Maternal psychological distress and parenting stress after the birth of a very low-birth-weight infant

Sleep quality, stress, caregiver burden, and quality of life in maternal caregivers of young children with bronchopulmonary dysplasia

Little is known about the influence of sleep quality, stress, and caregiver burden on quality of life in maternal caregivers of young children with bronchopulmonary dysplasia (BPD). In 61 maternal caregivers (mean age 29.59 years) of young children with BPD (mean age 13.93 months), caregivers reported sleeping a mean of 5.8 hours, and significant correlations were found between sleep quality and depressive symptoms and stress, as well as an inverse correlation with quality of life. Sleep quality was found to be the most significant predictor of quality of life in maternal caregivers.

Emotional distress in mothers of preterm hospitalized infants: a feasibility trial of nurse-delivered treatment

OBJECTIVE

Mothers of preterm infants in a hospital neonatal intensive care unit (NICU) are at risk for clinically significant depression and anxiety, but for these women their own treatment is likely a secondary priority. This study evaluated the feasibility, acceptability and effectiveness of an evidence-based, nurse-delivered, on-site depression treatment: listening visits (LVs).

STUDY DESIGN

Therapeutic LVs were delivered on site to 23 distressed mothers of NICU infants. The intervention was conducted by a neonatal nurse practitioner and the outcome was examined in an open-trial, pre-post evaluation.

RESULT

A part-time nurse practitioner delivered six LVs to each participant within a 1-month time frame. LVs were associated with significantly improved mood and well-being in mothers. The majority of eligible women took advantage of LVs and felt satisfied with their care.

CONCLUSION

This open trial provides 'proof-of-concept', with results that warrant further evaluation in a multisite randomized controlled trial.

Preterm birth and adolescent social functioning-alterations in emotion-processing brain areas

OBJECTIVE

To investigate the relationship between preterm birth, adolescent, and adult psychosocial outcomes, and alterations in gray matter volume.

STUDY DESIGN

Individuals (n = 73) born at <33 weeks of gestation (very preterm) and 49 controls completed the Child Behavior Checklist (CBCL) at age 15 years to identify 'social immaturity' (SI) cases. Voxel-based morphometry was used to investigate gray matter volumes according to CBCL-SI 'caseness.' The Clinical Interview Schedule-Revised (CIS-R) was administered at age 19 years.

RESULTS

Very preterm adolescents were almost 4 times more likely to reach CBCL-SI 'caseness' compared with controls. Ex-preterm SI 'cases' had increased gray matter volume in the fusiform gyrus bilaterally (Talairach coordinates: x = 60, y = -27, z = -30; Z = 3.78; x = -61, y = -35, z = -27; Z = 3.56, after correction for multiple comparisons) compared with ex-preterm SI 'noncases.' Left fusiform volume displayed a stronger correlation with ipsilateral orbitofrontal cortex in SI 'cases' (x = -15, y = 22, z = -26; Z = 3.64). CIS-R total scores were slightly higher in ex-preterm individuals compared with controls. In the whole sample, SI 'cases' in midadolescence also had higher CIS-R scores in adulthood compared with 'noncases' (SI 'cases': mean = 5.7, 95% CI = 4.0-7.4; SI 'noncases': mean = 2.7, 95% CI = 1.1-4.3; F = 6.4, df = 74; P = .013).

CONCLUSIONS

Ex-preterm adolescents had increased socialization problems in adolescence, which were associated with volumetric alterations in an emotion-processing brain network. Atypical social development is linked to an increased vulnerability to psychiatric disorder.

Predictors of parenting stress trajectories in premature infant-mother dyads

This prospective longitudinal study examined predictors of parenting stress trajectories over time in a sample of 125 mothers and their preterm infants. Infant (multiple birth, gestational age, days hospitalized, and neonatal health risks) and maternal (socioeconomic, education, depressive symptoms, social support, and quality of interaction during infant feeding) characteristics were collected just prior to infant hospital discharge. Parenting stress and maternal interaction quality during play were measured at 4, 24, and 36 months corrected age. Hierarchical linear modeling was used to analyze infant and maternal characteristics as predictors of parenting stress scores and change over time. Results indicated significant variability across individuals in parenting stress at 4 months and in change trajectories. Mothers of multiples and infants with more medical risks and shorter hospitalization, and mothers with lower education and more depressive symptoms, reported more parenting stress at 4 months of age. Parenting stress decreased over time for mothers of multiples and for mothers with lower education more than for mothers of singletons or for mothers with higher educational levels. Changes in parenting stress scores over time were negatively associated with maternal behaviors during mother-infant interactions. Results are interpreted for their implications for preventive interventions.

Born too soon: the global epidemiology of 15 million preterm births

This second paper in the Born Too Soon supplement presents a review of the epidemiology of preterm birth, and its burden globally, including priorities for action to improve the data. Worldwide an estimated 11.1% of all livebirths in 2010 were born preterm (14.9 million babies born before 37 weeks of gestation), with preterm birth rates increasing in most countries with reliable trend data. Direct complications of preterm birth account for one million deaths each year, and preterm birth is a risk factor in over 50% of all neonatal deaths. In addition, preterm birth can result in a range of long-term complications in survivors, with the frequency and severity of adverse outcomes rising with decreasing gestational age and decreasing quality of care. The economic costs of preterm birth are large in terms of immediate neonatal intensive care, ongoing long-term complex health needs, as well as lost economic productivity. Preterm birth is a syndrome with a variety of causes and underlying factors usually divided into spontaneous and provider-initiated preterm births. Consistent recording of all pregnancy outcomes, including stillbirths, and standard application of preterm definitions is important in all settings to advance both the understanding and the monitoring of trends. Context specific innovative solutions to prevent preterm birth and hence reduce preterm birth rates all around the world are urgently needed. Strengthened data systems are required to adequately track trends in preterm birth rates and program effectiveness. These efforts must be coupled with action now to implement improved antenatal, obstetric and newborn care to increase survival and reduce disability amongst those born too soon.

Parents' views on factors that help or hinder breast milk supply in neonatal care units: systematic review

OBJECTIVE

To synthesise what is known about the parents' views on factors that help or hinder breast milk supply during their infants' hospitalisation in neonatal intensive care units (NICU).

