Analysis of triadic interaction between parents,their preterm infants,and a sonorous object

Abstract

In the period between birth and approximately 9 months, adults introduce infants to triadic (adult–infant–object) communication. The objective of this study is to explore how early triadic interactions arise and develop in moderate–late preterm infants. We observed and analyzed seven preterm infants at 2, 3, and 4 months of age in triadic interactions with a caregiver and a sonorous object. In the first 2 months of the infant’s life, the responsibility for the interaction rests with the adult. As time went by, parents used a wider range of semiotic systems to communicate with the child, about and through the object. The results demonstrated the presence of triadic interactions in a preterm population beginning in the third month of life. Interaction is structured with the object, its sound, rhythm, and pauses. The parents’ use of pauses was adjusted to the child’s availability. These pauses became longer and more communicative over time, which allowed more participation on the part of the infants. Communication is facilitated by the rhythmic components of the triadic interaction (time/pauses/structure of the interaction sequence).

Keywords

preterm infants early triadic interactions parent–child communication rhythm gestures

The risks of prematurity

Major advances in neonatology in the last 30 years have given rise to a spectacular increase in the survival rate of preterm infants, and a clear improvement in their health (PMNCH, 2011; Stoll et al., 2010). This opens the possibility of studying the early development of these children from birth. It has been observed that preterm infants are less alert, active, and responsive, compared with full-term children (Boyle et al., 2015). However, although some delay in the first year for premature infants is common, research showed that it tends to disappear with time (Bakermans-Kranenburg et al., 2003; Crnic et al., 1983; Ravn et al., 2011). Some studies showed that the difficulties experienced by preterm infants mainly stem from medical complications or anomalous responses of some mothers, closely associated with their background (family psychiatric history, socioeconomic limitations, or social support deficits), rather than from the premature birth condition itself (Crnic et al., 1983; Greenberg & Crnic, 1988; Ionio et al., 2016; Minde et al., 1980; Schappin et al., 2013). Nevertheless, the gradual increase in preterm births (Raju, 2017) makes it necessary to study the specificities of preterm development and its possible complications (Sastre-Riba et al., 2015), and the possibility of mediating this process.

The mother–preterm child interaction

The first studies analyzing adult–preterm interaction as a possible source of risk focused on evaluating the sensitivity of the mother’s response pattern just after birth (Feldman, 2007). They found a lesser degree of maternal behavior, in terms of maternal gaze and affectionate touch (Cohen & Beckwith, 1979; Goldberg, 1978; Levy-Shiff et al., 1989; Miller, Holditch-Davis, 1992; Montirosso et al., 2010; Stefana & Lavelli, 2017), a lesser coordination of the mother’s behavior with respect to the infant’s responses (Feldman & Eidelmar, 2007), and less reciprocity (synchrony) in their interactions (Feldman, 2007; Karger, 1979). This coincides with a general disorganization in the degree of coherence of the mother’s responses to the infant’s affective states (Lester & Boukydis, 1985; Malatesta et al., 1989; Stefana & Lavelli, 2017), more so in stressful situations (Karger, 1979; Maroney, 2003) and is associated with a lower level of synchrony at 3 months of age. Feldman (2007) analyzed the rhythmic patterns of the mother–preterm child dyad and discovered a specific pattern characterized by low feedback between mother and child. This disruption of the rhythms implies patterns of interaction that are less well-adjusted to the child’s needs, more disorganized, and with fewer pauses. This was comparable to the synchrony difficulties found in the interactions of other populations of children that also experienced early separation at birth (Insel & Young, 2001; Swain et al., 2007), such as intrauterine developmental delay (Feldman, 2007; Feldman & Eidelman, 2007), children with eating disorders (Feldman et al., 2004), and autism spectrum disorder (Yirmiya et al., 2006).

Dyadic and triadic interactions: the role of objects in the interaction

The interest in the subject–subject (S-S) interactions (Stern, 1985/1995), such as mother–child, runs parallel to the study of subject–object (S-O) interactions (Piaget, 1936/2007), both known as dyadic interactions. Despite the widespread focus on the dyadic approach, daily interactions between adults and infants, such as feeding or hygiene activities, include many objects. These interactions between two subjects with an object are defined as triadic (S-O-S). In the case of mother/father–child–object, the object is a shared referent and favors the interaction. As common as they are in everyday life, there are few studies on triadic interactions that consider the object as a relevant factor.

One such paradigm is The Pragmatics of the Object (Rodríguez & Moro, 1998a). From this perspective, material objects are part of the historical and cultural framework of the people using them. They are endowed with public conventional uses and rules of use by the community, which gives meaning to the actions carried out with them. These uses and rules are transmitted through semiotic mediation between subjects, through sign systems such as rhythm, demonstrations of uses, gestures, and language (see, e.g., Moreno-Núñez et al., 2015, 2017). The object is part of communication and has a role in everyday life and culture. This perspective makes it possible to analyze actions during the agreement of actors around an object. The conventional uses of the objects are gradually constructed by the child as a result of the adult’s semiotic mediation in processes of reciprocal influence, which arises long before the development of language (Rodríguez & Moro, 1999).

