Journal of Adult Development

, Volume 20, Issue 4, pp 212–221 | Cite as

Relatedness and Individuation Among Young Adults Born Preterm: The Role of Relationships with Parents and Death Anxiety

Article

Abstract

Preterm birth may constitute a risk factor for long-term difficulties when facing developmental tasks of relatedness and individuation in young adulthood. Since these early experiences might leave individuals more susceptible to anxiety, we examined whether relationships with parents and death anxiety mediated the associations between preterm birth and difficulties in relatedness and individuation. The sample included 57 emerging adults who were born preterm, and a paired control group that filled out questionnaires: The Perceptions of Adult Attachment Questionnaire, Personal Assessment of Intimacy in Relationships, the death anxiety test, and projective assessment of death anxiety. Preterm young adults and their counterparts exhibited similar levels of closeness with their parents, with romantic partner, and with best friend. A different picture emerged with regard to differentiation and death anxiety. Preterm young adults exhibited higher levels of emotional reactivity and fusion with others, and higher levels of death anxiety than their counterparts. Death anxiety mediated the relations between preterm birth status and differentiation. It appears that, despite the fact that these youngsters experienced a traumatic event early in their lives, they overcame this difficult experience and were successful in maintaining closeness with close others. In contrast, the traces of the preterm birth might be more pronounced in the domain of differentiation. People who experienced separations from significant others, especially early in life, may develop high levels of death anxiety as death is experienced as the ultimate separation from a close person. Enduring death anxiety might complicate the individuation process. Gender differences that were found are in accord with previous findings. The strengths and limitations of the study as well as suggestions for future research are discussed.

Keywords

Death anxiety Individuation Preterm Relatedness Young adulthood 

Introduction

The advancement of modern medicine and technology has provided much better care for infants born preterm (Hack 2009; Saigal et al. 2006). Nevertheless, despite the fact that many preterm infants grow to become healthy adults and have similar life achievements as infants born at term (Dalziel et al. 2007; Lindström et al. 2007; Saigal et al. 2006), research has found that some differences in behavioral and emotional characteristics between these two groups persist throughout childhood and young adulthood (e.g., Hack 2009; Lindström et al. 2007). The current study explored the long-term implications of preterm birth on interpersonal and emotional functioning of young adults.

Relatively few studies have examined the long-term socio-emotional sequelae of preterm birth (Tideman et al. 2002). Studies have traditionally focused on the neurological, cognitive, behavioral, and health-related implications of preterm birth, while only a few studies examined the emotional and psychological effects (Hack 2009). Furthermore, most studies focused on children or adolescent samples (e.g., Hack et al. 2009), and findings were inconclusive, attributing some of the finding to the parent–child relationships. There is controversy regarding the persistence of difficulties in parent–child relationships overtime (Levy-Shiff et al. 1994). Some suggest that difficulties present especially during childhood, while others suggest that consequences of preterm birth may persist and present in later years (Macey et al. 1987). It is important to study preterm individuals also in adulthood because the sequelae of early risks may be intensified or mitigated by later influences (Rutter 1983) and because different developmental phases confront individuals with new challenges and new normative milestones.

Young adults are expected to expand their relationship network (Collins et al. 1997) and develop mature intimacy with close others (Grotevant and Cooper 1986; Scharf et al. 2004). They are further expected to advance in their individuation from their family of origin and to consolidate their self-definition (Blos 1979). Accordingly, we examined these developmental tasks—individuation and relatedness—with close others. We also explored whether relationships with parents and death anxiety mediate the associations between preterm birth and indicators of relatedness and individuation.