METHODS

A systematic search of PubMed, ISI WoK, PsycINFO and SciELO, targeting studies presenting original empirical data that examined parents' perspectives regarding breast milk supply experiences in NICU, was performed. Based on content analysis, three independent researchers synthesised the findings of seven studies. Categories of facilitators and barriers were identified using quotations stated in the studies: parents' breast milk supply experience; parents-professionals relationships; characteristics of the NICU; and parents' social background and expectations.

RESULTS

The studies, five qualitative and two mixed methods, were published between 1994 and 2011. With heterogeneous study designs, fathers' perspectives were analysed in one article. Only one study defined breastfeeding. According to parents' perspectives, successful breast milk supply in NICU depends on coherent and accurate knowledge about its techniques and benefits, reinforcement of mothers' motivation and alignment between NICU's routines and parents' needs. Parents perceived issues related to their own current breast milk supply experience, simultaneously, as main facilitators and barriers. Parents-professionals relationship constituted the second group of facilitators, but the fourth of barriers. The characteristics of the NICU were more relevant as a barrier than as a facilitator.

CONCLUSIONS

Although parents' perspectives are grounded on individual child-focused experiences, their emphasis on learning and motivation guided by short-term goals opens room to the collective intervention of experts. This may facilitate the engagement of mothers, fathers and health professionals on family-centred care.

Long-term risk of mental health problems in women experiencing preterm birth: a longitudinal study of 29 mothers

BACKGROUND

Several studies have reported significantly higher stress levels, both short and long terms, among mothers giving preterm birth compared with mothers giving birth at term. Stress, however, is a psychological phenomenon that may present as anxiety, depression and/or trauma reactions. In this study, the long-term mental health outcomes and the prevalence of anxiety, depression and trauma reactions in women experiencing preterm birth were explored. Interactional, main effect variables and predictors were identified.

METHODS

Twenty-nine mothers of 35 premature children born before the 33rd week of pregnancy were assessed within 2 weeks postpartum (T0), 2 weeks after hospitalization (T1), 6 months post-term (T2), and 18 months post-term (T3). The standardized psychometric methods Impact of Event Scale (IES), General Health Questionnaire (GHQ) and State Anxiety Inventory (STAI-X1) assessed the maternal mental health outcomes.

RESULTS

The maternal mental health problems except state anxiety decreased from T0 to T1, but remained high and stable at T3. The prevalence of posttraumatic stress reactions (PTSR) and posttraumatic stress disorder (PTSD) at T0 and T3 was 52% and 23%, respectively. We identified the time period between T0 and T1 to have a significant main effect on mental health outcomes. The predictors of higher levels of mental health problems were preeclampsia, previous psychological treatment, age, trait anxiety and infant's postnatal intraventricular haemorrhage. Bleeding in pregnancy predicted lower levels of mental health problems.

CONCLUSIONS

The prevalence of maternal mental health problems remained high, emphasizing the importance of effective interventions.

Interaction of child disability and stressful life events in predicting maternal psychological health. Results of an area-based study of very preterm infants at two years corrected age

This study aimed at exploring the relationship between severe neuromotor and/or sensory disability in very preterm infants assessed at 2 years corrected age and their mothers' psychological health. Data on 581 Italian singletons born at 22-31 weeks of gestation in five Italian regions and their mothers were analyzed. Maternal psychological distress was measured through the General Health Questionnaire short version (GHQ-12). The prevalence of any maternal distress (GHQ scores ≥ 2) and of clinical distress (scores ≥ 5) were 31.3% and 8.1% respectively. At multivariable analysis, we found a statistically significant association between child's disability and mothers' GHQ scoring ≥ 5 (OR 3.45, 95% CI 1.07-11.15). Also lower maternal education appeared to increase the likelihood of psychological distress (OR 1.38, 95% CI 1.14-1.66). The impact of child disability was weaker in women who had experienced additional stressful life events since delivery, pointing to the existence of a "ceiling" effect. Maternal psychological assessment and support should be included in follow-up programs targeting very preterm infants.

Screening parents of high-risk infants for emotional distress: rationale and recommendations

Having a baby hospitalized in a neonatal intensive care unit (NICU) is a potentially traumatic event for parents. This article summarizes research documenting heightened symptoms of depression and post-traumatic stress in these parents and reviews studies of the relationship of parental distress with impaired infant and child development. We describe an array of validated screening devices for depression and post-traumatic stress, along with research on risk factors for elevated scores. In making recommendations for screening both mothers and fathers for emotional distress in the NICU, we (a) present commentary on the pros and cons of screening, (b) propose a timetable for screening and (c) describe both supportive interventions for parents in the NICU and a variety of referral possibilities for parents most at risk.

Enhancing cross-system collaboration for caregivers at risk for depression

In the United States, many health care systems function independently from one another. Increasing coordination across systems has the potential to vastly improve services and patient outcomes, yet implementing these changes can be challenging, requiring increased communication, interaction, and coordination across systems that typically function independently. Parental depression is one health issue that could benefit greatly from a comprehensive systems approach. The Helping Families Raise Healthy Children initiative is a cross-system quality improvement initiative aimed at improving identification and treatment of families faced with the dual challenge of caregiver depression and early childhood developmental delays. Four main techniques were used to foster and sustain cross-system collaboration and communication: cross-system trainings, regular meetings of collaborative partners, a cross-system learning collaborative for service providers, and two cross-system facilitators. The initiative achieved successful cross-system collaboration, suggesting that these methods may be used in other initiatives to foster similar types of collaboration across systems.

Delivering perinatal psychiatric services in the neonatal intensive care unit

AIM

To describe characteristics of mothers who would likely benefit from on-site short-term psychiatric services while their infant is in the neonatal intensive care unit (NICU).

METHODS

For 150 consecutive mothers who were referred for psychiatric evaluation and psychotherapeutic intervention in an innovative NICU mental health programme, baseline information was collected. Data regarding their referrals, diagnosis, treatments and infants were analysed.

RESULTS

Most mothers were referred because of depression (43%), anxiety (44%) and/or difficulty coping with their infant's medical problems and hospitalization (60%). Mothers of VLBW infants were disproportionately more likely to be referred. A majority of mothers accepted the referral and were treated; most only required short-term psychotherapy. A minority resisted or refused psychiatric assessment; a quarter of these had more difficult interactions with staff or inappropriate behaviours. In these cases, the role of the psychiatrist was to work with staff to promote healthy interactions and to foster maternal-infant bonding.

CONCLUSION

Overall, on-site psychiatric services have been accepted by a majority of referred NICU mothers, and most did not require long-term treatment. A considerable need exists for psychiatric services in the NICU to promote optimal parenting and interactions.

