Supporting Parents: Can Intervention Improve Parent ...

JFN, May 2001, Letourneau et al. Vol. / Supporting 7 No. 2 Parents

Supporting Parents: Can Intervention Improve Parent-Child Relationships?

Nicole Letourneau, Ph.D., R.N. Jane Drummond, Ph.D., R.N. Darcy Fleming, M.Ed. Gerard Kysela, Ph.D., C. Psych. Linda McDonald, Ph.D., C. Psych. Miriam Stewart, Ph.D., R.N. University of Alberta Healthy child development has been identified as one of the key determinants of health and resiliency in adulthood. This article reports on the results of two pilot studies of randomized controlled trials of parent support interventions aimed at improving the parent-child relationship and indirectly enhancing the resilience capacity among at-risk children. Participating children were at risk for mental health problems due to poverty and/or their parents’ lack of educational attainment, inexperience, and young age. The interventions were composed of parenting skills training and social support. Eighteen families participated in Supportive Intervention I, and 34 families participated in Supportive Intervention II. Results suggested that parent-child relationships were enhanced in both pilot studies. These promising findings offer direction for future research and for nurses and other interventionists providing support to young at-risk families. Healthy child development has been identified as one of the key determinants of health and resilience in adulthood (Hamilton & For Pilot Study I, funding was received from the Canadian Nurses Foundation, the Sick Children’s Hospital Foundation, the National Health Research and Development Program, the Alberta Heritage Foundation for JOURNAL OF FAMILY NURSING, 2001, 7(2), 159-187 © 2001 Sage Publications, Inc. 159

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JFN, May 2001, Vol. 7 No. 2

Bhatti, 1996; Stewart, Reid, & Mangham, 1997). Healthy child development is believed to be affected by the quality of the parent-child relationship (Garcia Coll & Meyer, 1993; Ladd & LeSieur, 1995; Lyons-Ruth & Zeanah, 1993; Sternberg & Williams, 1995). In this article, the results of two pilot studies of parent support interventions aimed at increasing the quality of parent-child relationships are reported. The children studied are at risk for mental health problems due to poverty and/or their parents’ lack of educational attainment, inexperience, and young age.

VULNERABLE CHILDREN AND THEIR FAMILIES

Poverty, lack of education, adolescent parenthood, and single-parent status are significant challenges to children’s successful development. In Canada, 21% of children live in poverty (Canadian Council on Social Development, 1998; National Council on Welfare, 1999). Poverty rates for single-parent mothers and their children remain high. In 1997, the overall poverty rate for single-parent mothers was 57.1%, and the rate for families led by mothers younger than 25 was 93.3% (National Council on Welfare, 1999). Low socioeconomic status is often accompanied by high levels of stress, social isolation, a lack of personal and structural supports, low self-esteem, depression, substance use, poor nutrition, abuse or disruptive family environments, and a myriad of other personal and interpersonal risk factors (Bartko & Sameroff, 1995; Dunst, 1993; Dunst & Trivette, 1990; Garmezy, 1991). Multiple risk factors are particularly hazardous because their effects are synergistic rather than simply additive. Researchers have concluded that combinations of risk factors in the child’s background rather than the presence of any particular risk factor increases the like-

Medical Research, and the Alberta Association of Registered Nurses. For Pilot Study II, funding was received from Health Canada’s Children’s Mental Health Unit, the National Health Research and Development Program, the Alberta Heritage Foundation for Medical Research, and the Glenrose Rehabilitation Hospital Researcher-in-Residence Grant. All are gratefully acknowledged. Address all correspondence to Nicole Letourneau, Ph.D., R.N., Faculty of Nursing and Centre for Health Promotion Studies, 5-10 University Extension Centre, 8303-112th Street, University of Alberta, Edmonton, AB, T6G 2T4; e-mail: [email protected].


Letourneau et al. / Supporting Parents

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lihood of negative child outcomes (Bartko & Sameroff, 1995; Dunst, 1993; Dunst & Trivette, 1990; Pellegrini, 1990; Sameroff, Seifer, Barocas, Zax, & Greenspan, 1987). As an example, the “dual developmental crisis” of adolescence (Sadler & Catrone, 1983, p. 100) in combination with premature parenthood (Ketterlinus, Lamb, & Nitz, 1991) places the children of adolescents at risk for less than optimal child development. The developmental trajectories of adolescents’ children are further complicated by the prevalence of poverty and early termination of formal schooling by their parents (Buchholz & KornBursztyn, 1993; Hayes, 1987; Maynard, 1997; Wilkins, Sherman, & Best, 1991). Children reared in these risk conditions have more developmental challenges than children who are reared in families without these risks. They are more likely than children without these risk conditions to exhibit deficits in cognitive development, poor school performance, behavioral problems, poor social skills, and troubled peer relationships (Coley & Chase-Lansdale, 1998; Maynard, 1997; Moore, Morrison, & Greene, 1997; Werner, 1994).