Before the child begins to communicate intentionally to the adult about the object, at around 9 months (Bates et al., 1975; Bergeson & Trehub, 2007; Tomasello, 2008), children are brought into communication niches by the adults (Moreno-Núñez et al., 2015). Moreno-Núñez et al. (2017) followed six children with typical development during their second, third, and fourth months of life in interaction with their parents and a maraca. They highlighted that pauses open spaces of interchange between the adult and the child, which are essential for communication and early coordinated actions. In this line, rhythm is a powerful tool used to structure interaction (Moreno-Núñez, 2014; Moreno-Núñez et al., 2017). This allows infants to use the maraca conventionally, shaking it to produce sound, earlier than most classical theories suggest (Bates et al., 1975; Bergeson & Trehub, 2007; Tomasello, 2008). They concluded that the first shared references between adult and child take place in triadic interactions promoted by the adult around the object. However, to date the present analysis, there have been no studies of early triadic interactions in preterm infants that could improve guidance provided to caregivers.

The objective of this study is to analyze the pattern of the interactions between the preterm infant and their parents around a sonorous object: the maraca. In this regard, we will study the uses of objects and gestures produced by (1) the parents through their semiotic mediation and (2) the infants in their responses. We will also analyze the rhythmic structure of the interaction, in terms of the number of pauses and organization of the adults’ interventions.

We expect to find some differences in the pattern of interaction of the parents of preterm infants with respect to typical developing ones (Moreno-Núñez et al., 2017). In this regard, our hypothesis is:

1. Adults will include preterm infants in niches of triadic interaction through object uses and ostensive gestures. Infants will progressively take the initiative in interaction, as is the case with full-term infants.

However, we expect that:

2. Adult interactions will be less organized. That is, they will show (a) fewer pauses, (b) less coherent rhythmic actions, and (c) worse structure of maraca use (with less clear rhythm, very long uses of the maraca, with few pauses, and few gestures to invite action).

3. These differences will be associated with possible variations of maraca use during preterm infants’ development.

Methodology

Participants

We conducted a prospective longitudinal study monitoring seven moderate–late preterm infants (five male and two female; two moderate and five late preterm) in their second, third, and fourth months of life (see Table 1).

Table 1.

Gestational Age, Gender, and Bayley III Scale Percentiles in t4.

	Gestational age	Gender	PCS (PCSc)	PLS (PLSc)	PMS (PMSc)
n1	32 w 5 days	M	50 (50)	34 (50)	12 (42)
n2	35 w 6 days	M	91 (98)	34 (50)	58 (75)
n3	34 w 0 days	F	37 (63)	99 (99)	58 (75)
n4	34 w 5 days	M	63 (84)	23 (23)	42 (58)
n5	34 w 5 days	M	50 (84)	34 (50)	27 (75)
n6	35 w 4 days	M	11 (16)	27 (42)	21 (34)
n7	36 w 5 days	F	75 (84)	97 (98)	88 (96)

Note. Bayley Scale scores are indicated to describe the developmental level of the infants evaluated. Between brackets, the corrected score for preterm infants. PCS: Percentile Cognitive Scale; (PCSc): Percentile after correction; PLS: Percentile Language Scale; (PLSc): Percentile after correction; PMS: Percentile Motor Scale; (PMSc): Percentile after correction.

Data collection

Participants were selected by means of consecutive sampling at the Neonatology Unit of the La Paz Hospital in Madrid, between October 2015 and May 2016. The sampling inclusion requirements were (1) infants must have been born between weeks 32 and 36 of gestation, (2) infants must not have serious organic alterations,¹ and (3) infants’ auditory maturation must be above 95%. For all infants, signed consent of the responsible adult was requested.

The final parent sample consisted of four mothers (four boy–mother pairs) and three fathers (two girl–father pairs, one boy-twin–father pair). The parent sample had the following characteristics: average age of 33, middle-class, medium-high level education, with two cases of higher musical education. Only one of the families was of non-Spanish origin.

Data were collected under the supervision of the hospital management, with voluntary participation of the parents and signed informed consent, respecting the ethical recommendations established by the World Medical Association in the Declaration of Helsinki (World Medical Association, 2013), following the protocol approved by the IDIPAZ Committee (PI-2136, 18/11/2015).

Materials

The maraca was chosen as a sonorous mediator because it is easy for an infant to grasp and is easy to use conventionally. It favors triadic interactions involving rhythmic, sonorous, and melodic components (see Appendix A). Its conventional use consists of shaking it to produce sound. It is one of the first musical instruments presented to infants (Trehub, 2003), introducing them to the world of sound and rhythm.

A Canon IXUS 265 camera was used for making the video recording. All recorded material was processed and transcribed into ELAN (EUDICO Linguistic Annotator, 2011) files.