Parenting stress in mothers of very preterm infants -- influence of development, temperament and maternal depression

OBJECTIVE

To measure levels of parenting stress and postnatal depression in mothers of very preterm infants in comparison with mothers of infants born at term is the objective of this study. The study also aimed to explore factors associated with parenting stress in the mothers of the preterm infants.

METHODS

One hundred and five mothers who delivered 124 babies at ≤30 weeks gestation were enrolled together with 105 term mothers who delivered 120 babies. At one year of age (corrected for prematurity for the preterm cohort), the mothers completed the Parenting Stress Index Short Form (PSI), the Edinburgh Postnatal Depression Scale (EPDS) and the Short Temperament Scale for Toddlers. The infants had neurodevelopmental assessment. The preterm and term groups were compared.

RESULTS

Questionnaires were completed by 101 of the preterm mothers and 98 of the term mothers. The mean PSI Total Stress score was significantly higher for the preterm mothers (70.28 vs 64.52, p = 0.022), with 19% of the preterm group and 9% of the term group having high scores (p = 0.038).There was no group difference on the EPDS or measures of temperament, with disability being greater in the preterm infants. For the preterm group, maternal depression and infant temperament were independent predictors of Total Stress scores on multivariate analysis.

CONCLUSIONS

Parenting stress in mothers of preterm infants at one year of age is significantly greater than that found in mothers of term infants. For preterm mothers, symptoms of depression and infant temperament are independent risk factors for higher levels of parenting stress.

Twin birth: an additional risk factor for poorer quality maternal interactions with very preterm infants?

BACKGROUND

Twin birth can be considered an additional risk factor for poor interactions between mothers and their very preterm (VP; <32 weeks' gestation) infants.

AIMS

To explore if mothers of (VP) twins experience higher levels of stress than mothers of singletons and if mother-twin infant dyads experience poorer quality interactions.

METHOD

Mothers of VP twin infants (N=17) were closely matched to mothers of VP singleton infants (N=17). Mother-infant interaction was assessed before discharge from hospital and during a home visit at three months corrected age using the Nursing Child Assessment Teaching Scale (NCATS). Mothers' responsiveness to their infants was assessed using the Responsivity subscale of the Home Observation for Measurement of the Environment (HOME) and mothers completed the Parenting Stress Index short form (PSI-SF).

RESULTS

Mothers of twins had significantly lower HOME responsiveness scores (median 9 vs. 10) at three months corrected age and were more likely to have total PSI-SF scores in the clinical range (>90th percentile) compared to mothers of singletons (Fishers exact probability=0.05). Twin infants had lower mean Total Child Domain NCATS scores than singletons both at discharge (9.07 vs. 11.33) and at three months corrected age (13.18 vs. 15.71) indicating they were less responsive communicators.

CONCLUSIONS

VP twins present a greater challenge than singletons as their mothers experience high levels of parenting stress. Although mothers appear to compensate for twin infants' poorer clarity of cues in a structured, one to one task, mothers of twins were less responsive than mothers of singletons in an unstructured setting.

The impact of bronchopulmonary dysplasia on caregiver health related quality of life during the first 2 years of life

OBJECTIVES

Preterm children with bronchopulmonary dysplasia (BPD) frequently require complex home medical regimens and re-hospitalization during the first 2 years of life. The burden of caring for these medically complex children may negatively affect caregiver health related quality of life (HRQoL). The objectives of this study were to measure caregiver HRQoL of children with BPD and to identify factors that impact caregiver HRQoL during the first 2 years of life.

METHODS

Children (n = 186) were recruited from the Johns Hopkins BPD Outpatient Clinic between January 2008 and July 2011. Caregiver HRQoL was measured using The PedsQL(TM) Family Impact Module. Respiratory symptoms and morbidities were assessed using questionnaires.

RESULTS

Among caregivers of BPD children, significant improvement in physical, worry, and daily domains improved longitudinally as children aged. An association was found between lower total HRQoL scores and caregivers of BPD children who reported more respiratory symptoms and acute care usage. No difference in total HRQoL scores was found between caregivers of BPD children requiring respiratory/enteral support and caregivers of children who did not. Caregiver income and educational level did not predict total HRQoL score, but Non-White race and public insurance was associated with a higher total HRQoL score at the first outpatient visit.

CONCLUSION

An association was found between lower HRQoL scores and caregivers of BPD children with frequent respiratory symptoms and acute care usage. Screening for low HRQoL in caregivers of BPD children with frequent respiratory illnesses should be considered to identify those who may benefit from additional support and intervention.

Brief parenting intervention for parents of NICU graduates: a randomized, clinical trial of Primary Care Triple P

BACKGROUND

Preterm-born or asphyxiated term-born children who received neonatal intensive care show more emotional and behavioral problems than term-born children without a medical condition. It is uncertain whether regular parenting intervention programs to which the parents of these children are usually referred, are effective in reducing child problem behavior in this specific population. Our objective was to investigate whether a regular, brief parenting intervention, Primary Care Triple P, is effective in decreasing emotional and behavioral problems in preterm-born or asphyxiated term-born preschoolers.

METHODS

For this pragmatic, open randomized clinical trial, participants were recruited from a cohort of infants admitted to the neonatal intensive care units (NICU) of two Dutch hospitals. Children born with a gestational age <32 weeks or birth weight <1500 g and children born at a gestational age 37-42 weeks with perinatal asphyxia were included. After screening for a t-score ≥60 on the Child Behavior Checklist (CBCL), children were randomly assigned to Primary Care Triple P (n = 34) or a wait-list control group (n = 33). The primary outcome was child emotional and behavioral problems reported by parents on the CBCL, 6 months after the start of the trial.

RESULTS

There was no effect of the intervention on the CBCL at the trial endpoint (t64 = 0.54, P = .30). On secondary measurements of child problem behavior, parenting style, parenting stress, and parent perceived child vulnerability, groups either did not differ significantly or the intervention group showed more problems. In both the intervention and control group there was a significant decrease in emotional and behavioral problems during the trial.

CONCLUSIONS

Primary Care Triple P, a brief parenting intervention, is not effective in reducing child emotional and behavioral problems in preterm-born children or term-born children with perinatal asphyxia.

TRIAL REGISTRATION

Netherlands National Trial Register (NTR): NTR2179.

