Feasibility study of a preventive parenting program with mothers of children born preterm

Highlights

• This is the first feasibility study of ACT Program with target population of mothers of children born preterm.

• The ACT intervention enhanced positive parenting practices and reduced child behavioral problems.

• Two validated psychometric measures were used to evaluate parenting practices.

Abstract

Preterm infants constitute a high-risk population for presenting emotional and behavioral problems and developmental dysregulation. Parenting preventive interventions can support mothers to act as co-regulators and prevent child behavior problems. The ACT – Raising Safe Kids Program is recommended to strengthen positive parenting practices. The present study aimed to examine the feasibility of the ACT Program in a target sample of mothers of children born preterm, comparing parenting practices and child behavior problems at pre- and post-intervention. The sample consisted of 30 mothers of 1- to 7- year - old children born preterm. The mothers answered the ACT and Parenting and Family Adjustment scales, and the Strengthen and Difficulties Questionnaire, in the pre- and post-intervention. The within-group comparison was performed. The results showed that, after the intervention, there was a significant improvement in parenting practices dimensions of communication, emotional/behavioral regulation, monitoring of electronic media, positive encouragement, and parental consistency and adjustment. Also, the coercive practices decreased in the post-intervention. Furthermore, there was a decrease in child behavior problems and improvement in the pro-social behavior, from pre- to post-intervention. In conclusion, the ACT showed the feasibility to improve positive parenting practices, enabling mothers to act as a co-regulator of the behavior of children born preterm.

Introduction

Every year, an estimated 15 million infants are born preterm (<37 weeks of gestational age), and this number has been increasing worldwide (Liu et al., 2016). Preterm childbirth is a high-risk factor for neonatal mortality and morbidities on child development, demanding that this vulnerable population of preterm neonates stay hospitalized to receive intensive care support for survival.

Although being a relevant protective environment for preterm population, the Neonatal Intensive Care Unit (NICU) can be also considered as a “chaotic environment” (Evans & Wachs, 2010), since in this setting the preterm infants are exposed to a series of adverse events, such as invasive and painful procedures, lack of regularity in the routine, and disturbed contact with mothers (Linhares, Gaspardo, & Klein, 2012). Regarding the biological immaturity of the organism, the preterm infants are more sensitive to minimal stimuli, and they may present hyperactive and dysregulated responses to NICU stimuli (Als et al., 2004, Jones et al., 2013). The early stressor experiences of preterm infants influence the temperament (Klein, Gaspardo, Martinez, & Linhares, 2015), the physiological regulatory processes that underline subsequent emotional and behavioral regulatory processes (Feldman, 2009), and the behavior outcomes (Gaspardo, Cassiano, Gracioli, Furini, & Linhares, 2017).

Then, preterm childbirth is a high-risk factor to child emotional and behavioral problems, and developmental dysregulation (Dilworth-Bart, Poehlmann-Tynan, Taub, Liesen, & Bolt, 2018). In comparison to full-term counterparts, the preterm children were at-risk for behavioral problems in the first three years of age (Delobel-Ayoub et al., 2006), preschool age (Dilworth-Bart et al., 2018, Jones et al., 2013), and school-age (Treyvaud et al., 2013). Also, children born preterm were more likely to present criteria for the diagnosis of psychiatric disorders, including anxiety, attention deficit hyperactivity, and autism spectrum disorders at seven years of age (Treyvaud et al., 2013) and risk of Attention-Deficit/ Hyperactivity Disorder (ADHD) diagnosis and symptomatology (Franz et al., 2018).

Intervention programs that support mothers to act as co-regulator of children are essential, since they may contribute to neutralizing the negative impact of the risk factors that can trigger behavior problems (Linhares et al., 2012). The co-regulation refers to external regulation of emotions and behaviors of children by caregivers, contributing to their self-regulation process (Berger, 2011, Linhares and Martins, 2015). Usually, the programs to support mothers of preterm infants were developed targeting the neonatal phase (Borghini et al., 2014, Steinhardt et al., 2015, Castel et al., 2016) and the post-hospital discharge period (Cho et al., 2013, Flierman et al., 2016). In one hand, these studies showed positive results to reduce parental stress and improve parents‘ mental health status (Castel et al., 2016), depressive symptoms (Cho et al., 2013), and post-traumatic stress symptoms in mothers (Borghini et al., 2014). On the other hand, there were better maternal interactions (Cho et al., 2013), increasing maternal sensitivity and infant cooperation during interactions (Borghini et al., 2014), responsive interactions with consistency between parents and children (Flierman et al., 2016), and the quality of mother–child interaction positively correlated with the child neurodevelopment (Steinhardt et al., 2015).

A recent meta-review of systematic reviews studies showed consistently aggregate scientific evidence of the effectiveness of early intervention programs for parents of preterm infants at neonatal phase or immediately after discharge (Puthussery, Chutiyami, Tseng, Kilby, & 2018); the interventions presented positive impact mainly on maternal sensitivity and responsiveness on parent-child interactions, and decrease of parental anxiety, stress, and depressive symptoms. Additionally, a meta-analysis of preventive intervention programs, which were performed before the preterm child was age three years of corrected age, presented a broad, comprehensive finding of positive impact to reduce anxiety and depression and enhance self-efficacy of parents (Benzies, Magill-Evans, Hayden, & Ballantyne, 2013). The parenting style could impact on later development outcomes of preterm infants till school-age, showing that parental responsivity improved both child behavior and cognitive outcomes, and warmth improved specifically child behavior (Neel, Stark, & Maitre, 2018).