Procedure

The sessions took place at the participants’ homes during the second, third, and fourth months of the infant’s life. These sessions were agreed upon at the La Paz Hospital (Madrid) where the preterm were born, having informed the parents and collected the corresponding informed consent. For the observations, we asked one of the infants’ parents to place themselves in a comfortable place and position, where he/she and the infant could see each other face to face, while spontaneously interacting with the maraca. The instruction given to the parents was: “play with your infant as you normally would.” Five minutes of each interaction were recorded in video format as in the study by Moreno-Núñez et al. (2015).

Data analysis

This is an exploratory adult–preterm–sonorous object interaction analysis. A mixed methodology approach was used. The unit of analysis included the triad formed by the adult–child interaction with the object. The observations were segmented into sequences showing triadic interactions. A sequence began when one of the participants of the infant–parent pair started an action with the maraca and the other was sufficiently alert and quiet. A change of sequence was determined by a timelapse of more than 3 s or a change in attention focus. Any time the action stopped for less than 3 s it was considered a “pause.” The total number of sequences included in the analysis was 46 (see Appendix B, Table B.1).

Statistical analysis

For the quantitative analysis, we analyzed direct scores of frequency and duration of use. We used non-parametric tests (Friedman², Wilcoxon) to analyze the changes between the different moments compared. The level of significance was p < .05. The data were analyzed with IBM SPSS 20 software (IBM Corp, 2011). All statistical tests were considered bilateral distributions.

Protocol transcription

We performed a micro-genetic analysis of the adults’ communicative mediators and the infants’ response patterns. Microgenesis consists of the second-by-second transcription of behavior and representations during the observation, based on a system of categories (Saada-Robert, 1994). It is a useful method to describe and analyze the dynamic changes in the organization of behavior, occurring during and between, observational sessions (see Rodríguez & Moro, 1998b). The sequences were transcribed using the software ELAN [v.3.8.1 (EUDICO Linguistic Annotator, 2011)] following the protocol of Moreno-Núñez et al. (2015) (see Table 2 for the observation categories to be used in the analysis: “use of maraca,” “gestures,” and other communicative mediators).

Table 2.

Definition of Observation Categories.

Parent’s communicative mediators	Infant’s response patterns
1. Uses of the maraca
a. Organization in space a.1 Immediate Demonstrations (ID)—The adult introduces and directs the infant to the dynamics of object use a.1.1 Body I.D. (BD)—The adult plays with the maraca tapping on the infant’s body. a.1.2 Hand I.D. (HD)—The adult places the maraca in the infant’s hand and shakes his or her hand as the adult would do it. a.2 Distant Demonstrations (DD) —The adult uses the maraca conventionally for the child to see, complete or incomplete. b. Temporal structure b.1 Structured (St)—The adult organizes the use of the maraca by incorporating frequent small breaks in the tempo of the use. b.2 Unstructured (U)—The adult includes no breaks in the tempo of the use.	a. Organization by complexity a.1 Grasps on the adult’s initiative (AG) —The infant grasps the maraca the adult is placing in his or her hand. a.2 Attempt to grasp (anticipated CG) —The infant opens his or her hand in the direction of the maraca held by the adult, following the presentation of the object, waiting for the adult to give it to him/her. a.3 Grasp on the child’s initiative (CiG) —The infant directs his or her hand to grasp the maraca before the adult gives it to him/her, even if he/she does not remove it from the adult. a.4 Shaking (S) —The infant holds the maraca and waves it without the intervention of the adult. Conventional use.
2. Gestures
a. Ostensive gestures (OG)—The adult shares the maraca with the infant. a.1 Showing (SH)—The adult shows the maraca to the infant. a.2 Giving (G)—The adult gives the maraca to the infant.	a. Private ostensive gestures—The infant shows the maraca to him/herself. This suggests an exploratory function of the object.
Others
Language—The adult speaks to the infant. Glissandos—Two or several sounds giving rise to a melodic production which consists of a vocal or instrumental glide from one sound to another (Del Olmo, 2009, p. 21).	Attentive look—The infant looks at the action of the adult with the maraca. Vocalizations—The infant produces sound. Emotional expression—Smiling, crying, and sleeping.

i. Bodily Attitude (adult and infant). Not collected.

ii. Temporal and rhythmic patterns: duration of use, presence, and duration of pauses and structural behaviors. During the parents’ use of the objects, the frequency and duration of the pauses were also identified. These pauses are brief moments of silence in the tempo, which do not stop the current use. In musical language, they are the “silences” of a score. These pauses bring an element of organization to the use of the maraca, creating a more complex rhythm.

Note. All categories listed in this table were taken from the analysis protocol of Ana Moreno-Núñez et al. (2015), except explicitly indicated.

Intercoder reliability

The sequences were codified by two independent observers. Inter-rater Krippendorff’s alpha reliability coefficient (Hayes & Krippendorff, 2007) was calculated by applying it to 30% of the randomized videos, with the ReCal OIR calculator (Freelon, 2013). The obtained inter-rater coefficient (Krippendorff’s alpha 0.1) was total = 92.1%, adult uses = 92.6%, infant uses = 78.7%, and gestures = 96.8%.