Preterm Birth and Differentiation and Relatedness in Close Relationships

Preterm birth may constitute a risk factor for long-term difficulties in psychosocial functioning (Brisch et al. 2005). The separation between infant and primary caregivers shortly after birth, and the health-related problems accompanied by parents’ fears regarding the child’s health and survival might have long-term implications. Findings in several studies partly support this contention and show, as might be expected, heightened anxiety, control, and overprotection. For example, mothers of preterm children were more intrusive and less reciprocal, less harmonious and less sensitive (Feldman 2007; Lester et al. 1985), and displayed less positive affect and more anxiety toward their infants than did mothers of term children (Wille 1991). Mothers of preterm infants reported overprotective feelings toward their children were less willing to leave them with sitters and were more controlling. Further, preterm infants showed less exploratory play, stayed closer to their mothers during free play (Macey et al. 1987; Pyhälä et al. 2011), and exhibited higher negative emotionality with both parents than their counterparts (Feldman 2007). Pyhälä et al. (2011) found that preterm birth (in that study focusing on very low birth weight) may promote a more protective, as well as more supportive, parenting style (Pyhälä et al. 2011).

The findings regarding attachment quality of preterm children are inconclusive. Focusing on infants and toddlers, some studies have not found any differences in attachment quality between preterm and term children (Goldberg et al. 1986; Easterbrooks 1989; Rode et al. 1981). In contrast, in other studies, a higher percentage of insecure attachment among preterm than among term infants was found (Cox et al. 2000; Plunkett et al. 1988).

Only a few studies assessed the effect of premature birth on attachment styles later in life. A Swedish study (Hallin and Stjernqvist 2011) examined 18-year-olds who were born very premature. Preterm individuals reported having less social integration and were more likely to describe themselves as exhibiting the preoccupied style (having a negative view of self while holding a positive view of others) as applicable to them compared to the full-term group. Yet in other studies, preterm born young adults and adolescents were as likely as their full-term peers to have a secure attachment style, assessed via questionnaires (Hallin and Stjernqvist 2011; Lubetzky and Gilat 2002).

Tideman et al. (2002) longitudinally investigated the conscious and unconscious attachment models of both children and mothers when children were 9 and 19 years old. No differences were found on the conscious level between participants born at term and those born preterm. Interestingly, significant differences were found when using measures pertaining to the unconscious attachment figure model. Preterm participants received higher scores on projective measures, suggesting that the relationships with their mothers were more emotionally loaded. At age 19, preterm participants had a greater vulnerability regarding both attachment and separation themes. Mothers of preterm children exhibited more emotional over-involvement with their children compared to the full-term mothers. Tideman et al. (2002) concluded that the effects of prematurity may be more pronounced overtime, since preterm birth may harbor continued emotional vulnerability regarding attachment and separation. Similarly, when evaluating family functioning (Eriksson and Pehrsson 2003), families of preterm infants scored higher on measures of enmeshment. Examining relatedness processes in romantic relations, preterm adults also demonstrated a profile of lower levels of relatedness. They were less likely to experience sexual intercourse, had fewer sexual partners, and were less likely to have ever married, or found a life partner than those born at term (Moster et al. 2008; Kajantie et al. 2008).

Overall, a mixed picture regarding the link between preterm birth and relatedness was found whereby preterm individuals were either not different from others, or experienced more problems related to anxiety in the relations, and lower levels or lower quality of relatedness. The inconsistency found in earlier studies could be the result of the utilization of different measures, the inclusion of different samples (i.e., varied in terms of risk, birth weight), and the different constructs that were examined. It is possible that, although preterm adults function well with less challenging tasks, their vulnerability is revealed when coping with more challenging developmental tasks such as individuation and differentiation.

Differentiation of self refers to the ability to regulate emotional arousal, remains calm under stress and balances intimacy and autonomy in relationships (Kerr and Bowen 1988; Skowron and Friedlander 1998). Greater differentiation of self is associated with greater interpersonal competence and emotional maturity, and lower psychological distress (e.g., Kim-Appel et al. 2007; Skowron et al. 2009). In contrast, people who are less differentiated tend to either withdraw and distance themselves from others, or wish to merge with others, and have difficulties tolerating separateness of close others (Skowron and Schmitt 2003).

