Infant Behavior & Development 37 (2014) 131–154

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Infant Behavior and Development

Are parenting interventions effective in improving the relationship between mothers and their preterm infants? Tracey Evans a,b,c,∗ , Koa Whittingham a,b , Matthew Sanders e , Paul Colditz c,d , Roslyn N. Boyd a a Queensland Cerebral Palsy and Rehabilitation Research Centre, The School of Medicine, Faculty of Health Sciences, The University of Queensland, Australia b School of Psychology, Faculty of Social and Behavioral Sciences, The University of Queensland, Australia c Perinatal Research Centre, Royal Brisbane and Women’s Hospital, Brisbane, Australia d The University of Queensland Centre for Clinical Research, Royal Brisbane and Women’s Hospital, Brisbane, Australia e Parenting and Family Support Centre, The University of Queensland, Australia

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Article history: Received 2 July 2013 Received in revised form 27 November 2013 Accepted 29 December 2013 Available online 11 February 2014

Keywords: Mother–infant relationship Attachment Parenting intervention Preterm infant Prematurity

a b s t r a c t Aim: To systematically review the efficacy of parenting interventions in improving the quality of the relationship between mothers and preterm infants. Method: Randomized or quasi-randomized controlled trials (RCT) of parenting interventions for mothers of preterm infants where mother–infant relationship quality outcomes were reported. Databases searched: The Cochrane Library, PubMed, CINAHL, PsycINFO and Web of Science. Results: Seventeen studies met the inclusion criteria, 14 with strong methodological quality. Eight parenting interventions were found to improve the quality of the mother–preterm infant relationship. Conclusions: Heterogeneity of the interventions calls for an integrated new parenting program focusing on cue-based, responsive care from the mother to her preterm infant to improve the quality of the relationship for these mother–preterm infant dyads. © 2014 Elsevier Inc. All rights reserved.

1. Introduction 1.1. Preterm birth Globally, the average preterm birth rate is approximately 11% (Blencowe et al., 2012). For mothers, the preterm birth can generate feelings of guilt, helplessness, grief at the loss of the pregnancy, and anxiety and fear for their infant’s future (Goutaudier, Lopez, Séjourné, Denis, & Chabrol, 2011; Whittingham, Boyd, Sanders, & Colditz, 2013). Preterm birth is also associated with significant mortality and short and long term morbidity for the child, with increased prematurity leading to a greater health risk (Clark, Woodward, Horwood, & Moor, 2008; Greco et al., 2005; Laws & Hilder, 2008). Medical concerns can include lung dysfunction, chronic respiratory disease, seizure disorders, cerebral palsy (McCormick, McCarton, Tonascia, & Brooks-Gunn, 1993), deafness and blindness (Lorenz, Wooliever, Jetton, & Paneth, 1998).

∗ Corresponding author at: Perinatal Research Centre, The University of Queensland, Level 6, Ned Hanlon Building, Royal Brisbane & Women’s Hospital, Herston, QLD 4029, Australia. Tel.: +61 7 3636 1655. E-mail address: [email protected] (T. Evans). 0163-6383/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.infbeh.2013.12.009