Results

The results show the construction of early semiotic systems. To analyze the data, the most significant triadic sequences were taken. These sequences illustrate the different categories and offer a clear visual representation of the analyses and results (see Appendices B and C, Tables C.1–C.4). Adult use of communicative mediators and the infants’ response were summarized and analyzed (see Appendices D and E, Tables D.1–D.2 and E.1–E.2). The temporal patterns of adult-preterm-object interactions were also analyzed (Appendices F and G, Figure F.1 and Tables G.1–G.2).

Adult use of communicative mediators

The results show that over time adults progressively use a more varied range of semiotic systems to communicate with his or her children about and through the object (Figures 1 and 2 and Appendix D, Tables D.1–D.2). Initially, the adult uses ostensive gestures and demonstrations, sharing the object and its use, without using indexical or symbolic gestures.

Figure 1.

Absolute Frequency of Sonorous Ostensive Object Use (Adults).

Figure 2.

Absolute Frequency of Gesture (Adults).

The predominance of Distant Demonstrations (DD) is generally observed. High levels of DD are detected at t2, which increase to t3 and decline slightly at t4. Immediate Demonstrations against Body (BD) appear moderately at t2, which decline at t3 and rise again at t4. Immediate Demonstrations with Hand (HD) appear marginally at t2 and t3, which increases at t4. The Give (G) and Show (SH) ostensive gestures show a similar trend to HD. The adult’s object uses and gestures decrease coinciding with the appearance of the infant’s object use in t3, which grows in t4 (see Figures 1 and 4). When the values of these categories are compared throughout the different moments with the Friedman test, the differences obtained were statistically significant, χ²_{DD, BD, HD} (8, n = 7) = 40.34, p_DD, _{BD, HD} = 0, χ²_{SH, G} (5, n = 7) = 13.63, p_SH, _G = 0.001. The post hoc comparison with Wilcoxon showed only significant differences between Hand Demonstrations in t2 and t4 (p_HD_{t2, HDt4} = 0.028), and Giving (G) in t3 and t4 (p_G_{t2, Gt4} = 0.042).

Object use with regular presence of pauses (structured use)

Pauses are an important element in verbal and non-verbal communication. Their presence favors interaction between participants. The older the infant, the greater the probability that the adult’s use of an object is accompanied by pauses (see Appendix F). The pause values (see Appendix G, Tables G.1–G.2) show slight variation in the interaction with the infant and the maraca, with a slight increase in duration in the comparison of the different observational moments. During the second month, pauses are mainly very short or non-existent (see Appendices F and G, Tables G.1–G.2). In some cases, parents play the instrument for several minutes without any pauses. In the third month, brief pauses continue to predominate, but moderate pauses begin to appear. In two cases, we observed that pauses did not appear. During the fourth month, pauses are the longest and are usually accompanied by verbalizations (see Appendix F). These variations are statistically significant² (p_t4-2 = .023, p_t4-3 = .046, p_t3-2 = .046) (with Wilcoxon test).

A detailed analysis of the sequence of interaction shows that when these pauses are not sufficiently long, they do not elicit a response, as if the duration of the pauses determined the infants’ turn to use the object. Thus, the coordination of object use becomes more complex, more structured, and open to interaction and communication. Moreno-Núñez (2014), Moreno-Núñez et al. (2017) establishes a specific category, structured use (St), for those demonstrations, distant or immediate, that are accompanied by sufficiently long and regular pauses. The patterns allow the possibility of coordinating actions between the adult and the child. The analysis of these patterns is presented in Figure 3.

Figure 3.

Relative Frequency in Structural and Non-Structural Use (Adult).

In the use of the sonorous object, the adult acts as a guide, expressing him or herself with very diverse signs of variable multimodal complexity. The production of sounds that accompanying objects use to aid communication is analyzed in Appendix H, Figure H.1, which shows the distribution of sound production by adults and of the motor silences observed throughout monitoring.

The analysis of the sessions shows different productions: three of the families gradually increased their vocalizations with pauses and glissandos, and the remaining three participants had very few vocal interactions addressed to the infants. Only one mother (n5’s) made no vocalizations during interactions with the maraca. Parents’ vocalizations were addressed to the infants, without glissandos or maraca accompaniment.

Structured rhythmical use on the part of the adult is present from the first moments. The highest frequency is observed in t4: at least in 50% of Distant Demonstrations (DD), with statistically significant differences, χ²(14, n = 7) = 54.78, p < .001 (Friedman). To a lesser extent, in the Immediate Body Demonstrations (BD), coinciding in a modal peak in t2. In Immediate Hand Demonstrations (HD), a high frequency of pauses is observed (between 90% and 100%), with an upward tendency and a modal peak in t4. BD and HD variations were not statistically significant. Only the Giving ostensive gesture variations were statistically significant with the Wilcoxon test between t2–t4 (p = .042) and t3–t4 (p = .043).