It has been suggested that increased parental overprotection may account for shyness, anxiousness, and overdependence in preterm children (Blake et al. 1975), which could imply lower autonomy and differentiation levels. Indications for difficulties in separateness might be revealed in social behavior. Both classmates and teachers rated preterm children as more internalized, more socially isolated and socially immature, and more likely to be involved in withdrawal behaviors, as well as verbal and physical victimization (Nadeau et al. 2003, 2004; Tessier et al. 1997).

Preterm Birth and Death Anxiety

The hospitalization and medical intervention early in life and the fears regarding their survival might intensify the death anxiety of preterm individuals. It is also possible that an increased fear of death in individuals born preterm is induced by their mothers’ own fears and concerns regarding the children’s well-being. Preterm individuals expressed more anxiety (Hack et al. 2009, 2005 ; Hille et al. 2008). Children born preterm exhibited a higher tendency than their counterparts to perceive pain as more enduring and threatening (Hohmeister et al. 2009). Thus, a link between preterm birth and anxiety is expected.

Most people have low to moderate levels of death anxiety, which keeps them alert to potential threats to their own lives or the lives of other people. In dangerous situations, people become alert and then either dismiss, or take action to overcome, the threat. When they cannot respond in these ways, they are likely to be flooded by death anxiety (Kastenbaum 1987, 2000). Social contexts and personal experiences influence one’s fears. For example, women tend to report higher levels than men, perhaps because cultural display rules allow women to express their concerns more freely. Effective functioning of attachment figures in providing protection and support (Mikulincer and Shaver 2007) facilitates the buffering of anxiety. By contrast, attachment anxiety is associated with higher levels of fear of death at both conscious and unconscious levels. Avoidant individuals are effective in suppressing conscious death concerns. However, they are ineffective in decreasing their unconscious fear of death, which is revealed in heightened death-related anxiety when assessed with projective measures (Mikulincer and Shaver 2007). Furthermore, exposure to traumatic situations may increase one’s level of death anxiety (Kastenbaum 1987, 2000). Consequently, preterm birth might exert long-term effects in terms of death anxiety. In line with previous studies, we will examine conscious and less conscious qualities of death anxiety.

Lubetzky and Gilat (2002) examined fear of personal death among preterm adolescents. Findings indicated that participants born preterm scored higher on fear of personal death compared to adolescents born at term. Secure attachment was associated with lower scores on fear of personal death only among adolescents who were born at term. This association was not found among participants born preterm (Lubetzky and Gilat 2002). The authors suggested that among preterm born adolescents, secure attachment may not have sufficient protective power to reduce the emotional distress related to the fear of personal death. It is also possible that an increased fear of death in individuals born preterm is induced by their mother’s own fear and concerns regarding the child’s well-being. Mothers of preterm infants have higher levels of irrational fear regarding the loss of their child (Korja et al. 2009).

Summary and Hypotheses

Premature birth might leave children vulnerable when facing developmental tasks later in life. Based on previous mixed results regarding relatedness, we explored the link between preterm birth and relatedness in young adults as it is expressed in their relationships with parents, best friends, and romantic partners. We further hypothesized that preterm young adults will show more difficulties in individuation and death anxiety compared to their counterparts. Finally, since their early experiences of life might leave them more susceptible to anxiety, we examined whether relationships with parents and death anxiety mediated the associations between preterm birth and difficulties in relatedness and individuation.

Method

Sample

The sample consisted of 114 young adults, 46 males (40.4 %), and 68 females, from a diverse socio-economic background. A total of 77.2 % of the subjects were recruited via the snowball sampling technique, while the balance was recruited via postings of the study in advertisements and forums in social networks. The age of the participants ranged from 20 to 32, M = 26.63 (SD = 2.79), 94.7 % were born in Israel, and 77.2 % had academic education. A total of 72 % come from intact families (with no parental loss or divorce). A total of 17.5 % were married, 21.9 % lived with a partner, 16.7 % reported being in a relationship without living together, and 43.9 % of the participants were single.