NICU admissions and maternal stress levels

OBJECTIVE

To determine the stress levels among mothers of babies admitted in Neonatal Intensive Care Unit (NICU) and to identify demographic parameters that influence their stress levels.

METHODS

Stress levels were assessed using Parental Stressor Scale: Neonatal Intensive Care Unit (PSS: NICU) questionnaire among 100 NICU mothers by doctors between 6 and 8 d of admission. Maternal stress was quantified using Likert scale as low (1-2.9), medium (3-3.9) and high (4-5). The data was analyzed using SPSS Ver.16.

RESULTS

The mean scores for the subscales sights and sounds, looks and behaviour and alteration in the parental role were 2.55, 4.1 and 4.12 respectively. Increased maternal age, prematurity of baby, longer NICU stay and inability to directly breastfeed the baby were associated with higher stress levels.

CONCLUSIONS

NICU mothers are under significant stress and appropriate counseling targeted towards specific stressors is required.

Rethinking stress in parents of preterm infants: a meta-analysis

BACKGROUND

With improved medical outcome in preterm infants, the psychosocial situation of their families is receiving increasing attention. For parents, the birth of a preterm infant is generally regarded as a stressful experience, and therefore many interventions are based on reducing parental stress. Nevertheless, it remains unclear whether parents of children born preterm experience more stress than parents of term-born children, which would justify these interventions. This meta-analysis provides a comprehensive account of parental stress in parents of preterm infants, from birth of the infant through to their adolescence. Mean levels of stress in specific domains of family functioning were investigated, and stress levels in parents of preterm and term infants, and fathers and mothers of preterm infants, were compared. Furthermore, we investigated moderators of parental stress.

METHODS AND FINDINGS

A random-effects meta-analysis was conducted including 38 studies describing 3025 parents of preterm (<37 wk) and low birth weight (<2500 g) infants. Parental stress was measured with two parent-reported questionnaires, the Parenting Stress Index and the Parental Stressor Scale: Neonatal Intensive Care Unit. The results indicate that parents of preterm-born children experience only slightly more stress than parents of term-born children, with small effect sizes. Furthermore, mothers have slightly more stress than fathers, but these effect sizes are also small. Parents report more stress for infants with lower gestational ages and lower birth weights. There is a strong effect for infant birth year, with decreasing parental stress from the 1980s onward, probably due to increased quality of care for preterm infants.

CONCLUSIONS

Based on our findings we argue that prematurity can best be regarded as one of the possible complications of birth, and not as a source of stress in itself.

Key components of early intervention programs for preterm infants and their parents: a systematic review and meta-analysis

BACKGROUND

Preterm infants are at greater risk for neurodevelopmental disabilities than full term infants. Interventions supporting parents to improve the quality of the infant's environment should improve developmental outcomes for preterm infants. Many interventions that involve parents do not measure parental change, nor is it clear which intervention components are associated with improved parental outcomes. The aim of this review was to categorize the key components of early intervention programs and determine the direct effects of components on parents, as well as their preterm infants.

METHODS

MEDLINE, EMBASE, CINAHL, ERIC, and Cochrane Database of Systematic Reviews were searched between 1990 and December 2011. Eligible randomized controlled trials (RCTs) included an early intervention for preterm infants, involved parents, and had a community component. Of 2465 titles and abstracts identified, 254 full text articles were screened, and 18 met inclusion criteria. Eleven of these studies reported maternal outcomes of stress, anxiety, depressive symptoms, self-efficacy, and sensitivity/responsiveness in interactions with the infant. Meta-analyses using a random effects model were conducted with these 11 studies.

RESULTS

Interventions employed multiple components categorized as (a) psychosocial support, (b) parent education, and/or (c) therapeutic developmental interventions targeting the infant. All interventions used some form of parenting education. The reporting quality of most trials was adequate, and the risk of bias was low based on the Cochrane Collaboration tool. Meta-analyses demonstrated limited effects of interventions on maternal stress (Z = 0.40, p = 0.69) and sensitivity/responsiveness (Z = 1.84, p = 0.07). There were positive pooled effects of interventions on maternal anxiety (Z = 2.54, p = 0.01), depressive symptoms (Z = 4.04, p <.0001), and self-efficacy (Z = 2.05, p = 0.04).

CONCLUSIONS

Positive and clinically meaningful effects of early interventions were seen in some psychosocial aspects of mothers of preterm infants. This review was limited by the heterogeneity of outcome measures and inadequate reporting of statistics. IMPLICATIONS OF KEY FINDINGS: Interventions for preterm infants and their mothers should consider including psychosocial support for mothers. If the intervention involves mothers, outcomes for both mothers and preterm infants should be measured to better understand the mechanisms for change.

Unexpected: an interpretive description of parental traumas' associated with preterm birth

BACKGROUND

Preterm birth (PTB) places a considerable emotional, psychological, and financial burden on parents, families, health care resources, and society as a whole. Efforts to estimate these costs have typically considered the direct medical costs of the initial hospital and outpatient follow-up care but have not considered non-financial costs associated with PTB such as adverse psychosocial and emotional effects, family disruption, strain on relationships, alterations in self-esteem, and deterioration in physical and mental health. The aim of this inquiry is to understand parents' experience of PTB to inform the design of subsequent studies of the direct and indirect cost of PTB. The study highlights the traumatic nature of having a child born preterm and discusses implications for clinical care and further research.

METHOD

Through interviews and focus groups, this interpretive descriptive study explored parents' experiences of PTB. The interviews were audiotaped, transcribed, and analyzed for themes. Analysis was ongoing throughout the study and in subsequent interviews, parents were asked to reflect and elaborate on the emerging themes as they were identified.

RESULTS

PTB is a traumatic event that shattered parents' taken-for-granted expectations of parenthood. For parents in our study, the trauma they experienced was not related to infant characteristics (e.g., gestational age, birth weight, Apgar scores, or length of stay in the NICU), but rather to prolonged uncertainty, lack of agency, disruptions in meaning systems, and alterations in parental role expectations. Our findings help to explain why things like breast feeding, kangaroo care, and family centered practices are so meaningful to parents in the NICU. As well as helping to (re)construct their role as parents, these activities afford parents a sense of agency, thereby moderating their own helplessness.

CONCLUSION

These findings underscore the traumatic nature and resultant psychological distress related to PTB. Obstetrical and neonatal healthcare providers need to be educated about the symptoms of Acute Stress Disorder (ASD) and Posttraumatic Stress Disorder (PTSD) to better understand and support parents' efforts to adapt and to make appropriate referrals if problems develop. Longitudinal economic studies must consider the psychosocial implications of PTB to in order to determine the total related costs.