PARENT-CHILD RELATIONSHIPS

Mental health and developmental difficulties experienced by vulnerable children may be influenced by the quality of early interactions that the children as infants have with their parents. Most studies have focused on mother-infant interaction (Brooks-Gunn & Chase-Lansdale, 1995; Censullo, 1994; Landy & Tam, 1998; Shore, 1997; Wakschlag & Hans, 1999; Wendland-Carro, Piccinini, & Millar, 1999). Mothers in highly stressed conditions are less sensitive to infant cues, more unrealistic about expectations of infant behavior, less verbal and responsive toward the infant, more impatient, and more prone to use physical punishment (Barnard, 1997; Maynard, 1997; Ruff, 1987; Sumner & Spietz, 1995a; vonWindeguth & Urbano, 1989). These maternal behaviors threaten children’s developmental health. When vulnerable children achieve long-term developmental health, they are characterized as resilient (Landy & Tam, 1998; Werner, 1994). Resilience has been described as “a process or capacity that develops over time in the context of person-environment interactions” (Egeland, Carlson, & Sroufe, 1993, p. 517). People who exhibit resilience cope under adverse conditions and more readily achieve and maintain developmental milestones.


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High-quality parent-child interactions are characterized by mutual warmth, sensitivity, and responsiveness (Barnard et al., 1989). When infants are reared in a warm, sensitive, and responsive caregiving environment, they are more likely to use their parents as a secure base for exploring their environments (Ainsworth & Bell, 1974; Goldberg, 1977, 1990). Such exploration fosters cognitive and social skill development (Ainsworth & Bell, 1974; Letourneau, 1997; McCain & Mustard, 1999; Shore, 1997). Early parent-infant interactive experiences are linked to children’s later IQ (McCain & Mustard, 1999; Sternberg & Williams, 1995) and may provide the model for later peer relationships (Coates & Lewis, 1984; Farel, Freeman, Keenan, & Huber, 1991; McCain & Mustard, 1999; Schaefer & Edgarton, 1985). In high-quality interactions, children send clear cues about their needs and wants while parents must be sensitive and respond to children’s needs. When these social interactions are mutual, they are referred to as being contingently responsive: The behavior of one evokes the appropriate response of the other. Contingent responsiveness between parent and child promotes healthy social interactions that foster children’s successful development or resilience (Barnard, 1997; Sumner & Spietz, 1995a). Parents in highly stressed situations have been observed to display noncontingent interaction styles. A recent evaluation study of the interaction styles of low-income mothers found that 66% (n = 41) were insufficiently contingent to support their children’s optimal development (Drummond & Kysela, 1999). Studies of Romanian institutionalized children and studies using contemporary medical imaging techniques have also linked noncontingent interaction styles with altered mental development and delayed neurological development (Ames, 1997; Bertrand, 1997; Carnegie Corporation, 1994; McCain & Mustard, 1999).

FAMILY FUNCTIONING

Parents who are contingently responsive may provide a rewarding environment that increases the likelihood that children will positively engage their parents in interactions (Kochanska, 1997; Kochanska, Tjebkes, & Forman, 1998; van den Boom, 1994). Parents may enjoy their experiences with their children more, thereby contributing to



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improved family functioning and cohesion (Kochanska, 1997; Maccoby, 1992). In turn, both higher family cohesion (Duis, Summers, & Summers, 1997) and higher quality parent-child interaction (Barnard, Morisset, & Spieker, 1993) have been found to be strong predictors of lower family stress levels.

SUPPORTING PARENTING CAPACITIES

Researchers point to the relationship between support for child-rearing families and the developmental health of children (Barnard et al., 1993; Olds & Kitzman, 1990; Olds et al., 1998; Reynolds, Mavrogenes, Bezruczko, & Hagemann, 1996; Roberts, 1996). Parenting capacity is partly based on the parent’s adult relationships because within these relationships comes the social support necessary to maintain the demanding role of parenting a child (Barnard et al., 1993). Children’s cognitive and peer competence have been linked to characteristics of the maternal support network (Melson, Ladd, & Hsu, 1993). As a result, intervention programs should not neglect the cultural and ecological context of the family’s environment (Ramey & Ramey, 1998). Attrition from parenting intervention programs may be reduced when participants’ emotional and instrumental support needs are addressed (Navaie-Waliser et al., 2000). Optimal support interventions are oriented to support processes and outcomes. Support processes include providing practical assistance, positive role models, and emotional, informational, and affirmational support. Outcomes include parents’ increased understanding of children’s physical and emotional needs and reduced family isolation (Darmstadt, 1990; Stewart, 2000). Support mechanisms help parents develop realistic expectations of child development, improve the quality of parent-child interactions, and significantly reduce family stress (Dinnebeil, 1999; Mahoney & Kaiser, 1999). Consequently, parenting skills are an important and necessary component of any family support intervention. Family support interventions include “information, advice, guidance, parent education . . . that strengthen and promote the knowledge and skills of parents to provide their children with development-instigating and development-enhancing learning opportunities” (Dunst, 1999, pp. 145-146). Two pilot studies were conducted to compare the effects of the following two types of social support for families on parent-child


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relationships: (a) support with extensive and intense parent training and (b) support without extensive and intense parent training. Support Intervention Pilot I provided support to adolescent parents in the newborn period and Support Intervention Pilot II provided support to other at-risk parents (e.g., low-income, low educational attainment, and single-parent status) of 3- to 4-year-old children identified as having developmental delays. In both studies, written consent to participate was obtained before random assignment to either the intervention or comparison group.