The preterm group included 57 emerging adults who were born preterm, and the control group (full term) included 57 paired emerging adults who were born at term and at normal weight. Matching of preterm and full-term respondents was based on age, family status, education, ethnicity, and religiosity. There were no differences between the groups in the characteristics of their socio-economic backgrounds. The preterm group consisted of young adults who were temporarily separated from their parents for a period of at least 2 weeks due to hospitalization in a neonatal intensive care unit. To avoid confounding variables that are more health related, only participants who were generally healthy and without particular medical problems were included in the sample. Mean weight at birth is 1,798 g (SD = 519), and mean length of pregnancy is 29.63 (SD = 2.70). The average hospitalization period post-birth was 44.34 days (SD = 33.92). There were no associations between the preterm characteristics and the variables examined in this study.

Measures

Relatedness Variables

Relationships with Parents

The Perceptions of Adult Attachment Questionnaire (PAAQ; Cassidy et al. 2009) were used to assess (a) perceptions of early childhood experiences with the primary caregiver and (b) current state of mind with respect to attachment. On a 5-point Likert scale, participants rated the extent to which they agree with each of the 60 items. Three subscales tapped perceptions of childhood relationships: rejection/neglect (11 items; e.g., “When I was a child, my mother sometimes told me that if I was not good, she would stop loving me”), being loved (6 items; e.g., “In childhood, I felt like I was really treasured by my mother”), and role-reversal/enmeshment (10 items; e.g., “I often felt responsible for my mother’s welfare”). Five subscales tapped current state of mind with respect to attachment: vulnerable (5 items; e.g., “My mother’s issues are still interfering with my life”), balancing-forgiving (7 items; e.g., “Even with all our past difficulties, I realize my mother did the best for me that she could”), angry (5 items; e.g., “No one gets under my skin like my mother”), dismissing/derogating (4 items; e.g., “My family was not particularly intimate, but this has never bothered me”), and lacking in memory about childhood (4 items; e.g., “I have forgotten what most of my early childhood was like”). In previous studies, the measure demonstrated good reliabilities ranging between .63 and .94, except dismissing/derogating. In the current study, alphas were similar: being loved = .73, role-reversal/enmeshment = .75, rejection/neglect = .79, vulnerable = .71, balancing/forgiving = .68, angry = .60, dismissing/derogating = .52, and lacking in memory = .83. The measure also showed good test–retest reliability and good validity. For example, it demonstrated significant correlations with the Adult Attachment Interview subscales, social support, and representations of caregiving (for details, see Cassidy et al. 2009).

Personal Assessment of Intimacy in Relationships

Personal assessment of intimacy in relationships (PAIR) (Schaefer and Olson 1981) assesses the degree of intimacy that individuals experience with romantic partners in five areas of intimacy. Each scale contains six items that are rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). In the current study, we included three scales: emotional intimacy, the ability to feel close to one’s partner; social intimacy, the ability to share mutual friends and social networks; and sexual intimacy, the ability to express affection and sexual activities. Internal consistencies of the scales in previous study are emotional .75, social .71, and sexual .77. In the current study, alphas are .83 for emotional, .72 for social, and .79 for sexual. The PAIR has also demonstrated good validity, showing significant correlations with family environment, and with marital adjustment and marital satisfaction (Greeff and Malherbe 2001; Schaefer and Olson 1981).

Emotional Closeness

Participants rated 8 items assessing emotional closeness in a same-sex friendships on a 4-point scale ranging from 1 (really disagree) to 4 (really agree), to which degree the sentences fit their relationships with their best friends. The scale measures shared affect, availability, and instrumental assistance (Shulman et al. 1997). Alpha reliability of the scale in the current study is .85.