Depressive symptoms among immigrant and Canadian born mothers of preterm infants at neonatal intensive care discharge: a cross sectional study

Background

Mothers of preterm infants are considered at higher risk for depressive symptoms, higher than for mothers of healthy term infants. Predictors of depressive symptoms in mothers of preterm infants are not yet well established. Immigrant mothers of term infants have higher prevalence of depressive symptoms than Canadian born mothers but the relative prevalence for immigrant mothers of preterm infants is unknown. This study had two aims: (i) to investigate the prevalence of depressive symptoms in immigrant as compared to Canadian born mothers of preterm infants, and (ii) to determine what factors are associated with depressive symptoms in mothers of preterm infants.

Methods

This is a multi-site, cross sectional study of mothers whose preterm infants required hospitalization in neonatal intensive care unit (NICU). Consecutive eligible mothers (N = 291) were recruited during the week prior to their infant’s NICU discharge. Mothers completed a self-administered questionnaire booklet of validated psychosocial/cultural measures including the Center for Epidemiological Studies Depression Scale (CES-D), Parental Stressor Scale:NICU, General Functioning Subscale of the McMaster Family Assessment Device, Social Support Index, and Vancouver Index of Acculturation; and demographic characteristics questions. Infant characteristics included gestational age, birth weight, sex, singleton/multiple birth, and Score for Neonatal Acute Physiology-II.

Results

Immigrant mothers (N = 107), when compared to Canadian born mothers (N = 184), reported more depressive symptoms, poorer family functioning, less social support, and less mainstream acculturation. Hierarchical regression for a subsample of 271 mothers indicated that single parent status, high stress, poorer family functioning, and less social support were associated with increased depressive symptoms and accounted for 39% of the variance on the CES-D. Immigrant status did not contribute significantly to the final regression model.

Conclusions

Immigrant mothers of preterm infants are at increased risk for depressive symptoms. For immigrant and Canadian born mothers of preterm infants hospitalized in NICU and particularly for single mothers, interventions to reduce stress and increase family functioning and social support may reduce depressive symptoms. Given the effects of depression on maternal health and functioning, such an intervention may improve child outcomes.

Reliability of the postpartum depression screening scale in the neonatal intensive care unit

BACKGROUND

Rates of postpartum depression have been found to be significantly higher in mothers of infants in the neonatal intensive care unit (NICU) than the general population estimate of 10%-15%, making routine screening for these mothers essential.

OBJECTIVES

The aim of this study was to examine the reliability (internal consistency) and construct validity of the Postpartum Depression Screening Scale with a sample of mothers of infants in the NICU.

METHODS

A total of 111 (40% of eligible) mothers participated in the study. Mothers completed a brief demographic questionnaire and the screening scale at 14 or greater days postpartum. Estimates of internal consistency were evaluated using Cronbach's coefficient alpha.

RESULTS

On the basis of the scale total score, 52% of mothers had a positive screen and an additional 30% received a score indicating that they were at-risk. Reliability estimates were consistent with previous research and indicate excellent internal consistency for the total score and adequate to good internal reliability for subscales scores. The coefficient alpha for total score equaled .95, and alpha for subscale scores ranged from .72 (Anxiety/Insecurity) to .89 (Suicidal Thoughts). Interscale correlations were consistently lower than subscale reliability estimates (coefficient alpha) and were lower than subscale-to-total score correlations, suggesting initial support for the proposed structure of the scale for mothers in the NICU.

DISCUSSION

Most of this sample of mothers experienced significant symptoms of postpartum depression. The Postpartum Depression Screening Scale is a promising tool for screening mothers with infants in the NICU. Additional research is necessary to better understand the construct and predictive validity of scores among these mothers. Current and future research will contribute to the routine use of scale as a screening tool in this environment.

Supporting Fathers in a NICU: Effects of the HUG Your Baby Program on Fathers' Understanding of Preterm Infant Behavior

Fathers of preterm babies in a neonatal intensive care unit (NICU) are under stress. Lack of knowledge about a preterm infant's behavior challenges new fathers who may be required to make decisions about the hospitalized infant, to update concerned family and friends, and to provide support to the mother while she recovers from giving birth. The NICU nurses have the opportunity to support and guide these new fathers, although no previous research has confirmed how to do so effectively. This study confirmed that using The HUG Your Baby DVD and family-friendly educational program with fathers of preterm babies in a NICU increased fathers' knowledge of infant behavior and, as previous research suggests, is likely to boost fathers' confidence and to promote the parent-child relationship and strengthen the family unit.

Pilot study of experiences and needs of 111 fathers of very low birth weight infants in a neonatal intensive care unit

OBJECTIVE

To study the experiences and needs of the fathers of very low birth weight (VLBW, <1500 g) infants in a neonatal intensive care unit (NICU).

STUDY DESIGN

An anonymous self-report questionnaire was administered to fathers of VLBW infants born between Jan 1, 2008 and December 31, 2009 at two tertiary NICUs.

RESULT

A total of 111 of 273 fathers responded to the questionnaire. Responses to a variety of items, including self-perception, parenting attitudes, confidence, emotional pressure to satisfaction and self-efficacy as a parent were similar for the fathers of this survey and previous results for mothers of VLBW infants. Fathers judged direct bedside support by the NICU team as sufficient. However, 54.4% of fathers reported missing nonbedside interventions such as VLBW father-specific baby care courses, seminars or workshops, and platforms or chatrooms on the internet.

CONCLUSION

Bedside support of fathers, accomplished by the NICU team, could be complemented by additional father-specific non-bedside support, such as peer-education measures or interactive mass media.

Mothers' experiences expressing breast milk for their preterm infants: does NICU design make a difference?

PURPOSE

This study examined differences in outcomes of provision of mothers' milk before and after implementation of a single-family room (SFR) neonatal intensive care unit (NICU) and described issues related to long-term milk expression.

SAMPLE

The sample included 40 mothers (15 in the original NICU and 25 in the SFR NICU).

DESIGN

Descriptive comparative.

METHODS

Mothers were recruited 2 months before and 3 months after opening an SFR NICU. Nutritional data were collected throughout hospitalization. Mothers used a milk expression diary during hospitalization and completed a survey, "My Experiences With Milk Expression" immediately before infant discharge.