SUPPORT INTERVENTION I: KEYS TO CAREGIVING Research Question and Hypotheses

What is the effect of the supportive intervention for parents (Keys to Caregiving) on parent and infant interactive behaviors? It was hypothesized that the intervention group parents would be more sensitive to infant cues, more responsive to distress, provide more cognitive growth fostering, and more social-emotional growth-fostering activities than comparison parents. It was also hypothesized that the intervention group infants would give clearer cues and be more responsive to their parents than the comparison group infants. Sample

Twenty-four mothers were originally recruited, and 18 completed one of the two follow-up sessions. Of those, 15 completed data collection at 7 to 9 weeks of infant age, and 16 completed data collection at 11 to 13 weeks of infant age. Completing mothers were first-time, inexperienced primary caregivers, aged 16 to 19.8 years (M = 18, SD = 1). All reported low socioeconomic status according to the Hollingshead (1965) index, and 50% were partnered. Average educational attainment was grade 10 (SD = 1.32). All experienced an uneventful postpartum recovery and were not known to have abused illegal substances or alcohol during pregnancy. Mothers were English speaking and able to understand the information letter and to sign the consent form. All were Caucasian except for 4 first nations mother-infant pairs. All resided in the greater metropolitan area of a large western Canadian city. Infants were singleton births, weighing between 2,590



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and 3,960 grams at birth (M = 3221, SD = 383) and were 37.5 to 41.3 weeks gestational age (M = 39.4, SD = 1) with no apparent major difficulties at birth. All but 1 infant were discharged from the hospital within 3 days of birth. One infant was kept in the hospital for observation for 8 days due to benign heart arrhythmias and oxygen desaturations following birth and then discharged following an unremarkable stay. All infants progressed normally during the course of the study. Method

A posttest-only experimental design was used. Families were randomly assigned to either the intervention or comparison group following receipt of written consent to participate. The intervention group received the Keys to Caregiving program (Nursing Child Assessment Satellite Training, 1990). The program is designed to promote high-quality parent-infant interaction and contingent responsiveness through improving parents’ understanding of infant behaviors, cues, and needs. The program is designed to gradually introduce parents to five concepts that together provide the tools necessary for parents to have high-quality interactions with their infants. Parents learn about (a) infant states, (b) infant behavior, (c) infant cues, (d) how to modulate states, and (e) interacting during feeding. The intervention began when parents and their infants were discharged home in the first week postpartum. They received six weekly home visits in total, one visit per topic and a final visit for review and reinforcement. Outcomes were measured at 7 to 9 weeks and 11 to 13 weeks of infant age. A master’s-prepared pediatric nurse delivered the intervention program after completing 12 hours of self-study in the Keys to Caregiving program. The nurse-interventionist prepared and followed a detailed intervention protocol manual for the duration of the study. A family-centered approach was emphasized in the program training and implementation. This approach is designed to foster sensitivity to parents’ individuality, strengths, and ethnic differences (Dunst & Deal, 1994; Shelton, Jeppson, & Johnson, 1987). To enable examination of the integrity of intervention delivery, two sessions on each Keys to Caregiving topic were audio recorded, and field notes were compiled following each session. During each visit, parents were provided with a Keys to Caregiving pamphlet that related to one of the five program topics. The parent and interventionist discussed


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the concepts in the pamphlets and applied them to the adolescent’s new infant. A brief video was shown of babies exhibiting similar and different behaviors than those observed in the parent’s new infant. Parents were encouraged to relate examples of the behaviors discussed to their own infants. By drawing from parents’ own experiences, the interventionist was able to tailor the program to meet individual families’ needs and differences. As parents proceeded through the intervention program and continued to build on their knowledge, they learned when and how to interact with their infants in optimal ways. Comparison group families received home visits on the same schedule as the intervention families. Both intervention and comparison groups received social support from the nurse-interventionist. Examples of social support consisted of information about needed resources (informational support), affirmation and appropriate reinforcement of parent’s perspectives or behaviors (affirmational support), and listening and responding to parents (emotional support). Instruments

Demographic data and descriptive data were collected to ensure equivalency of groups. Two outcome measures of parent-child interaction were administered. Detailed reporting of subscale measures of parent-child relationships are provided here, and results of additional outcome measures are reported elsewhere (Letourneau, 2000, in press-b). Nursing Child Assessment Feeding and Teaching Scales (Sumner & Spietz, 1995a, 1995b). The Feeding and Teaching Scales are the most widely used measures of parent-infant interactions and may be used to assess parental sensitivity to cues (Subscale 1), responsiveness to distress (Subscale 2), social-emotional growth fostering activities (Subscale 3), and cognitive growth fostering activities (Subscale 4) toward their infant. The scales also provide a measure of infant clarity of cues (Subscale 5) and responsiveness to parent (Subscale 6). The Feeding and Teaching Scales are observational binary measures consisting, respectively, of 76 and 73 behavioral items. The scales provide two conceptually parallel descriptions of social interaction between parents and infants. Normative data are available as both scales have been administered to large samples of children younger than 1 year of age (Sumner &



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Spietz, 1995a, 1995b). It has been repeatedly demonstrated that the measures are predictive of later relationships and behavior related to successful outcomes in children, including IQ (Barnard, 1995a, 1995b). Tenth-percentile cutoff scores, indicative of clinically relevant or “worrisome” interactions, are reported in the literature. If these were observed, the parent and infant were referred to an appropriate health professional. Mothers and babies returned to the hospital for videotaping during feeding and play sessions when they were 7 to 9 weeks and 11 to 13 weeks old. A coinvestigator, who is a certified instructor, taught one data coder, blind to participants’ group assignments, to score the videotaped data according to the Feeding and Teaching Scales protocols. The data coder achieved a reliability of ≥ 90% for coding. The reliable coder recoded six randomly selected tapes of the complete set of 31 tapes as an intrarater reliability check. The mean intrarater reliability was 95% for the Feeding Scale and 94% for the Teaching Scale. Analysis