Differentiation

The Differentiation of Self Inventory (DSI; Skowron and Friedlander 1998) is a self-report assessing differentiation of self within one’s current significant relationships. Participants rate 43 items, using a 6-point Likert-type scale, ranging from 1 (not true of me) to 6 (very true of me). Three scales reflect difficulties in differentiation: Emotional reactivity refers to emotional flooding, emotion liability, or hypersensitivity in response to stimuli. Fusion with others assesses emotional over-involvement and/or overidentification with one’s significant others and the need of others’ approval. Emotional cutoff refers to detachment from emotions and to isolation when experiences are too intense. The forth scale I-position reflects healthy differentiation expressed in a clearly defined sense of self and the ability to assert one’s beliefs and attitudes. Internal consistency of the subscales in previous studies was moderate to high and ranged from .70 to .88. Test–retest reliabilities were also high (Murdock and Gore 2004; Skowron and Friedlander 1998). In the current study, Cronbach’s alphas were reactivity .88, fusion .78, cutoff .80, and I-position .78. The scale showed good validity. (Skowron and Friedlander 1998; Tuason and Friedlander 2000).

Death Anxiety

Death anxiety was assessed in two ways: a questionnaire to examine the conscious aspects and a projective test to examine the less conscious aspects. The death anxiety test (DAS) is a widely used scale (Templer 1970) to asses a single dimension of death anxiety. The measure consists of 15 items related to fear of death and dying (e.g., “I am very much afraid to die,” “I often think about how short life really is”). Participants rated the items on a 5-point Likert scale (from 1 = “strongly disagree,” to 5 = “strongly agree”). The scale has a test–retest reliability of .83 and adequate internal consistency of .76. The scale correlates with another Fear of Death scale and correlates only moderately with MMPI anxiety subscales (Hill and Hood 1999). Cronbach’s α in the current study was .79.

To examine the less conscious aspects of death anxiety, participants were shown the picture “All Is Vanity” by Charles Allan Gilbert as a projective test. The picture can be interpreted as depicting a woman sitting in front of a mirror, or as a skull. Participants were requested to write the first 10 words that came to mind when they saw the picture. Two coders separately classified all the words into death- related words (e.g., skull and skeleton) and non-death-related words (woman). Disagreements (10 %) were resolved by consensus after discussion. The score is considered a measure of explicit death-thought accessibility. In a previous study, higher levels of self-control were associated with fewer death-related words (Gailliot et al. 2006). The correlations between the two indicators was .16, p < .10.

Results

We adopted the level of .05 significance throughout the analyses. To examine the differences between emerging adults who were born preterm and the matched control group, we computed MANOVAs, followed by ANOVAs and post hoc tests when significant. The MANOVA conducted to examine relationships with parents revealed non-significant main effect of preterm status, F(8,103) = 1.39; p = n.s; η2 = .10, significant main effect of gender F(8,103) = 3.24; p < .01; η2 = .20, and a non-significant interaction effect. Follow-up ANOVAs of vulnerable and balancing/forgiving were significant, with females exhibiting higher levels than males (see Table 1).
Table 1

The differences between preterm emerging adults and the full-term group

 

Preterm (n = 57)

Full term (n = 57)

Males (n = 45)

Females (n = 69)