Infants’ responses to the adults’ actions

In the first months, the responsibility for initiative-taking lies with the adult, given that an infant younger than 2 months cannot manipulate an object by himself/herself. Starting from 3 or 4 months of age, their level of participation increased, as did their capacity for manipulating an object, although the latter was still small (see Figure 4, Appendices C and E, Tables C.1–C.4 and E.2). Child attempt to grasp (CG) type of use predominated, followed by Grasping with the Adult’s Help (AG). In these cases, object use also grows in complexity, becoming more structured and open to interaction and communication (Appendix F and Figure 3). No ostensive gestures were observed in the infants.

Figure 4.

Absolute Frequency of Object Use (Infant).

The fourth month (t4) appears to be a critical moment, in which the more active attitude of the infant converges with more frequent object use and ostensive gestures on the part of the adult. However, when the Friedman test is applied, no significant differences are observed throughout the different moments of observation (p = .157).

If we compare each adult–infant interaction (see Appendix C, Tables C.1–C.14), we observe that the willingness of the infant determines the action of the adult. The infant’s initiative limits the frequency and duration of the adult’s action.

Infants’ looking at the adults’ maraca use and gestures

A good indicator of the effectiveness of the adult’s communication through the sonorous object is the infant’s attentive look toward the adult’s proposal. This category is understood as the infant looking or listening in response to the adult’s action. It was calculated as the percentage of time in which the infant is attentive to the adult’s action in relation to the total time of the session. A general increasing tendency of this focus of attention can be observed, with slight variations between t2 and t4 in some infants (see Appendix I, Figure I.1).

The Friedman test was applied to evaluate the differences between subjects during the monitoring. The post hoc comparison with Wilcoxon showed significant statistical differences were found, χ²(2, n = 7) = 10.28, p = .006, between t2–t4 (p = .018) and t3–t4 (p = .028).

Micro-genetic qualitative analysis

In the micro-genetic analysis of each triadic interaction studied (adult–preterm–object), we can see that, as the infant is developing, the parents increase the length of the pauses during interaction with the maraca. Figure 3 and Appendices F and H, Figure F.1 and Figure H.1 show that in t4, the pauses grow in frequency when the infant performs actions with the shared object (in Demonstration with Hand -HD-, Showing -SH- and Giving -G-).

The following Table 3 is a summary of each of n1’s observation sessions, shown in pictures:

Table 3.

Summary of Each of n1’s Observation Sessions (Photos of Maraca Use Sequences More Than Three Months).

T2: 28/1/16 (5′ of 10′40") The infant is awake and very active. Random encounters with the object facilitated by the mother. There are no clear object uses of n1.	Figure A . Photo of n1’s mother doing DD at t2.
T3: 25/2/16 (5′ de 15′) Four sequences: in the first 2 and in the fourth, intentional use of the object of n1. Attempts to Grasp (CG) appears and the response to the adult’s ostension of Giving (G).	Figure B. Photo of n1’s mother at t3. We observe distant demonstration that by static vision could be mistaken for a showing ostension (SH).
	Figure C. Photo of n1’s mother at t3. We observe ostensive gesture of Giving ostension ( G ).
T4: 1/4/16 (5′ of 7′) Six sequences, six attempts to grasp (CG), and six grasps (AG) with assistance. Increasing participation, response to ostensions, and firmer grasp (AG).	Figure D. Photo of n1’s mother in t4. n1 Shakes (S) the maraca while looking at her.

Let us take the last two sequences of t3 and one of t4 of infant n1 to analyze the adult–preterm interaction sequence. Each sequence is composed of two parts: above, the mother’s action, and below, n1’s action. An intentional use of the object by n1 can be seen both in the first two sequences (from t3) and in the third (from t4). These sequences are paradigmatic as they show the first moments of the use of Attempt to Grasp (CG) and the response to the adult’s Giving ostensive gesture (G).

The sequences chosen in t3 are shown below:

This sequence shows a succession of uses of the object that follow a certain proximal rhythm: Distant Demonstration (DD) alternates with Body Demonstration (BD) and repeats itself, with the time of DD after BD progressively increasing. In addition, ostensive gestures such as Giving (G) are added, as shown in sequence 2.

The Distant Demonstration (DD) precedes the Grabbing Attempt (CG), after the DD-BD sequence, an ostensive gesture of Giving (G) follows which ends in an Immediate Demonstration of Hand (HD).

At first glance, it seems that the mother’s action elicits n1’s response. This assessment is based on the fact that in the two sequences presented, the infant’s action coincides with the adult’s use of DD. On the other hand, at the end of the second sequence, there are several ineffective attempts (CG) by the infant, to which the mother responds with actions similar to those of the first (sequence), closer to him. It is also noteworthy how the pauses change throughout the interactions, increasing slightly as the infant’s action increases in prominence.³

As can be seen in the following figures, at t4 we begin to see interactions with a more clearly reciprocal quality. This final observation of n1 is composed of six sequences, six Attempts to Grasp (CG), and six Grasps on Adult’s initiative (AG). Increasing participation, response to ostensive gestures, and firmer Grasp (G).