As this was a pilot study, a small sample size was recruited and retained. The small sample size poses limitations to assessment of normality of data before statistical analysis. As well, the outcome subscale measures are dependent as they arise from the same validated instruments. In other words, coded behaviors are not exclusive to a particular subscale. For example, eye contact, touch, and smiling may be coded in multiple subscales. Interdependence of study measures makes it difficult to obtain meaningful interpretations of significance tests and increases the likelihood of Type I error. As a result, significance testing was not conducted. Nonetheless, meaningful interpretations may be derived from these pilot data. Descriptive statistics are reported here. Effect size calculations were also conducted to determine the strength of the intervention. This evidence was sought for both clinical and exploratory purposes. The effect size calculations used pooled standard deviation terms. Results

There were no significant differences between groups on any of the demographic or descriptive variables examined, including gestational age, birth weight, educational level, age, partner status, ethnicity, socioeconomic status, depression, or life stress. Participants who


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dropped out before follow-up measurement were compared with those who remained for follow-up. No significant differences were found, although this may be attributable to the limited amount of data available for comparison (Letourneau, in press-a). Tables 1 and 2 record the descriptive statistics for the intervention and comparison groups at each time point on the feeding and teaching subscales, respectively. Of 24 comparisons made, 21 revealed that the intervention group had better outcome scores than the comparison group. All 16 comparisons of parents’ behaviors indicated that the intervention parents had better outcome scores than the comparison parents (sensitivity to cues, responsiveness to distress, social-emotional growth fostering, and cognitive growth fostering). These proportions are well above what should have occurred by chance. Three cases of comparison group scores exceeding intervention scores were in the subscales that describe the infant’s influence on the interaction (Clarity of Cues and Responsiveness to Caregiver subscales). This is not surprising as the intervention focus was on the parents. Effect sizes are reported in Tables 3 and 4. Large effect sizes greater than .8 are noted for 11 of 16 comparisons in the subscales relating to parental behavior change, suggesting mean change scores approaching 1 standard deviation were achieved for most subscale measures.

SUPPORT INTERVENTION II: NATURAL TEACHING STRATEGIES Research Question and Hypotheses

What is the effect of the supportive intervention (Natural Teaching Strategies) on parent and child interactive behaviors? It was hypothesized that postintervention, the intervention group parents would initiate parent-child interactions less than the comparison group parents, have fewer nonengaged behaviors in interactions, be more responsive in interactions, and provide more praise in interactions. Postintervention, it was hypothesized that the intervention group children would initiate more in interactions with their parents, demonstrate fewer responses in interactions, and demonstrate fewer nonengaged behaviors in interactions. Finally, it was hypothesized that intervention parents and children would engage in longer turn-taking sequences than the comparison group parents and children.


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0.95 0.49 0.90 1.25 1.11 1.62

7.71 12.29 7.43

SD

0.47 0.42 0.61

0.36 0.18 0.34

SE

Intervention

14.71 10.29 12.14

M

7 7 7

7 7 7

n

6.00 11.75 6.38

13.25 9.50 10.50

M

7 to 9 Weeks

2.51 1.67 1.41

1.67 1.20 1.93

SD

0.89 0.59 0.50

0.59 0.42 0.68

SE

Comparison

8 8 8

8 8 8

n

7.38 11.50 6.50

14.00 9.75 11.75

M

Feeding Scale Means of Intervention and Comparison Group Over Time

0.92 1.60 2.45

1.20 0.71 0.71

SD

0.32 0.57 0.87

0.42 0.25 0.25

SE

Intervention

Note: SS = subscale. Cases where the comparison mean exceeds the intervention mean are bolded.

Parent SS1 SS2 SS3 Child SS4 SS5 SS6

Table 1:

8 8 8

8 8 8

n

5.63 12.00 6.88

12.88 9.13 10.25

M

11 to 13 Weeks

1.85 1.31 1.64

1.36 1.25 1.83

SD

0.65 0.46 0.58

0.48 0.44 0.65

SE

Comparison

8 8 8

8 8 8

n

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0.95 0.95 1.57 3.24 2.61 1.62

8.14 5.86 8.43

SD

1.22 0.99 0.61

0.36 0.36 0.59

SE

Intervention

9.71 10.29 9.14

M

7 7 7

7 7 7

n

7.00 6.00 8.00

8.38 9.50 7.63

M

7 to 9 Weeks

3.21 2.39 2.39

1.60 1.41 1.85

SD

1.13 0.85 0.85

0.56 0.50 0.65

SE

Comparison

8 8 8

8 8 8

n

10.25 8.00 9.88

8.75 9.75 8.50

M

Teaching Scale Means of Intervention and Comparison Group Over Time

2.38 1.31 1.55

1.04 2.38 1.20

SD

0.84 0.46 0.55

0.37 0.84 0.42

SE

Intervention

Note: SS = subscale. Cases where the comparison mean exceeds the intervention mean are bolded.