F Preterm status

F gender

Relationships with parents

 Being loved

3.83

.77

3.60

.87

3.84

.80

3.64

.83

1.67

1.77

 Role-reversal/enmeshment

2.58

.65

2.61

.67

2.52

.72

2.65

.61

.01

1.00

 Rejection/neglect

1.94

.56

1.93

.51

1.95

.55

1.92

.52

.01

.05

 Dismissing/derogating

2.19

.75

1.99

.67

2.20

.71

2.02

.71

2.41

1.97

 Lacking in memory

2.84

1.01

2.45

.92

2.59

.85

2.68

1.06

4.25*

.18

 Vulnerable

2.76

.83

2.64

.86

2.37

.82

2.92

.79

.21

12.72***

 Angry

2.26

.70

2.24

.59

2.27

.70

2.23

.60

.01

.09

 Balancing/forgiving

3.40

.63

3.50

.61

3.31

.63

3.54

.60

.20

3.60*

Pair intimacy

 Sexual intimacy

3.11

.70

3.07

.77

3.02

.82

3.14

.67

.37

.72

 Emotional intimacy

2.88

.82

2.92

.88

2.93

.83

2.88

.87

.15

.12

 Social intimacy

2.08

.89

2.01

.80

1.96

.86

2.10

.83

.09

.67

Intimacy—best friend

 Emotional closeness

3.38

.58

3.30

.46

3.27

.58

3.38

.48

1.12

1.30

Differentiation of self

 Reactivity

3.79

1.01

3.44

.88

3.17

1.02

3.90

.81

4.12*

17.90***

 I-position

3.98

.72

4.14

.75

4.35

.77

3.87

.65

1.17

12.97***

 Cut-off

2.66

.84

2.54

.73

2.76

.86

2.50

.71

1.31

3.09+

 Fusion

3.96

.69

3.59

.68

3.54

.70

3.92

.67

9.28**

8.67**

Death anxiety

 Death anxiety (DAS)

3.63

.80

3.20

.80

3.09

.72

3.64

.83

7.01**

4.75*

 Death words

3.11

1.51

2.49

1.43

2.67

1.73

2.88

1.32

14.75***

.53

p < .05; ** p < .01; *** p < .001

The MANOVA conducted to examine romantic intimacy and emotional closeness with best friend revealed non-significant effects of preterm status, gender, and interaction. Thus, there were no differences between preterm individuals and their counterparts in various dimensions of relatedness.

In contrast, the MANOVA conducted to examine differentiation revealed significant main effect of preterm status F(4,107) = 2.42; p < .05; η2 = .08 and significant main effect of gender F(4,107) = 8.70; p < .001; η2 = .25, while the interaction effect was not significant. Follow-up ANOVAs of emotional reactivity and fusion with others were significant, with preterm emerging adults and females exhibiting higher levels than their counterparts. Additionally, males reported higher levels of I-position than females (see Table 1).

Finally, the MANOVA conducted to examine death anxiety revealed significant main effect of preterm status F(2,109) = 5.73; p < .01; η2 = .10 and significant main effect of gender F(2,109) = 7.00; p < .001; η2 = .11, while the interaction effect was not significant. Follow-up ANOVAs showed that preterm emerging adults exhibited higher levels of death anxiety (in the questionnaire and in the projective test) than their counterparts, and females reported higher levels of death anxiety (in the questionnaire) than males (see Table 1).

Examining the Mediation of Relationships with Parents and Death Anxiety in Predicting Differentiation

Since relationship with parents was not associated with preterm birth status, we did not examine the mediation of relationships with parents. The mediating role of death anxiety was tested by hierarchical regression analyses. Following Baron and Kenny (1986), we first regressed the criterion variable (differentiation variables) on the predictor variable (preterm birth) and then regressed the criterion variable on both the predictor and the mediator (i.e., death anxiety). Following Baron and Kenny’s (1986) suggestions regarding the assessment of mediation, we examined whether death anxiety (the mediator) was associated with the predictor (differentiation variables). Only DAS scores (and not number of death words) were significantly associated—(p < .05)—with all differentiation variables: reactivity (r = .48), cut-off (r = .20), fusion (r = .47), and I-position (r = .35). Consequently, two hierarchical regression analyses were conducted for predicting reactivity and fusion. Gender was included in the first step, preterm birth status was added in the second step (0 = preterm, 1 = full term), and the mediator (death anxiety) in the third step.

The hierarchical regression analyses predicting emotional reactivity and fusion with others showed mediation: with the inclusion of death anxiety, the β coefficients of preterm birth status significantly decreased and became non-significant, and the β coefficient of death anxiety was significant (see Table 2). Application of the Sobel test (MacKinnon et al. 1995) to examine whether death anxiety carries the influence of preterm status to the differentiation variables (indirect pathway) showed that the Sobel test was significant in both cases: (z = 2.55, p < .01) in emotional reactivity and (z = −2.54, p < .01) in fusion with others. Thus, death anxiety mediated the relations between preterm birth status and differentiation.
Table 2

Prediction of differentiation dimension—the role of death anxiety

Step and predictors

Emotional reactivity

Fusion with others

β

F

ΔR2

β

ΔF

ΔR2

First step

 

