heb later wel getracht zo dicht mogelijk bij de voorgeschreven tekst te blijven.

De apparatuur kon nog wel eens voor hinder zorgen. Vooral de VU-AMS had vele oorzaken voor een slechte werking en hierdoor moest er stapsgewijs naar de oorzaak van het probleem gezocht worden, veelal in aanwezigheid van de participant. Met de hulp van collega’s werden deze problemen echter vaak zonder al te veel ophef opgelost. Daar ik pas halverwege het jaar instapte, hadden de meeste medewerkers al enige ervaring met het meegeven van de pop en de labsessies. Zij waren immer bereid om hulp te bieden, uitleg te geven over bepaalde onderdelen en hun ervaringen met bepaalde problemen te delen. Deze vorm van samenwerking vond ik erg prettig en is naar mijn mening ook het meest leerzaam.

Ik heb de sensitiviteitstraining zeer gewaardeerd, daar ik begrip van sensitief gedrag erg belangrijk vind. Het maakt je minder subjectief en oordelend over ‘goede en slechte ouders’ en het doet je realiseren dat ouders soms verkeerd handelen vanuit goede intenties. Ook niet onbelangrijk was het stuk praktijkwerk dat deze training mogelijk heeft gemaakt. Het heeft mij het gevoel gegeven dat ik bij afronding van mijn opleiding ook op praktisch gebied iets te bieden heb.

Een van de belangrijkste vaardigheden die ik binnen dit onderzoek heb opgedaan is het uitbalanceren van verschillende werkzaamheden, vooral wanneer de werkdruk erg hoog was. Ik heb ontdenkt dat je met een goede planning meer kan bereiken dan je in eerste instantie dacht. Waar ik voorheen de voorkeur gaf aan het stapsgewijs afwerken van diverse

opdrachten en taken, kan ik deze nu beter combineren. Ik heb overigens ook ontdekt dat mijn positieve instelling, initiatief en committent aan een project soms te ver kan gaan wat

negatieve gevolgen met zich mee kan brengen. Daarnaast merkte ik dat ik in het begin wat moeite had om mijn plaats binnen de groep te vinden; de bachelorstudenten hadden binnen het project veelal meer kennis omtrent het reilen en zeilen, waardoor mijn in eerste instantie bewakende functie weinig uit de verf kwam. Het is erg fijn dat voor beide zaken begrip was en dat er met enige bijsturing geen afbreuk is gedaan aan wie ik als persoon ben. Vooral in het werkveld zullen deze ervaringen een voordeel zijn en tegelijkertijd een punt van aandacht voor de toekomst. Mede door deze interne stage ben ik kritischer geworden omtrent de kennis die men tegen komt, ben ik mijns inziens vaardiger geworden in de sociale omgang en nog meer bedacht op het gehele proces waarin men zich met collega’s bevindt. De vaardigheden waarover ik al beschikte zijn aangescherpt, waardoor deze internship een nuttige bijdrage heeft geleverd aan de ontwikkeling van mijn competenties en mijn algehele functioneren.

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