RESULTS

Seventy-five percent of mothers planned to express breast milk or breastfeed before delivery. The majority of the mothers (55%) were most comfortable pumping in their own homes because of the increased privacy. There were no statistically significant differences between the 2 groups regarding the place where they were most comfortable pumping or where they usually pumped, although more mothers pumped in their babies' rooms in the SFR NICU. The majority of the mothers reported concern about their milk supply at some time during hospitalization and 47.5% reported having breast problems. At discharge, 71.8% of the total group was providing some breast milk and 44.7% of the total group was providing breast milk exclusively. There were no significant differences between the groups in outcomes concerning the provision of breast milk.

CONCLUSIONS

Individual mother's needs for privacy need to be determined and interventions to support mothers' feeding plans throughout hospitalization and at discharge need to be developed.

Parenting Stress, Social Support, and Mother-Child Interactions in Families of Multiple and Singleton Preterm Toddlers

The study investigated family support as a buffer of stress in 153 mothers and preterm toddlers. Data were collected regarding maternal depressive symptoms, parenting stress, and family support; infant health; and videotaped mother-child interactions. Although more parenting stress related to less optimal child play, only information support functioned as a protective factor. Information support predicted positive play under high, but not low, maternal stress. Mothers of multiples reported more parenting stress than mothers of singletons.

Developing maternal self-efficacy for feeding preterm babies in the neonatal unit

Developing maternal self-efficacy offsets negative psychological consequences of premature birth, improving maternal well-being. We investigated women's experiences in a neonatal unit (NNU) in Scotland in semistructured interviews with 19 primiparous mothers of preterm babies. We explored their experience of preterm birth and development of self-efficacy in infant feeding behaviors, identifying emergent and a priori themes. Women reported experiencing loss and biographical disruption in relation to mothering, loss of autonomy, and searching for normality after premature birth. Providing breast milk symbolized embodied contact with their baby and increased maternal confidence. They developed motivation, knowledge, and perseverance and perceived success from positive feedback, primarily from their baby and health professionals' support and encouragement. Women actively constructed opportunities to develop ownership, control, and confidence in relation to interactions with their baby. We linked sources of self-efficacy with potential behavior change techniques to be used in practice to improve maternal confidence in the NNU.

Parental involvement and kangaroo care in European neonatal intensive care units: a policy survey in eight countries

OBJECTIVE

To compare, in a large representative sample of European neonatal intensive care units, the policies and practices regarding parental involvement and holding babies in the kangaroo care position as well as differences in the tasks mothers and fathers are allowed to carry out.

DESIGN

Prospective multicenter survey.

SETTING

Neonatal intensive care units in eight European countries (Belgium, Denmark, France, Italy, The Netherlands, Spain, Sweden, and the United Kingdom).

PATIENTS

Patients were not involved in this study.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A structured questionnaire was mailed to 362 units (response rate 78%); only units with ≥50 very-low-birth-weight annual admissions were considered for this study. Facilities for parents such as reclining chairs near the babies' cots, beds, and a dedicated room were common, but less so in Italy and Spain. All units in Sweden, Denmark, the United Kingdom, and Belgium reported encouraging parental participation in the care of the babies, whereas policies were more restrictive in Italy (80% of units), France (73%), and Spain (41%). Holding babies in the kangaroo care position was widespread. However, in the United Kingdom, France, Italy, and Spain, many units applied restrictions regarding its frequency (sometimes or on parents request only, rather than routinely), method (conventional rather than skin-to-skin), and clinical conditions (especially mechanical ventilation and presence of umbilical lines) that would prevent its practice. In these countries, fathers were routinely offered kangaroo care less frequently than mothers (p < .001) and less often it was skin-to-skin (p < .0001).

CONCLUSIONS

This study showed that, although the majority of units in all countries reported a policy of encouraging both parents to take part in the care of their babies, the intensity and ways of involvement as well as the role played by mothers and fathers varied within and between countries.

Symptoms of acute stress disorder in mothers of premature infants

PURPOSE

: To determine whether significant symptoms of acute stress disorder (ASD) are present in mothers of premature infants in the neonatal intensive care unit (NICU).

SUBJECTS

: Forty mothers of premature infants born less than 33 weeks and admitted into NICU.

DESIGN

: Prospective, cohort, within-subjects.

METHODS

: Mothers completed the Stanford Acute Stress Reaction Questionnaire, Edinburgh Postnatal Depression Scale, and the Acute Stress Disorder Interview to explore the number and severity of stress-related symptoms at 2 separate time periods, 7 to 10 days after birth, and 1 month after birth.

RESULTS

: Twenty-eight percent of the mothers met diagnostic criteria of ASD at 7 to 10 days after birth, and at 1 month after birth ASD symptoms persisted. The majority of the mothers described premature birth as a traumatic stressor. The most commonly met criteria were dissociation and anxiety. Significant symptoms of depression were found in 43% of mothers and persisted 1 month after birth. Rates of depression and moderate to severe symptoms of ASD were significantly related in mothers at 1 week and at 1 month after birth.

CONCLUSIONS

: The premature birth experience is traumatic for mothers and may lead to various emotional responses including stress-related symptoms such as depression and/or ASD. Mothers with significant symptoms of depression and those with symptoms of stress seem to be more at risk for developing symptoms of ASD.

Does maternal depression predict developmental outcome in 18 month old infants?

AIM

Our aim was to examine the associations between maternal depression in the first 6 months postpartum, home environment and cognitive, language and motor development in infants at 18 months of age.

STUDY DESIGN AND METHODS

This article reports results from the control group (n=312 full term; n=48 preterm) of the prospective Docosahexaenoic acid (DHA) to Optimise Maternal Infant Outcome (DOMInO) Randomised Controlled Trial. Mothers in South Australia completed the Edinburgh Postnatal Depression Scale (EPDS) at 6 weeks and 6 months postpartum. Infant development was assessed when children were 18 months old with the Bayley Scales of Infant and Toddler Development Version III and mothers completed the Home Screening Questionnaire at this assessment.

RESULTS

There were no significant associations between maternal depression in the first 6 months postpartum and cognitive, language or motor development after controlling for infant prematurity, breastfeeding status and socio-economic level. Home environment remained a significant predictor of development after controlling for potential confounding variables. Using mediation models, we did not find an association between maternal depression and developmental outcome through home environment.

CONCLUSIONS

Maternal depression in the first 6 months postpartum was not associated with infant development at 18 months of age. Further studies should focus on women with chronic depression.