Parent SS1 SS2 SS3 Child SS4 SS5 SS6

Table 2:

8 8 8

8 8 8

n

7.00 5.88 8.63

8.00 8.75 8.13

M

11 to 13 Weeks

3.78 2.03 2.33

2.00 1.83 1.13

SD

1.34 0.72 0.82

0.71 0.65 0.40

SE

Comparison

8 8 8

8 8 8

n

Letourneau et al. / Supporting Parents Table 3:

Feeding Scale Effect Sizes at 7 to 9 Weeks and 11 to 13 Weeks

Subscale Parent SS1: Sensitivity to Cues SS2: Response to Distress SS3: Socio-Emotional Growth SS4: Cognitive Growth Infant SS5: Clarity of Cues SS6: Responsiveness to Caregiver

Table 4:

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7 to 9 Weeks

11 to 13 Weeks

1.07 0.86 1.09 0.86

0.87 0.61 1.08 1.19

0.38 0.69

— —

Teaching Scale Effect Sizes at 7 to 9 Weeks and 11 to 13 Weeks

Subscale Parent SS1: Sensitivity to Cues SS2: Response to Distress SS3: Socio-Emotional Growth SS4: Cognitive Growth Infant SS5: Clarity of Cues SS6: Responsiveness to Caregiver

7 to 9 Weeks

11 to 13 Weeks

1.02 0.66 0.88 0.35

0.47 0.45 0.32 1.03

— 0.21

1.24 0.63

Sample

The original sample consisted of 34 families of 3- to 4-year-old at-risk children enrolled in Head Start. This pilot study was conducted within a larger Child and Family Resiliency Project (Drummond, Kysela, McDonald, Alexander, & Fleming, 1997). Participation numbers fluctuated due to family moves and changes in family circumstances. Thirty-four families participated in the baseline period and 29 families at the 6-month posttest. Only families for which there are complete data (n = 29) are presented here. All families received a $100 acknowledgement and had access to free weekly child care. Participants who received the Natural Teaching Strategies intervention during the first 6 months of the larger study (n = 9) and the comparison group (n = 20) are included in the present report. All participating families had a preschool child enrolled in Head Start in a


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large western Canadian city. To qualify for inclusion in the study, children had a 6-month or more delay in two or more developmental areas (cognitive, social, and/or behavioral). As well, the families had two or more of the following risk factors: education less than grade 10, family income less than $20,000, divorced or lone parent, and unemployed. Of the female adult respondents, 25 were mothers, 2 were the child’s grandmother, and 2 did not specify their relationship to the child. Of the 20 male respondents, 12 identified themselves as the father, and 8 identified themselves as partners. The female caregivers in the families had a mean age of 29 years (range = 21 to 52 years), and the male respondents had a mean age of 31 years (range = 22 to 44 years). There were 10 married partnerships, 5 common-law relationships, and 10 families headed by either a divorced, separated, or single person. Four families had no report on partnership status. Gross family income was generally below the poverty line: 23 families reported a gross income less than $20,000, and 2 families considered their income to be under $30,000 (4 families did not report their gross family income). Ethnicity data were not collected; however, 6 families reported using English as a second language. Fifteen of the female respondents reported less than a high school education, 11 had completed high school, and 1 identified some college training. Of the male respondents, 5 had less than high school, 10 had completed high school, and 3 had some college training. The mean age of the children in the study at baseline was 50 months (SD = 4.6). Of the study children, 21 were girls, and 8 were boys. Design and Method

A pretest/posttest experimental design was used. Intervention families received Head Start and the Natural Teaching Strategies (McDonald, Kysela, Alexander, & Drummond, 1996) intervention, and comparison families received only Head Start. The Head Start program in this study had three primary components: a school readiness program, weekly parent group meetings, and monthly home visitation by Head Start outreach workers (M. Craig, personal communication, June 22, 2000; Webster-Stratton, 1998). The parent groups and outreach workers provided families with informational, affirmational, and emotional support. The skills taught in Natural Teaching Strategies are natural in the sense that most parents have used the techniques at one time or



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another without prompting in their everyday activities. The program consists of the following five topics: (a) Following Your Child’s Lead: Turn Taking Through Imitation, (b) Keeping the Action Going, (c) Expansion—Adding Something More, (d) Incidental Teaching, and (e) A New Look at Challenging Behavior. Together, parents and interventionists work on ways to make the most of time spent with their children by establishing effective, enjoyable, and mutually satisfying methods of communicating with their preschoolers. Interventionists were master’s students in educational psychology with a special education focus. Before implementing Natural Teaching Strategies, the students were trained to implement Natural Teaching Strategies over 15 days of instruction and coaching. As with the Keys to Caregiving support intervention, a family-centered approach was used throughout training and implementation to maximize interventionists’ sensitivity to families’ strengths, individuality, and ethnicity (Dunst & Deal, 1994; Shelton et al., 1987). Ongoing debriefing sessions among the investigators and interventionists were held every 2 weeks for the duration of the study to monitor the integrity of the intervention and to problem solve challenging family situations. As well, interventionists were required to make field notes following home visits about family responsiveness to intervention, families’ questions, and any issues or problems for discussion at debriefing sessions. Parents and interventionists devoted two home visit sessions to each topic. Visits were conducted on a biweekly basis. Parents were provided with a Natural Teaching Strategies manual that closely resembled the interventionists’ manuals but without the instructions for the interventionists. Parents and interventionists worked through the material each week. Parents were asked to complete very small homework assignments that documented parents’ application of the program content to their everyday interactions with their preschoolers. This provided a context for subsequent sessions. Instruments

Demographic and descriptive data were collected to examine the equivalency of groups with respect to variables that could affect parent-child relationships. The Preschool-Parent Interactive Behavior (PPIB) Coding System was the outcome measure and was conducted at the baseline pretest and 6-month posttest.