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The medical condition of the infant can lead to the absence of close physical contact between the mother and the infant (Amankwaa, Pickler, & Boonmee, 2007). It may also find the mother withdrawing from her critically ill preterm infant to protect herself from disappointment, guilt and hurt (Miles, Holditch-Davis, & Burchinal, 1999). This can increase maternal depression and anxiety, and decrease maternal responsiveness (Amankwaa et al., 2007; Borghini et al., 2006; Fiese, Poehlmann, Irwin, Gordon, & Curry-Bleggi, 2001; Poehlmann & Fiese, 2001) increasing the risk for mother–preterm infant relationship difficulties (Amankwaa et al., 2007; George & Solomon, 2008; Korja et al., 2008; Miles et al., 1999). These difficulties can lead to both short-term (Borghini et al., 2006) and long-term problems (Tideman, Nilsson, Smith, & Stjernqvist, 2002). For mother–preterm infant dyads at the 9- and 18-year follow-ups, there were more feelings of anxiety and uncertainty about the dyad, and anxiety and separation difficulties, respectively (Tideman et al., 2002). 1.2. Mother–preterm infant relationship difficulties Mother–preterm infant dyads can be at higher risk of relationship difficulties than mother–full-term dyads (Borghini et al., 2006; Forcada-Guex, Pierrehumbert, Borghini, Moessinger, & Muller-Nix, 2006; Wille, 1991). Only 20 and then 30% of mothers of preterm infants had secure attachment representations at 6 and 12 months respectively following the birth compared to 53 and 57% in a term comparison group (Borghini et al., 2006). They were also less likely than mothers with full-term infants to have a cooperative dyadic pattern of interaction and demonstrate balanced representations of their infant when assessed with a videotaped play session and the Working Model of the Child Interview (Forcada-Guex et al., 2006). For preterm infants, only 44% were securely attached at 12 months ca compared to 83% of full term infants when assessed by the Strange Situation task (Wille, 1991). Other studies have found the distribution of maternal attachment classifications (Korja et al., 2009), infant attachment classifications (Pederson & Moran, 1996) and mother–infant attachment relationships (Pederson & Moran, 1995) did not differ between preterm and full-term groups. (Borghini et al., 2006; Forcada-Guex et al., 2006). A systematic review concluded similar results for all three categories (Korja, Latva, & Lehtonen, 2012). Of the 29 studies included in the review however, approximately half found maternal attachment representation difficulties, insecure infant attachment, or interactional behavior and affect differences for the mother–preterm infant dyads. Variables such as socioeconomic status, infant neurological impairment, and altered maternal representations due to the contrast between prenatal expectations and postnatal experience were cited as possible reasons for the disparity (Korja et al., 2012). Several other studies have also found socioeconomic status (Borghini et al., 2006; Wille, 1991), infant neurological impairment (Brisch, Bechinger, Betzler, & Heinemann, 2003) and the contrast between prenatal expectations and postnatal experience (Borghini et al., 2006; Evans, Whittingham, & Boyd, 2012; Korja et al., 2009) to have a negative impact on the quality of the mother–preterm infant relationship. A meta-analysis using the standardized Strange Situation task to assess infant attachment, also found the distribution of preterm attachment classifications to be similar to that of normal samples (IJzendoorn, Goldberg, Kroonenberg, & Frenkel, 1992). In contrast, there was a decrease in secure attachment and an increase in insecure ambivalent attachment for children whose mothers had maternal problems, including mental illness, maltreatment and being a teenage mother (IJzendoorn et al., 1992). Interestingly, mental illness (Brandon et al., 2011), maltreatment (Noll, Trickett, Harris, & Putnam, 2009) and being a teenage mother (Chen et al., 2010), have been found to be higher in mothers of preterm births compared to mothers of term births. Other maternal factors including unresolved grief (Shah, Clements, & Poehlmann, 2011) and decreased maternal responsiveness (Fuertes, Lopes-dos-Santos, Beeghly, & Tronick, 2009) following a preterm birth have also been related to insecure infant–mother attachment. This evidence suggests that infant attachment maybe affected by maternal rather than infant problems, and difficulties could be higher in preterm populations where these maternal problems exist. Focusing on maternal problems may therefore help improve attachment. 1.3. Parenting interventions Effective parenting interventions can increase maternal sensitivity which can increase infant attachment security (Bakermans-Kranenburg, Van Ijzendoorn, & Juffer, 2003). This can be explained through the transactional model, where the degree to which the preterm infant’s biological problems impacts upon development depend upon the infant’s caregiving environment (Sameroff & Chandler, 1975). Improving the infant’s caregiving environment through parenting interventions has been found to improve attachment and relationship outcomes for mother–preterm infant dyads (Kang et al., 1995; Newnham, Milgrom, & Skouteris, 2009; Pridham et al., 2005) 1.4. Infant development Improving the quality of the mother–preterm infant relationship can have consequences for the infant’s later development (Beckwith & Rodning, 1996; Forcada-Guex et al., 2006; Wijnroks, 1998). Decreased mother–preterm infant relationship quality predicted increased behavioral problems and decreased personal-social development at 18 months-of-age (ForcadaGuex et al., 2006). Alternatively, increased levels of maternal involvement predicted improved cognitive status at both 12

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and 24 months as assessed by the Bayley Scales of Infant Development (Wijnroks, 1998) and increased language skills at 3 years and problem solving at 5 years (Beckwith & Rodning, 1996). 1.5. Aims In the last 50 years, a decrease in preterm infant mortality has led to an increase in the number of mothers and their preterm infants who will be exposed to these attachment and relationship difficulties (Goldenberg & Rouse, 1998). Examining interventions which are effective in reducing these difficulties may lead to improved outcomes for these dyads. The primary aim of this paper was to systematically review the literature to determine the efficacy of parenting interventions in improving relationship outcomes between mothers and their preterm infants. The secondary aim was to identify at the post intervention assessment, if the delivery location, content, intensity, duration or delivery mode of these interventions determined which parenting interventions are most effective in improving relationship outcomes between mothers and their preterm infants. 2. Method 2.1. Literature search strategy This systematic review followed the guidelines of the Cochrane Review Group search strategy (Higgins, Green, & Collaboration, 2008). The following databases were comprehensively searched by two reviewers (TE and KW in the: Cochrane Library (1996–April 2013), PubMed (1951–April 2013), CINAHL (1982–April 2013), PsycINFO (1966–April 2013) and Web of Science (1900–April 2013). The search strategy comprised the following MESH headings or key words: (1) preterm infant or prematurity; (2) and parenting intervention OR parent education OR intervention OR parent intervention; (3) and attachment OR mother–infant interaction OR mother infant interaction OR parent–infant interaction OR parent infant interaction. 2.2. Selection criteria Studies had to meet the following inclusion criteria: (i) (ii) (iii) (iv) (v) (vi) (vii)

randomized control trials (RCT) or quasi-RCT; preterm infants born 37 weeks gestation; non-randomized studies, single case studies, observational studies; articles not addressing interventions or without a clear explanation of the intervention; studies that did not have a control group; studies without available means and standard deviations, standardized outcome measures or outcome measures not accessing attachment and/or the mother–infant relationship.