In a comparison between the evolution of pauses and object use, we also observed the following relationship: the greater the frequency of use, the greater the frequency of pauses and the shorter their duration (see Figures 5 to 7). The stability of this pattern favors taking turns and the use of the object by the infant.

Figure 5.

Micro-Genetic Sequence 3.1 and 3.2 of nl and His Mother (Duration: 1′ 20").

Figure 6.

Micro-Genetic Sequence 3.4 of nl (Duration: .227").

Figure 7.

Micro-Genetic Sequence t4 (Duration: 5′ 07").

Discussion

The analysis of the emergence of triadic interactions and the use of objects is important for understanding typical development, as well as better understanding the course of development in situations of functional diversity. Observing preterm infants showed evolutive processes that present a slight delay compared to those observed in typical samples (Madden, 2005; Schilte & Auzouy, 2005). We will discuss the results in relation to the three hypotheses presented.

Do adults include preterm infants in niches of triadic interaction through object uses and ostensive gestures? Do infants progressively take the initiative in the interaction?

Triadic interactions (adult–preterm–object) are present in the third month of life in this study. In this regard, we can conclude that triadic musical interactions appear early in the development of our sample, as evidenced by the findings of previous studies (Moreno-Núñez et al., 2015; Moro & Rodríguez, 2005; Rodríguez & Moro, 1998b). However, studies with full-term infants found them earlier, at least from the second month of life (Moreno-Núñez et al., 2017). In both populations, the adult’s intention and initiative dominate in dyadic and triadic interactions during the first months of the infant’s life. However, this does not place the infant outside the interaction with the object (Rodríguez, 1996), as some authors maintain (Tomasello, 1999; Trevarthen, 1990). From the moment of birth, the preterm is an active subject with a capacity to interact in the presence of a sensitive and motivated adult (Gortázar, 2001) and presentation of an object that is directed and adapted to his or her state (Rivière & Coll, 1987).

The general results show that over time, infants progressively increase their participation in interactions that include everyday objects. They move from looking to grasping, and to producing sound, and from a less organized sound production to more organized, in coordination with the adult’s actions. Each subject’s willingness to communicate varies with their age and the person with whom they share the object. These results confirm our first hypothesis, which coincides with what was suggested by Bruner (1984) and Butterworth (1991).

How is an adult (–preterm–object) interaction? Are adult interactions less organized?

Parents use a progressively more varied and complex range of semiotic systems to communicate with their infants about and through the objects. We found predominantly the preterm parental object presentation closer to the body and more frequent Unstructured Distant Demonstrations (UDD) with few pauses than in a typical developing population. (This is elaborated in the following subsections Spatial and temporal characteristics of the adults’ interaction. ) In no case, we observe indexical or symbolic gestures, despite the fact that they are the gestures most commonly described in scientific literature dealing with the first months of life (Butterworth, 2003). Instead, we found that object reference is shared through demonstrations of object use and ostensive gestures, which coincides with the analogous descriptions of typical population samples (Moreno-Núñez et al., 2015).

This sharing of references implies an adjustment that goes beyond simple grasping of the material world. In some cases (such as n1 and n2), it is as though the mother was “giving life” to the object in the shared interaction (Adamson & Bakeman, 1984) and providing an affective structure to promote face-to-face interaction (Adamson & Bakeman, 1985), through repetitions of uses, gestures, glissandos, and variations of the object position such as close-far, right-left, or forward-backward. In this process, the object acquires meaning as an essential element of a shared routine, rather than owing to its intrinsic characteristics or the elicited actions (Bakeman & Adamson, 1984), thus turning into a mediator of the interaction. This type of usage, which turns the demonstration of an object into a specific communicative act, might increase the infant’s motivation in the interaction (see Appendix I, Figure I.1) (Moreno-Núñez et al., 2017).

Spatial characteristics

Further examining the context of the interaction in n1 and n2 (see Appendix B, Table B.1, and Figures 5 to 7), we find a spatial organizational structure in which, initially, the adult invites the infant to take part in a joint action. The parent constantly introduces the infant into the interaction, drawing the infant’s attention through demonstrations, reproducing the infant’s vocalizations, and giving them a voice (as in n1 and n2). It is notable that the adult expects the child to assume agency and use the maraca in a conventional manner, by shaking (S) it. This can finally be observed in t4. As was stated in the introduction, the rules of usage are constructed in the interaction between subjects and objects in processes of reciprocal influence (Rodríguez, 2006).

A particularity of this sample is the specific manner in which the parents often initially present the sonorous objects to the infants. Distant Demonstrations (DD) were the most prevalent, and this is notable given that, as these are more complex uses, they are more frequent in older children (Basilio & Rodríguez, 2011). However, some of these DDs are characterized by a presentation in close proximity to the child in the early phases. The presentation of the object close to the body is more frequent than what is observed in the typical population. This singularity of nearness to the body contrasts with what has been reported in prior studies, in which Distant Demonstrations (DD) are always present in interactions where there is no body contact with the child (Basilio & Rodríguez, 2011; Moreno-Núñez et al., 2017; Rodríguez & Moro, 1999). The child’s age implies changes in proximity to the mother’s body, mediated by cultural factors (Rodríguez, 2006). This proximity does not necessarily imply a lesser presence of the object.