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The Preschool-Parent Interactive Behavior Coding System (Fleming, 2000; Hemmeter & Kaiser, 1994, personal communication, July 1995). Parent-child interactions were videotaped during two 15-minute episodes of play in the families’ homes. From each videotape, one randomly selected 3-minute section was analyzed using the PPIB Coding System. The coding system involves continuous observations in which each parent and child behavior is coded from videotape. Behaviors are coded into the following four types: (a) initiations, (b) responses, (c) nonengaged, and (d) turn taking for both parents and children. A subcategory of parental response behaviors quantified the amount of parental praise. Examples of parent initiations include giving instructions, recruiting child’s attention, and providing prompts. Examples of child initiations include verbal and nonverbal requests. Examples of parent responses include repeating, mirroring behaviors, providing praise, and following the child’s lead. Child responses are coded according to the dimensions of correctness, relatedness, clarity, and originality. Nonengaged behaviors of the parents were unintelligible remarks, comments, and failing to respond. Nonengaged behaviors of children included verbal and nonverbal indicators of disinterest in interaction. Turn taking was coded as the number and duration of engagements and the number of reciprocal turns within 3 minutes of coded interaction. Percentages were calculated from frequencies of adult or child behaviors. Calculating coefficients of agreements was the method employed for estimating reliability (Sulzer-Azaroff & Mayer, 1977). The following formula was used: [Number of agreements / (number of agreements + disagreements)] × 100. Agreement was recorded when both observers coded a behavior in the same way, and disagreement was recorded when the two observers differed in their categorizations of a behavior. Coding of the study data did not begin until the two coders received a minimum of 80% agreement on three successive 30-second segments on three different videotapes. Reliability was reassessed every 4 days. Ongoing reliability assessments revealed agreements ranging from 74% to 98% (M = 89%, 31 observations). Analysis

Three levels of analysis were used. First, all hypotheses were tested using repeated measures analysis of variance. Second, when no sig-



175

nificant repeated measures interactions were found, independent sample t tests were used to compare the means of the two groups at one time. As all of the hypotheses are directional, one-tailed t tests were used. In contrast to Intervention I, inferential statistics are appropriate given the independence of coded behaviors on the PPIB Coding System. Third, treatment effect sizes were calculated. The standard deviation of the comparison group was used to determine the effect of intervention. Results

Intervention and comparison groups did not differ significantly on any of the demographic or descriptive characteristics at baseline, including education level, income, partner status, English as a second language, children’s cognitive functioning, or family functioning. Families with boys had a higher rate of attrition (27.3%) than families with girls (12.5%). Otherwise, no meaningful differences were noted between families who completed the study and those who did not. Means and standard deviations for parent and child behaviors are presented in Table 5. Parent behavior. Although the interaction for the repeated measures was not significant, parents in the intervention group performed significantly fewer initiations than the comparison group at 6 months (t = 2.56, p = .008). In other words, parents were less directive in their interactions with their children as a consequence of this intervention. The effect size for the intervention group was 1.09, suggesting that individuals in the Natural Teaching Strategies group had a mean change score greater than 1 standard deviation. A significant time by treatment interaction (F = 4.5, p = .022) was observed in parent responses. Furthermore, parents in the intervention group made significantly more responses than the comparison group (t = –2.64, p = .018, unequal variances). In short, intervention parents responded more to their children at 6 months than the control group parents. The effect size for the Natural Teaching Strategies group was 1.83, suggesting that individuals in the intervention group had a mean change score of almost 2 standard deviations. Although there were no significant differences between groups with respect to nonengaged behaviors, there was significantly more variability in the proportion of adult nonengaged behaviors in the intervention group than in the comparison group. The effect size for


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14.2 12.7 13.2 1.3 8.5 22.6 21.1

4.5

24.2

10.8 47.1 42.1

13.9

40.4

SD

Intervention

48.0 34.2 17.7 0.83

M

8

8

9 9 9

9 9 9 9

n

68.4

28.0

11.0 45.1 43.9

33.9

20.2

7.3 13.1 13.1

14.8 13.8 7.0 2.0

SD

Comparison

47.8 32.6 19.6 1.88

M

Baseline Pretest

20

20

20 20 20

20 20 20 20

n

62.0

24.9

24.5 38.67 36.8

24.9

23.1

12.0 14.3 12.4

14.4 18.7 6.8 2.6

SD

Intervention

31.9 59.5 8.7 2.22

M

8

8

9 9 9

9 9 9 9

n

57.0

23.7

20.5 43.1 36.5

44.6 41.9 13.5 0.7

M

6-Month Posttest

Parent and Child Interactive Behavior Means of Intervention and Comparison Groups Over Time

Parent Initiations Responses Nonengaged Praise Child Initiations Responses Nonengaged Turn taking Average number of turns/engagement Percentage of engagements ϖ more than 10 turns

Table 5:

32.6

22.9

6.0 11.6 12.7

11.4 10.4 7.3 0.86

SD

Comparison

20

20

20 20 20

20 20 20 20

n


Baseline Pre-Test

177

6-Month Post-Test

13%

20%

45%

47% 42%

33%

Comparison Group

Comparison Group Initiations Responses Non-Engaged

9%

18%

32%

48% 59%

34%

Natural Teaching Strategies Intervention Group

Natural Teaching Strategies Intervention Group

Figure 1: Profile of Parental Behavior Change

the Natural Teaching Strategies group was 1.3, suggesting that the parents in the intervention group had a mean change score of more than 1 standard deviation. Refer to Figure 1 for a profile of change in initiations, responses, and nonengaged behaviors between baseline and 6 months for the intervention group. The frequency of praise behavior was used as a measure of the affective quality of parent-child interactions. These behaviors occurred very infrequently within a 3-minute session, and variances were not equal at baseline pretest. Consequently, analysis of


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covariance was used instead of a repeated measures analysis of variance. Parents in the intervention group performed significantly more praise behaviors than the comparison group at 6 months (F = 5.2, p = .0065). Child behavior. No significant differences between the intervention and comparison groups were observed for child behaviors at baseline pretest or at the 6-month posttest.

DISCUSSION Limitations

A key limitation of these studies pertains to the small sample sizes. Convergence of findings on significance testing lends some credibility to the data; however, results should be interpreted with caution. As well, although intervention integrity was monitored via regular debriefing sessions, field note taking, and selected audio recordings of intervention sessions, support processes were not documented. These limitations will be discussed in the context of the intervention effects on parent-child relationships. Parent-Child Relationships and Family Functioning

These preliminary findings point to the potential effect of supportive intervention on parent-child relationships over time. The need for support for vulnerable children and their families has been well documented in the literature (e.g., Bartko & Sameroff, 1995; Dunst, 1993; Ritchie et al., 2000). The families in both studies were at risk due to poverty, single-parent status, and/or age of the mother in combination with other risk factors. These multiple risk factors can potentially have a negative effect on child development (e.g., Maynard, 1997; Pellegrini, 1990). In Intervention I, the intervention resulted in the treatment group parents surpassing the comparison group parents on four different aspects of parent-infant interaction (sensitivity to cues, responsiveness to distress, social-emotional growth fostering, and cognitive-growth-fostering activities) and on two separate occasions. The intervention group infants outperformed the comparison group infants in five of eight assessments. Research supports the need to



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enhance the quality of early interactions between parents and their children to reduce mental health and developmental difficulties in children (Wakschlag & Hans, 1999; Wendland-Carro et al., 1999), reduce family stress, and improve family cohesion (Duis et al., 1997). Effect sizes greater than 1 were noted for intervention parents’ enhanced sensitivity to infant cues and social-emotional and cognitive-growth-fostering activities. Typical examples of behaviors more likely to be exemplified by the intervention parents included safe positioning of the infant, making eye contact, smiling, using gentle touch, praising the child, and using rich language to describe events or objects in the child’s environment. Because intervention was targeted at supporting the parents as they gained new knowledge and skills in parenting, the larger intervention than comparison means and effect sizes were reassuring. Barnard et al. (1989) indicated that high-quality parent-child interactions are characterized by mutual warmth, sensitivity, and responsiveness. The results of the first pilot study indicate that adolescent mothers with a limited support intervention do participate in more high-quality parent-child interactions than comparable mothers who did not receive the support intervention. It was not surprising that the intervention did not appear to affect the infants in the same way as the parents. Maturational effects take precedence in early stages of infant development (Siegel, 1989). Furthermore, the intervention targeted the parents, with observable effects anticipated in the infants on longer term follow-up. This will be examined in a full trial in the future. In Intervention II, the profile of results suggests that the intervention was effective in changing parents’ behaviour with their children in interaction. Parents in the intervention group were less directive, and were more responsive and positive with their children after receiving the intervention. As well, effect sizes, reflecting change, indicate that the intervention helped parents to become more engaged in interactions with their preschoolers. Helping parents develop realistic expectations of their child’s development and improving the quality of parent-child interactions are important support mechanisms for families at risk (Dinnebeil, 1999; Mahoney & Kaiser, 1999) and may function to reduce family stress and increase cohesion (Duis et al., 1997). These findings, although limited by the small sample size, are important because they demonstrate the potential of parent training and support to alter the style of interactions between parents and their children. By the time


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children are 3 years of age, parents and children have had considerable experience in developing a routine or style of interaction. These experiences often consolidate a style of interacting that is resistant to change. Consequently, the results of the second pilot study are promising. It will be important for future research to test if these changes are maintained over a long period of time. Given that interaction is by necessity bidirectional, sustained changes in parents’ behavior would likely influence changes in children’s development and children’s behavior in interactions with both parents and others. These assumptions need to be examined in future research. Social Support

Both studies emphasized improvement of the parent-child relationship via parent training in a supportive context. The interventionist training, parent training intervention, and outcomes were well documented. However, support processes, although assumed to be offered and delivered equally to both intervention and comparison group families, were not systematically documented. It is impossible, therefore, to report the real role of the support component in the success of the interventions. Documentation of support intervention processes may also improve the intervention delivery in the current trial, future trials, or in practice (Gottlieb, 2000; Morse, Penrod, & Hupcey, 2000). Support processes will be documented more fully in the future trial. Supportive Interventions I and II were both delivered by interventionists with advanced educational preparation. The feasibility of implementing the interventions with alternative interventionists should be examined. For example, the effects of supportive intervention by experienced peers versus professionals or peers in collaboration with professionals could be tested. These approaches may more fully capture the social comparison and social learning aspects of social support (Stewart, 1993) and enhance participants’ engagement in the intervention program (Webster-Stratton, 1998).