The result of the screening process to identify relevant articles is presented in Fig. 1. Note: Relationships can be measured in three ways, either as a dyad where the mother and the infant are assessed, or from the perspective of the mother, or from the perspective of the infant. All three have been included in this review. 2.3. Validity assessment Methodological quality assessment of included studies is reported according to the Physiotherapy Evidence Database (PEDro) Scale (Verhagen et al., 1998) (see Table 1). The scale assesses internal and external validity across 11 criteria. 2.4. Data extraction The information extracted from the studies included population characteristics and methods of included studies. The delivery location, content, intensity, duration and delivery mode of the intervention programs were tabulated. The variables

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Table 1 Methodological quality assessment of included studies – PEDro Scale. Study

1

2

3

4

5

6

7

8

9

10

11

Total

Brisch et al. (2003) Browne and Talmi (2005) Bustan and Sagi (1984) Cho et al. (2013) Glazebrook et al. (2007) Kaaresen et al. (2006) Kang et al. (1995) Meijssen et al. (2010) Meijssen et al. (2011) Melnyk et al. (2006) Meyer et al. (1994) Neu and Robinson (2010) Newnham et al. (2009) Parker-Loewen and Lytton (1987) Schroeder and Pridham (2006) Ravn et al. (2011) Zahr et al. (1992)

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

1 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 0

0 0 0 0 0 1 1 1 0 1 0 1 0 0 0 1 0

1 0 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0

0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1 1 1 0 1 0 1 1 1 1 1 1 1 1 1 1 1

0 1 0 0 1 1 1 0 1 1 1 0 1 1 1 0 0

1 0 0 0 0 1 0 0 0 1 0 1 0 0 1 1 0

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

7 6 4 4 6 8 7 6 6 8 6 7 6 7 8 7 4

Key: Scale of item score 0 = absent/unclear, 1 = present. The PEDro scale criteria are: (1) specification of eligibility criteria; (2) random allocation; (3) concealed allocation; (4) prognostic similarity at baseline; (5) subject blinding; (6) therapist blinding; (7) assessor blinding; (8) greater than 85% follow up of at least one key outcome; (9) intention to treat analysis; (10) between group statistical comparison for at least one key outcome; (11) point estimates and measures of variability provided for at least one key outcome.

and characteristics were extracted by the first author and checked by the second author. The authors discussed any uncertain variables and characteristics to reach agreement on included and excluded data. Means and standard deviations were extracted for continuous variables and the number of occurrences was extracted for categorical variables. 2.5. Quantitative data synthesis All studies reported results for the control and experimental groups. For continuous variables, the reported means and standard deviations for both groups were used to perform a t test to determine if there was a significant difference between the groups who received the parenting intervention compared to the control groups. For studies with two parenting interventions, each intervention group was compared to the control group, using each group’s mean, standard deviation and sample size to calculate a t test value (Browne & Talmi, 2005; Kang et al., 1995; Neu & Robinson, 2010). The mean difference, confidence intervals and effect sizes were also calculated. For categorical variables, a chi square test was performed. If studies reported data for more than one time-point, only post-intervention data was analyzed. It was the original intention of this review to conduct a meta-analysis of all the data using RevMan 5. The diversity of the methods used to measure outcomes meant a meta-analysis was only possible for three studies (Browne & Talmi, 2005; Glazebrook et al., 2007; Kang et al., 1995). Measures used included observation, self-report questionnaire, interview or a combination of these. Some of the measures using continuous variables provided an overall mean and standard deviation for each group, while others reported a mean and standard deviation for each discrete mother and/or infant behavior. The discrete behaviors measured varied between studies. Measures using a categorical variable reported the number of participants for each outcome. Studies using the same assessment measure, reported assessment times that varied. 3. Results Seventeen RCT’s (11) or quasi-RCT’s (6) met the inclusion criteria. Results were calculated on a total of 1940 participants, 987 in the experimental groups and 953 in the control groups (see Table 2). Fourteen of the 17 RCT’s were considered to have a high methodological rating with a PEDro score of ≥6 and were included in the final reporting. This included a total of 1817 participants, 927 in the experimental groups and 890 in the control groups. Of the 14 RCT’s, 14 different parenting interventions were identified, eight finding an improvement in the quality of the mother–preterm infant relationship. 3.1. Participants Two trials recruited only singleton births (Cho et al., 2013; Melnyk et al., 2006), two included first born infants (Bustan & Sagi, 1984; Neu & Robinson, 2010), one included only first born infants of the pregnancy (Brisch et al., 2003), and three excluded triplets (Kaaresen, Ronning, Ulvund, & Dahl, 2006; Meijssen et al., 2011; Newnham et al., 2009). Mothers who were randomized to the intervention group received a parenting program. All studies included preterm infants

Are parenting interventions effective in improving the relationship between mothers and their preterm infants?

To systematically review the efficacy of parenting interventions in improving the quality of the relationship between mothers and preterm infants...
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