F(1,112) = 17.89, p < .001

.14

 

F(1,112) = 8.66, p < .01

.07

 Gender

.37***

  

.27**

  

Second step

 

F(2,111) = 11.29, p < .001

.03

 

F(2,111) = 8.98, p < .001

.07

 Gender

.37***

  

.26**

  

 Preterm birth status

−.18*

  

−.26**

  

Third step

 

F(3,110) = 15.29, p < .001

.13

 

F(3,110) = 13.92, p < .001

.14

 Gender

.24**

  

.13

  

 Preterm birth status

−.08

  

−.16

  

 Death anxiety

.39***

  

.41***

  

Final model

  

.40

  

.28

Preterm birth status was coded: 0 = preterm, 1 = full term; Gender was coded 0 = male, 1 = female

p < .05; ** p < .01; *** p < .001

Discussion

The aim of the study was to examine relatedness and individuation among young adults born preterm. There were no differences between preterm young adults and their counterparts in the various dimensions of relatedness. They exhibited similar levels of closeness with their parents, with romantic partner, and with best friend. A different picture emerged with regard to differentiation and death anxiety. Preterm young adults exhibited higher levels of emotional reactivity and fusion with others, and higher levels of death anxiety, than their counterparts.

It appears that, despite the fact that these youngsters experienced a traumatic event early in their lives, they overcame this difficult experience and were successful in maintaining closeness with close others. These findings partially confirm previous results. Relationships with parents were assessed pertaining to inferred childhood experiences, as well as to current state of mind variables. It is possible that the protective and supportive parenting style (Pyhälä et al. 2011), as well as other experiences in various close relationships during their lives, facilitated their functioning and buffered the possible harmful effects of preterm birth. Thus, this group of young adults born preterm seems to function as well as other young adults in the important domains of life that are deemed central during this developmental period. This is the prerequisite for building a family and future parenting.

During young adulthood, as the child–parent relationship becomes more mature and more egalitarian, there is a tendency to reevaluate one’s relationship with parents (Scharf et al. 2004). It is possible that the redefinition of the relationship with the parents changes or ameliorates the current stance of young adults toward their childhood experiences, which in turn could explain the lack of differences between the preterm and the control groups with regard to perceptions of childhood attachment experiences.

Mothers of children who were born prematurely perceive their children as especially vulnerable and fragile (Perrin et al. 1989), and as a result, they might attempt to compensate for the child’s trauma by emotional over-involvement in the child’s life, sensitivity, and high maternal investment (Brisch et al. 2005). It is thus possible that, due to maternal attempts and increased attention, the young adults who were born preterm experienced a protective and involved motherhood that could compensate for the initial crisis they experienced in infancy. Because of their actual increased need, this at least according to our study was perceived favorably by preterm young adults. If this interpretation is valid, those past experiences with close others may encourage intimacy and involvement with others, and could possibly account for the uncompromised ability of these young adults for intimacy and closeness to others.

In contrast, the findings of our study reveal that the traces of the preterm birth might be more pronounced in the domain of differentiation. Parents’ involvement might contribute to children’s relatedness skills, and overprotection might convey care and love. However, the continuous concerns about children’s health and development may affect their parenting and the child’s development, thus explaining the association between preterm birth and difficulties in individuation. Though we included only healthy participants, it is possible that their relative physical weakness contributes to their wish and need for intense closeness with close others, which in turn could contribute to their lower levels of individuation.

In the current study, we explored the conscious and the unconscious aspects of fear of death and found that preterm participants exhibited more fear of death than the control group on both conscious and unconscious levels. Based on theory and research (Kastenbaum 1987), it is possible to assume that young adults who were born preterm and experienced a prolonged hospitalization in their infancy would be more sensitive and fearful of subjects related to physical morbidity and death. Our data support this assumption. Exposure to traumatic situations may increase one’s level of death anxiety (Kastenbaum 2000). The results of our study demonstrated that participants’ death anxiety explained the difficulties in individuation. The possible effects of premature birth are revealed in elevated levels of death anxiety (Lubetzky and Gilat 2002). Kastenbaum (1987) suggested that people who experienced separations from significant others, especially early in life, would develop high levels of death anxiety as death is experienced as the ultimate separation from a close person. Enduring death anxiety might complicate the individuation process, due to the wish to stay close to close others, which counteracts the need to separate and develop a unique identity.