CONCLUSION

In conclusion, these preliminary findings represent the pilot work for a larger trial that will combine the interventions into a 6-month intervention program for adolescent parents. Keys to Caregiving will



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provide a solid foundation for parents of infants on which to base the Natural Teaching Strategies program approaches. Natural Teaching Strategies has already been adapted to serve the needs of families of infants for the full trial. In the full trial, as in both of the pilot tests, the parent training interventions will be implemented in a context of family support. Finally, support processes will be documented in the larger trial to test the quality and quantity of support necessary to ensure the success of parent support interventions.

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Nicole Letourneau, Ph.D. (nursing), B.N., R.N., is a postdoctoral fellow funded by the Alberta Heritage Foundation for Medical Research and by the Medical Research Council of Canada. She is currently working with Dr. Miriam Stewart in Stewart’s Social Support Research Program at the Centre for Health Promotion Studies, University of Alberta. Dr. Letourneau is interested in supports for parents to promote vulnerable children’s optimal development. Recent publications include “Attrition Among Adolescents Involved in a Parenting Program” (in press) in Child: Care, Health & Development and (with J. Drummond, N. Letourneau, S. Neufeld, H. Harvey, R. Elliott, & S. Reilly) “Infant Crying and Parent-Infant Interaction: Theory and Measurement” (1999) in Infant Mental Health Journal. Jane Drummond, Ph.D. (psychology), M.Sc. (family studies), B.Sc.N., R.N., is a professor in the Faculty of Nursing, University of Alberta and a National Health


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Research and Development Program Scholar. She is interested in child and family health, resiliency, family adaptation, early intervention, and family-centered intervention, particularly with at-risk families. Recent publications include (with G. M. Kysela, L. McDonald, J. Alexander, & B. Query) “Family Adaptation: The Goal of Promoting Resiliency in Families At-Risk” (in press) in Exceptionality Education and (with G. M. Kysela, L. McDonald, J. Alexander, & D. Fleming) “Risk and Resiliency in Two Samples of Canadian Families” (1997) in Health and Canadian Society. Darcy Fleming, M.Ed., B.A., is a doctoral student in the Department of Educational Psychology at the University of Alberta. He is interested in an ecological approach to understanding human health and development and its implication for working with children, families, communities, agencies, and the development of policies. Recent publications include (with L. Wilgosh & K. Scourgie) “Effective Life Management in Parents of Children With Disabilities: A Survey Replication and Extension” (in press) in Developmental Disabilities Bulletin and (with J. Drummond, G. M. Kysela, L. McDonald, & J. Alexander) “Risk and Resiliency in Two Samples of Canadian Families” (1997) in Health and Canadian Society. Gerard Kysela, Ph.D. (child development), M.A. (clinical child psychology), B.Sc. (psychology), C. Psych., is a professor emeritus with the Department of Educational Psychology at the University of Alberta. He has extensively studied the development of family-focused assessment approaches consistent with current models of family adaptation. Dr. Kysela spearheaded the Child and Family Resiliency Research Project. Recent publications include (with L. McDonald, J. Drummond, C. Martin, W. Wiles, & J. Alexander) “Assessment of Clinical Utility of the Family Adaptation Model” (1997) in Journal of Family Studies and (with J. Drummond, L. McDonald, & J. Alexander) “The Child and Family Resiliency Research Program” (1996) in The Alberta Journal of Educational Research. Linda McDonald, Ph.D. (educational psychology), M.A. (experimental psychology), B.A. (psychology), C. Psych., is a professor in the Department of Educational Psychology, University of Alberta. She has worked with and conducted researched pertaining to people with severe and multiple disabilities since 1970. Dr. McDonald is currently coinvestigator on a longitudinal interprovincial study of resiliency in families of children with or at risk for developmental disabilities. Recent publications include (with G. Kysela, J. Drummond, A. Alexander, R. Enns, & J. Chambers) “Using the Family Adaptation Model to Facilitate Individual Family Planning” (1999) in Developmental Disabilities Bulletin and (with G. Kysela, J. Drummond, C. Martin, & W. Wiles) “Assessment of the Clinical Utility of a Family Adaptation Model” (1997) in Journal of Family Studies.



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Miriam Stewart, Ph.D. (education), M.N., B.Sc.N., R.N., is director of the Centre for Health Promotion Studies, professor in the Faculty of Nursing and Department of Public Health Sciences, and a senior scholar funded by the Alberta Heritage Foundation for Medical Research. She has studied social support extensively in multiple-risk populations and has published the findings of her Social Support Research Program widely. Recent publications include Chronic Conditions and Caregiving in Canada: Social Support Strategies (2000), University of Toronto Press; and (with J. Ritchie, M. Ellerton, D. Thompson, D. Meade, & P. Viscount) “Parents’ Perceptions of the Impact of a Telephone Support Group Intervention” (2000) in Journal of Family Nursing.