In this respect, it should be noted that there are other particular uses that do not quite fit the definitions observed in typical populations (Moreno-Núñez et al., 2015). These are different from DD, BD, and HD, an example would be the case of the placing gestures observed in n1’s mother in t2 (see Appendix B, Table B.1), when she leaves the maraca closeby, inviting the infant to explore the object. These variations provide information about possible precedents and transitions between categories that should be explored further. Boulch (1983/1995) considered the actions of bringing the object closer or placing it farther away, which would make the leap from the partial world of the child at birth toward the integration of projected plans with respect to the object. According to this idea, the most basic relationship would begin with spatial proximity to then pass to a separation between neighboring and distant elements.

Temporal characteristics

In addition, we also identified the importance of the temporal characteristics of those presentations: their frequency, duration, rhythm, and pauses. These variables must be adapted to the context and the needs of the interacting participants. In this sample, we observed that, initially, Unstructured Distant Demonstrations (UDD) with few pauses predominated with greater frequency than in populations with typical development. However, in each session, in addition to the increase in the adult’s dialogue and listening, the frequency of Structured Demonstrations (StDD and StHD) with more pauses grew (see Appendix G, Tables G.1–G.2), as observed in typical populations. All in all, these results partially confirm our second hypothesis. It appears that the adults in this sample are less organized at the beginning of their child’s life, but grow in organization progressively.

What is behind these differences according to our observations? A qualitative analysis of the duration of demonstration reveals that in overly prolonged DDs infants withdrew their attention (see Appendix I, Figure I.1). This also occurs when the presentations are too brief or there are too few pauses that would not allow infants to focus their attention. This is consistent with the results of another research with preterm infants (Kiepura et al., 2022). Hence, pauses might be understood as moments of listening and invitation to interaction, rather than as silences, and involve a certain recognition of the other as an interactive agent (Santacatalina, 2017). Based on qualitative analysis, it was also observed that the greater the frequency of the pauses, the greater the rates of Distant Demonstrations (DD), Hand Demonstrations (HD), and Ostensive Gestures (OG) (see Appendices C and F, Table C.2, Figure F.1). The pauses allow for interruption in the movement of the object and the coordination of movements between partners. Thus, the interactions are coordinated gradually (Moreno-Núñez et al., 2017).

Del Olmo’s (2009) thoughts on these rhythmic scenarios suggested that when the adult displays a coherent rhythmic action to the infant with his or her movement, this places the child in a multimodal context that concerns not only the senses—looks, vocalizations, positions—but also involves emotions, which may be appreciated in the qualities of the actions. Rodríguez (1996) sustains that “these feelings or primitive sensations are the base for the semiotic mediation process” (p. 123). At the same time, the use and synchronization of kinetic, vocal, and melodic patterns accompanying object use might help to regulate the child’s emotional state (Español, 2007; Papôusek, 1996).

Are these differences (from a typical population) associated with possible variations of maraca use during preterm infants’ development?

We observed that the growing complexity of the infant’s interactions is related to the adult’s guidance and initiative. Despite a certain lack of symmetry in the interaction, with the caregiver sustaining the weight of the activity, the infant’s response is also a determinant of the interaction (Bruner, 1984). In this respect, it should be said that we saw preterm infants’ first object use at the third month of age when their reactions and their ability to manipulate objects increased. The most frequent object use is of the Attempt to Grasp type (CG), followed by the Grasp on the Adult’s initiative (AG).

It seems that the condition of moderate-late prematurity implies a certain delay in the assimilation of this type of use, contrasting with a typical population. In the selected triadic interactions recorded, only one preterm infant started to shake the maraca at t4 (see Appendices B and C, Tables B.1 and C.2, and Figure 4). However, in spontaneous interactions, it was observed that all preterm infants shook the maraca at t4. In contrast, 100% of full-term infants achieve this use in t4, which was present from the second month with a lower frequency (Moreno-Núñez et al., 2015).

Despite the one- or two-month delay, the infants’ participation increases progressively, while their parents’ participation diminishes, which coincides with a description of the typical population (Moreno-Núñez et al., 2015). Gradually, the initially most frequent use (Grasp on the Adult’s initiative—AG), in which the presence of the adult is notable, declines to give way to other categories, such as Attempt to Grasp (CG), Attempt to Grasp on own Initiative (CiG), or Shaking (S). The older the infant and the more active the joint action, the greater the concentration and the focus on the action and the more frequent the attentive looks and silences. The moments of sustained attention become accompanied by other, equally significant behaviors such as smiling, agitation, and vocalization (see Table 2).