Gender Differences

Females showed higher levels of vulnerability and balancing/forgiving toward their parents, higher levels of emotional reactivity and fusion with others than males, and higher levels of death anxiety (in the questionnaire measure), whereas males exhibited higher levels of dismissing style and higher levels of I-position. These differences are similar to findings in previous studies demonstrating the different societal expectations from males and females. Women are socially expected to place high importance on interdependence, while men value independence and competition (Caldwell and Peplau 1982; Vangelisti and Daly 1997). Mothers are more involved in their daughters’ lives compared to their involvement in their sons’ lives (Moon and Hoffman 2008). As a result, females feel more warmth and closeness toward their mothers, together with difficulties in freeing themselves from this influence. Females also ascribe more importance to maintaining social and familial harmony, and responding to societal expectations (Maccoby 1990; Walton et al. 2009). Thus, females are more relationship oriented, whereas males focus more on consolidating their independent self and views (Goldshmidt and Weller 2000).

The finding regarding differences in death anxiety confirms previous work (Kastenbaum 2000; Robbins 1989). Whereas females have societal legitimization to express their fears, males are expected to hinder their expression. This might explain the gap between the lack of gender differences in the projective assessment that targets less conscious fear of death, and the assertion of males regarding lower levels of death anxiety compared to females in the self-report questionnaires.

Strengths and Limitations

The current study used a paired sample design, with a normative population, to examine the possible long-term effects of premature birth. It extends previous research by examining the psychosocial functioning of young adults who are a less studied population in this regard. Our findings indicate that even though many years have passed since the experiences related to premature birth in infancy, young adults who were born preterm have unique characteristics with regard to individuation and death anxiety.

Most of the data in this study are based on questionnaires that may be biased toward positive self-presentation. In this study, we also used projective assessment to examine death anxiety, which can more successfully bypass defenses that are common in self, although in the current study, both measures of death anxiety differentiated between the groups. To enrich our understanding, it might be interesting to use additional methods in future studies, such as observations and interviews, as well as reports from additional sources (e.g., friends, mothers, partners), and more detailed medical data, as well as larger samples. Furthermore, using more than one reporter has been shown to provide a more nuanced understanding of the processes involved (Bogenschneider and Pallock 2008).

Further research is called for to explore the long-term effects of preterm birth on more subtle aspects of psychosocial adjustment. This is relatively small sample, and we do not have detailed medical records of our participants. Degree of prematurity was based on respondents’ reports regarding their birth. More comprehensive medical information and a larger sample could enable the exploration of the possible moderation of medical-risk variables. Additional potential mediating and moderating variables that were not examined in this study, such as the child’s personality and temperament, parental resolution of the premature birth, socio-economical variables, and socio-cultural context should also be considered. In this study, we did not examine mothers and fathers separately, and assessed the main childhood caregiver or both parents. Future studies should include fathers as well as, since especially in the case of at-risk conditions, their involvement (or lack thereof), and its quality might play an important role in the short- and long-term adjustment of their offspring.

This study was conducted in the Israeli cultural context and examined a rather homogenous sample with regard to SES and education. In general, this is a well-educated sample from a moderate SES, which might explain their good psychosocial functioning and the relatively minimal impairment. Hence, the ability to generalize the findings to other contexts needs to be further explored. Further research calls for additional follow-up of preterm individuals throughout adulthood, as they deal with various developmental tasks such as parenting that might re-challenge the coping with relatedness and individuation with one’s offspring.

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Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Department of Counseling and Human DevelopmentUniversity of HaifaHaifaIsrael

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