To date, as far as we know, studies examining the effectiveness of intervention programs for mothers of infants born preterm mainly targeted to enhance positive mother-child interactions and to protect mothers‘ mental health. Few intervention studies examined the parenting practices of mothers of preterm children at pre-school age. We detected only two studies of the same group of researchers using a clinical intervention with a therapeutic purpose. The Parent-child Interaction Therapy program was effective in improving parenting practices with less laxness, overactivity, verbosity and increased child compliance to maternal commands; otherwise, they decreased parent stress, and child internalizing and externalizing behavior problems, specifically, less attentional and aggressive problems (Bagner, Sheinkopt, Vohr, & Lester, 2010). Also, when they studied exclusively children born preterm with elevated externalizing behavior problems, there was a decrease of disruptive behaviors in pre-school children after the Parent-child interaction therapy program (Rodríguez, Bagner, & Graziano, 2014).

Regarding preventive parenting intervention programs for mothers of preterm children, the metanalysis review of randomized controlled trials (Herd, Whittingham, Sanders, Colditz, & Boyd, 2014) mentioned three programs that showed a positive effect in behavior of pre-school children: Infant Health and Development Program, Mother-Infant Transaction Program, and Victorian Infant Brain Studies. These programs focused on childcare and mother-child interactions, using mainly home-visiting strategies, and the duration varies from three months to three years. Otherwise, two studies of specific parenting practices using Primary Care Triple P did not show improvement in the quality of parent-child interaction and/or to decrease child behavioral problems (Schappin et al., 2013, Schappin et al., 2014).

Regarding other option of preventive parenting programs, the ACT – Raising Safe Kids (Silva, 2011), which is a group-based parenting intervention, in a universal approach, which was developed by the American Psychological Association (APA) aiming to enable families to create safe, stable, and healthy family environments to protect child development (Silva, 2011). The ACT is a program to strengthen positive parenting practices and prevent violence (Silva & Willians, 2015), improving parents‘ positive communication, emotional and behavior regulation, positive discipline, and electronic media monitoring (Altafim, McCoy, & Linhares, 2018). This program is a low-cost intervention, that can be incorporated into programs and services that already exist (Portwood, Lambert, Abrams, & Nelson, 2011), and has been previously implemented in high-, middle- and low-income countries (Howe et al., 2017).

The ACT program has been recommended twice by the World Health Organization (Hardcastle et al., 2015, World Health Organization, 2018) to prevent violence against children. The ACT program is also recognized by the Centers for Disease Control and Prevention, Division of Violence Prevention (Fortson, Kleven, Merrick, Gilbert, & Alexander, 2016) as a program that improves parental skills and promotes healthy child development, applied in both developed and developing countries (Howe et al., 2017). The program includes specific sessions about child development, inhibitory control, self-regulation, and anger management of parents and children, monitoring electronic media, positive discipline strategies, and violence prevention.

Three randomized controlled trials with the ACT program found improvements in more effective parenting with the increased use of positive practices, such as welcoming behavior, and reduction of negative practices (Altafim and Linhares, 2019, Knox et al., 2013, Portwood et al., 2011). The effectiveness of the ACT Program in improving parenting practices was also showed in another studies through designs with a control group without randomization (Burkhart et al., 2013, Knox et al., 2010, Knox et al., 2011) and with only an intervention group, with pre- and post-intervention assessments (Altafim et al., 2016, Knox and Burkhart, 2014, Pedro et al., 2017, Porter and Howe, 2008, Weymouth and Howe, 2011). Two of them also showed improving the monitoring of electronic media, knowledge about child development, anger management, and social problem solving (Weymouth and Howe, 2011, Porter and Howe, 2008). Other non-randomized studies also showed the effectiveness of the ACT program in reducing harsh parenting and increasing affective behavior (Knox and Burkhart, 2014, Porter and Howe, 2008), and reducing in children externalizing behavior problems (Knox and Burkhart, 2014, Knox et al., 2011) and bullying behavior (Burkhart et al., 2013). The effectiveness of the ACT Program to improve parenting practices and child behavior was also confirmed in a developing country, in community non-referred samples of different socioeconomic levels (Altafim et al., 2016, Pedro et al., 2017, Altafim and Linhares, 2019).

However, we detected that there are still gaps in the literature. First, to our knowledge, there are no conclusive results about the effectiveness of a group-based universal preventive intervention to improve parenting practices of mothers of children born preterm at pre-school-age. Second, to date, there is no study evaluating the feasibility of the ACT program in a target population of mothers of children born preterm. The feasibility studies with a small number of children and caregivers have the purpose of shown preliminary evidence of the intervention theory of change and identifying targeted populations that will be most likely to benefit from the program (Schindler, Fisher, & Shonkoff, 2017). Therefore, a feasibility study with a specific population of mothers of preterm children could add new findings to the literature, as well as verifying the need for adaptations.

The present study aimed to examine the feasibility of the ACT - Raising Safe Kids Program to strengthen positive parenting practices in a target sample of mothers of children born preterm, through comparison the parenting practices and child behavior before and after the intervention. It is important to note that this is the first study using the ACT program in a vulnerable preterm population.

The current study hypothesized is that the ACT intervention program would be effective for improving the mothers‘ positive parenting practices and decreasing child behavior problems, when compared pre- and post-intervention moments. The theory of change is that the ACT program will improve parenting practices of mothers of preterm children (main target), from pre- to post-intervention. We also expected positive changes in child behavior outcomes.