The seven preterm infants analyzed increased their attentive looks in the last moment of monitoring (t4) (see Appendix I, Figure I.1), especially with familiar stimuli. Although this increase is notable, there is a certain delay with respect to the typical sample (Moreno-Núñez et al., 2015). Nonetheless, these results coincide with the results of prior studies pointing to the differences in cognitive performance between term infants and preterm infants without neurological alterations (Blanco et al., 2010; Sastre-Riba, 2009). The evolution of the infant’s attention is one of the factors that pave the way to accessing Immediate Hand Demonstrations (HD), a landmark in the construction of conventional object use. We can observe its precedents starting with the second month of life of these preterm infants. These uses might be considered the first intrinsically joint action, in which we glimpse a certain intention on the part of the child (Bates et al., 1975) of moving the hand with the use of the sonorous object. This interpretation contrasts with other theories that place this possibility in the 6th or the 12th month (Tomasello, 1999; Trevarthen, 1990).

This complex action (HD) introduces the conventional use of the infant’s hand with the action and intention borrowed from the adult, which allows for a quasi-conventional joint use. Despite this, there were fewer Hand Demonstrations (HD) than in the typical samples (Moreno-Núñez et al., 2015). These data give rise to the question regarding the causes of the preterm infant’s immaturity. In the first session, the parents showed unstructured uses and less synchronization with their infants compared to full-term infants (Moreno-Núñez et al., 2015, 2017). However, these differences were reduced by the third session (t4). Although our design cannot provide an answer, these analyses confirm our third hypothesis (see Figure 3). From what has been presented so far, the small delays that our preterm sample showed in the use of the maraca could be explained as variations from typical triadic interactions.

Limitations and future lines of research

The work carried out includes certain limitations. The qualitative analysis of these interactions made it possible to capture a great deal of detail about the first uses of a sound object by the premature infants studied. On the other hand, it involved a great deal of observation and follow-up time, and a great deal of effort on the part of the researchers and the families, especially given this condition of prematurity. All this increased the risk of experimental mortality All these conditions had the consequence of working with a small sample size. Although this is a thorough work, it is still a study close to “field formats” (Anguera, 2003) and its quantitative analyses have limited validity.

In this regard, the small sample of infants’ uses may explain the greater variation in the inter-rater coefficient, especially because the object uses were much shorter and more variable according to the particularity of each child and his or her context. Hence, the proposed categories taken from previous work would need to be revised to improve their level of reliability, and more data should be collected before generalizing on infants’ uses of the object at this age.

The non-participant observer model (Serra, 2004), chosen in order to respect the spontaneity of the families in their natural context, is at odds with the impossibility of the camera not interfering in the process (Campbell & Stanley, 1963/2002). Hence arises the question of the extent to which the inclusion of the appreciation of the observer as another category (as a participating observer) might give a deeper understanding of the situation (Bleger, 2011).

This suggests the need for further optimization of the study design, extending both the sample and its representative possibilities (especially in the age range taken for monitoring and its cultural variability).

Conclusion

The interactions employing objects are present earlier than what is suggested by the most accepted theories (Corbetta & Thelen, 1999; Liszkowski & Tomasello, 2007; Trevarthen, 1999), even in preterm infants.

Infants’ first interactions with the world are necessarily mediated by adults, as asserted by Vygotski (1984/1996), and following The Pragmatic View of the Object (Rodríguez & Moro, 1998a). The results introduce us to the process of the construction of semiotic “references” in the adult–child–sonorous object interaction. As the preterm infant develops and the triadic interaction progresses, the adult uses a greater range of semiotic systems to communicate with him/her about and through the object, initially without using symbols or symbolic gestures. Instead, they share the referent by using the object and through ostensive gestures. It has been observed how the parents of preterm infants use the sonorous objects in proximity to them. Progressively, they add more frequent pauses and promote the infants’ initiative. The rhythmic components of the triadic interaction (time / pauses / structure of the interaction sequence) favor the construction of these semiotic systems from the first months of life, which allows the communication between the adult and the infant (De León, 2020). The present work is an exploratory analysis that could give us some evidence to support further research. Our hypotheses need to be further tested in larger samples and the proposed variables need to be further analyzed in depth. We hope that future analysis of these patterns may allow early detection and intervention in cases of potential risk.

Supplemental Material

sj-docx-1-pom-10.1177_03057356231225673 – Supplemental material for Analysis of triadic interaction between parents, their preterm infants, and a sonorous object

Supplemental material, sj-docx-1-pom-10.1177_03057356231225673 for Analysis of triadic interaction between parents, their preterm infants, and a sonorous object by María Jánez-Álvarez, Iván Moreno-Llanos, Cristina Santacatalina-Pulido, Yinay José De León-Barrios, Eduardo García-Laredo, María Jesús Del Olmo-Barros and Cintia Rodríguez-Garrido in Psychology of Music

Footnotes

Acknowledgements

The authors would like to thank the following people and institutions for their cooperation with the study: the unit of La Paz Hospital (Madrid) where the study was conducted; Universidad Autónoma de Madrid (UAM); Instituto de Investigación Hospital La Paz, IDIPAZ (Madrid), Music Therapy and Health Foundation (Madrid), which provided guidance for the research; all the participants of the study.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

María Jánez-Álvarez

Supplemental material

Supplemental material for this article is available online.

Notes

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