Mutter-Kind-Interaktion bei Frühgeborenen

Die Mutter-Kind-Interaktion (MKI) Frühgeborener ist im Vergleich zu Reifgeborenen durch eine erhöhte mütterliche Intrusivität und Kontrolle gekennzeichnet. Analysiert wurde die MKI von Früh- und Reifgeborenen im Alter von 36 Monaten. 39 Frühgeborene < 1500 g (Studiengruppe) und 26 Reifgeborene (Kontrollgruppe) wurden im korrigierten Alter von 36 Monaten mittels Mannheimer Methode zur standardisierten Beobachtung der MKI im Kleinkindalter untersucht. Hierzu werden zwei fünfminütige Interaktionssituationen videographisch aufgezeichnet. Für die Lernsituation konnte nachgewiesen werden, dass die Mütter Frühgeborener weniger supportiv, häufiger restriktiv und unangemessen steuern, „negativer“ auf ihre Kinder reagieren und häufiger „negative“ Interaktionsauffälligkeiten zeigen. In der Spielsituation zeigte sich, dass Mütter frühgeborener Kinder häufiger negative Interaktionsauffälligkeiten sowie eine höhere negative Gestimmtheit und eine unangemessenere Steuerung aufweisen. Die Lernsituation zeigte sich in der Gruppe der Frühgeborenen als die „schwierigere“ Interaktion. Die Problematik der Mutter- Kind-Interaktion Frühgeborener bedarf besonderer Beachtung sowie früher Interventionen.

The effectiveness of video interaction guidance in parents of premature infants: a multicenter randomised controlled trial

Background

Studies have consistently found a high incidence of neonatal medical problems, premature births and low birth weights in abused and neglected children. One of the explanations proposed for the relation between neonatal problems and adverse parenting is a possible delay or disturbance in the bonding process between the parent and infant. This hypothesis suggests that due to neonatal problems, the development of an affectionate bond between the parent and the infant is impeded. The disruption of an optimal parent-infant bond -on its turn- may predispose to distorted parent-infant interactions and thus facilitate abusive or neglectful behaviours. Video Interaction Guidance (VIG) is expected to promote the bond between parents and newborns and is expected to diminish non-optimal parenting behaviour.

Methods/design

This study is a multi-center randomised controlled trial to evaluate the effectiveness of Video Interaction Guidance in parents of premature infants. In this study 210 newborn infants with their parents will be included: n = 70 healthy term infants (>37 weeks GA), n = 70 moderate term infants (32–37 weeks GA) which are recruited from maternity wards of 6 general hospitals and n = 70 extremely preterm infants or very low birth weight infants (<32 weeks GA) recruited by the NICU of 2 specialized hospitals. The participating families will be divided into 3 groups: a reference group (i.e. full term infants and their parents, receiving care as usual), a control group (i.e. premature infants and their parents, receiving care as usual) and an intervention group (i.e. premature infants and their parents, receiving VIG). The data will be collected during the first six months after birth using observations of parent-infant interactions, questionnaires and semi-structured interviews. Primary outcomes are the quality of parental bonding and parent-infant interactive behaviour. Parental secondary outcomes are (posttraumatic) stress symptoms, depression, anxiety and feelings of anger and hostility. Infant secondary outcomes are behavioral aspects such as crying, eating, and sleeping.

Discussion

This is the first prospective study to empirically evaluate the effect of VIG in parents of premature infants. Family recruitment is expected to be completed in January 2012. First results should be available by 2012.

Trail registration number

NTR3423

Mortality and neonatal morbidity among infants 501 to 1500 grams from 2000 to 2009

OBJECTIVE

To identify changes in mortality and neonatal morbidities for infants with birth weight 501 to 1500 g born from 2000 to 2009.

METHODS

There were 355806 infants weighing 501 to 1500 g who were born in 2000-2009. Mortality during initial hospitalization and major neonatal morbidity in survivors (early and late infection, chronic lung disease, necrotizing enterocolitis, severe retinopathy of prematurity, severe intraventricular hemorrhage, and periventricular leukomalacia) were assessed by using data from 669 North American hospitals in the Vermont Oxford Network.

RESULTS

From 2000 to 2009, mortality for infants weighing 501 to 1500 g decreased from 14.3% to 12.4% (difference, -1.9%; 95% confidence interval, -2.3% to -1.5%). Major morbidity in survivors decreased from 46.4% to 41.4% (difference, -4.9%; 95% confidence interval, -5.6% to -4.2%). In 2009, mortality ranged from 36.6% for infants 501 to 750 g to 3.5% for infants 1251 to 1500 g, whereas major morbidity in survivors ranged from 82.7% to 18.7%. In 2009, 49.2% of all very low birth weight infants and 89.2% of infants 501 to 750 g either died or survived with a major neonatal morbidity.

CONCLUSIONS

Mortality and major neonatal morbidity in survivors decreased for infants with birth weight 501 to 1500 g between 2000 and 2009. However, at the end of the decade, a high proportion of these infants still either died or survived after experiencing ≥ 1 major neonatal morbidity known to be associated with both short- and long-term adverse consequences.

Biopsychosocial risks of parental care for high-risk neonates: implications for evidence-based parental counseling

OBJECTIVE

Provide an evidence base for counseling parents of high-risk neonates about the biopsychosocial impact of providing long-term care.

STUDY DESIGN

A review of the effects of long-term care on families of high-risk neonates. Our search was limited to 1993-2010. We used the terms 'long-term care,' 'family,' 'neonate' and 'technology dependence.' Results were organized based on Engel's biopsychosocial model.

RESULT

Physical-parental caregivers reported more health problems, had fewer health-promoting behaviors and lower vitality.Psychological-parental caregivers had higher rates of post-traumatic stress disorder and depressive symptoms, although some improved with time. Siblings reported greater stress and depression. Social-parental caregivers achieved fewer years of education, higher unemployment and lower incomes. Couples reported greater family strain. The effect on divorce was mixed. Siblings reported disruption in their academic and social lives.

CONCLUSION

Providing long-term care involves biopsychosocial risks. Counseling of parents should identify them and advocate strategies for prevention.

Preventive interventions for preterm children: effectiveness and developmental mechanisms

This article provides an integrative review of the effectiveness of and possible developmental mechanisms associated with preventive interventions for preterm children. An analysis of randomized clinical trials carried out within the last 15 years was framed within a contemporary developmental model emphasizing the role of parental adjustments to preterm children's characteristics. Evidence suggested positive outcomes could be understood in terms of improvements in developmental pathways associated with parental sensitive-responsiveness and child participation in intensive intervention-oriented child care. Implications for the critical role of the Medical Home model for preventive interventions for preterm children were discussed.

Parental psychological well-being and behavioral outcome of very low birth weight infants at 3 years

OBJECTIVE

The purpose was to explore whether poor parental psychological well-being is associated with behavioral problems of very low birth weight (VLBW, ≤1500 g) infants at 3 years of age.

METHODS

In this prospective cohort study, 189 VLBW preterm infants born between January 2001 and December 2006 at the Turku University Hospital, Finland, were followed. Validated questionnaires (Beck Depression Inventory, Parenting Stress Index, and Sense of Coherence Scale) were mailed to the parents when their children were 2 years corrected age. A total of 140 parents evaluated the behavior of the child at 3 years by filling out the Child Behavior Checklist.

RESULTS

There were significant associations between most of the measures of parental symptoms of depression, parenting stress, and sense of coherence and the behavioral outcome of the VLBW infants. The concomitant symptoms of both parents were associated with more problematic child behavior.

CONCLUSIONS

Parents report more behavioral and emotional problems in VLBW children at age 3 if they themselves have had symptoms of depression, parenting stress, or weak sense of coherence 1 year earlier. The new finding of this study was to show the significance of the father's psychological well-being on the behavioral development of a preterm child.

Parenting Stress and Psychosocial Health in Mothers with Twin–Twin Transfusion Syndrome Managed with Laser Surgery: A Preliminary Study

Twin–twin transfusion syndrome (TTTS) is a severe complication of twin pregnancies with high risk for perinatal mortality and long-term morbidity. This cross-sectional cohort study aimed to determine parenting stress and psychosocial health in mothers with a pregnancy complicated by TTTS that had been managed with laser ablation of communicating placental vessels. Questionnaires were sent to the mothers for completion: Parenting Stress Index (PSI), Edinburgh Postnatal Depression Scale (EPDS) and a semi-structured questionnaire related to mental health problems and support received from health professionals. Thirty-seven mothers were sent questionnaires with 32 being returned. The results showed that 47% of women had total scores equal to or greater than the 85th percentile on the PSI, which is considered abnormally high. Twenty-six per cent of mothers had evidence of depression on the EPDS. Mothers of children with prolonged medical conditions or neurological problems had significantly higher scores (p =.011). Parenting stress was not associated with high scores on the EPDS. Medical and midwifery staff were considered to provide high levels of support, with social work providing none or low levels of support. In conclusion, women whose TTTS pregnancy was managed by laser surgery have high levels of parenting stress. As the results showed that parenting stress cannot be predicted at the time of hospitalization, it is suggested that more support should be provided in hospital with further follow-up after discharge.

Maternal depressive symptoms and participation in early intervention services for young children

Many young children with developmental delay who are eligible for early intervention (EI) services fail to receive them. We assessed the relationship between depressive symptoms in mothers, a potentially modifiable risk, and receipt of EI services by their eligible children. We conducted multivariable analyses of a nationally representative sample of children eligible for EI services at 24 months using data from the Early Childhood Longitudinal Study-Birth Cohort. Maternal depressive symptoms were assessed at 9 and 24 months. Birthweight <1,000 g, genetic and medical conditions associated with developmental delay, or low scores on measures of developmental performance defined EI eligibility. Service receipt was ascertained from parental self-report. Models were adjusted for sociodemographic and child risk. Among the 650 children who were eligible to receive EI services as infants, 33.2% of children whose mothers were depressed received services compared to 27.0% whose mothers were not depressed (aOR 1.8; 95% CI 0.8, 4.0). Among the 650 children who became eligible to receive services as toddlers, 13.0% of children whose mothers were depressed received services compared to 2.6% whose mothers were not depressed (aOR 4.6, 95% CI 1.5, 14.6). Among children receiving EI services, prevalence of depressive symptoms was 23.0% for mothers whose children became eligible as infants and 57.5% for mothers whose children became eligible as toddlers. Depressive symptoms in mothers of children eligible to receive EI services did not appear to limit participation. EI programs may be an appropriate setting in which to address maternal depressive symptoms.

Parenting stress in mothers of preterm infants during early infancy

OBJECTIVE

Mothers of preterm infants during the first year of life may experience stresses greater that those found in mothers of term infants. The aim of the study was to determine the levels of parenting stress and psychological well-being in mothers of very preterm babies in comparison to a control group of term mothers.

METHODS

One hundred and five mothers who delivered 124 babies at ≤30weeks gestation were recruited together with 105 mothers who delivered 120 babies at term. At 4months of age (corrected for prematurity for the preterm babies), the mothers completed the Parenting Stress Index Short Form, the Edinburgh Postnatal Depression Scale (EPDS), the Dyadic Adjustment Scale (DAS) and the Short Temperament Scale for Infants (STSI). The preterm and term groups were compared.

RESULTS

Questionnaires were returned from 86 of the preterm mothers and 97 of the term mothers. The mean Total Stress score for the preterm and term groups was 67.0 and 63.79 respectively (P=0.32) with 17% of the preterm and 9% of the term group having high scores (P=0.135). There were no differences of the EPDS and the DAS between the groups. The temperament of the preterm infants was similar to the term infants. For both groups, scores on the EPDS, DAS and the STSI were independent predictors of Total Stress scores on multiple regression analysis.

CONCLUSION

Parenting stress in mothers of preterm infants during early infancy does not appear to be greater than that in mothers of infants born at term. For both groups of mothers, depression symptoms, marital satisfaction and infant temperament were independent risk factors for high levels of parenting stress.

Adaptation of problem-solving treatment for prevention of depression among low-income, culturally diverse mothers

Adapting evidence-based interventions to be more accessible and culturally sensitive to the needs of diverse populations is a potential strategy to address disparities in mental health care. We adapted an evidence-based depression-treatment strategy, Problem-Solving Treatment, to prevent depression among low-income mothers with vulnerable children. Intervention adaptations spanned 3 domains: (1) the intervention's new prevention focus, (2) conducting a parent-focused intervention in venues oriented to children; and (3) cultural competency. The feasibility of adaptations was assessed through 2 pilot-randomized trials (n = 93), which demonstrated high participant adherence, satisfaction, and retention, demonstrating the feasibility of our adaptations.