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With the evidence still uncertain, where to next for interventions for new parents?

The first three years of life have long been recognised as fundamental to a child’s future development, and the role of parents in those early years is widely acknowledged as being critical.

For the new parent, there is an abundance of information on parenting babies both in the popular media and from health and social service agencies.

Yet how much of this is evidence-based and how much do we really know about what interventions work for parents of under threes?  Although there are still many gaps in our knowledge about parenting interventions for older children, these are minor compared to those for parents of babies.

Triple P is a widely known evidenced-based parenting intervention, and while there is support for its effectiveness in the toddler and pre-schooler years (for example, Morawska & Sanders, 2006) and into the primary school years, there is still limited evidence for interventions that target parents of babies.

This is not unique to Triple P. Most parenting programs target older children, and the majority of evidence-based, widely disseminated programs such as Triple P and Incredible Years is for older children.

Addressing the gap

To address this significant gap in supporting parents in the early years of parenting we developed Baby Triple P. Baby Triple P was designed as a comprehensive, preventative, group-based approach to support parents at the transition to parenthood, and targets known risks factors common across the transition (i.e., early parenting confidence and behaviour, parental coping, and supporting the couple relationship).

Our efforts to evaluate the efficacy of Baby Triple P are ongoing but to date findings have been mixed and largely not supportive of the efficacy of the program.

Interestingly, a recently published pre-post trial of Incredible Years Parents and Babies found limited evidence of effectiveness (Jones, Erjavec, Viktor, & Hutchings, 2016). Incredible Years, like Triple P, is based on social learning principles and has a strong evidence base, so it is intriguing that this version of the program has also shown few positive outcomes.

Four randomised controlled trials to date for Baby Triple P (Mihelic, Morawska, & Filus, 2016b; Seah & Morawska, 2016; Spry, 2013; Tsivos, Calam, Sanders, & Wittkowski, 2015) have shown two things: parents really like the intervention and yet report no or very limited change in any of the outcomes assessed. Each of these trials had significant limitations. For example, the sample in Spry (2013) was older, more educated, better off financially and better adjusted than the general population, thus causing ceiling effects on all outcome measures at baseline.

Several large-scale studies are currently ongoing in Australia and Scotland with more high-risk and vulnerable families. These studies will provide more definitive evidence pertaining to longer term effects of Baby Triple P.

Parents clearly like Baby Triple P

What we do know currently, however, is that parents clearly like Baby Triple P and find it highly acceptable, including families with premature babies (Ferrari, Whittingham, Boyd, Sanders, & Colditz, 2011), mothers in a psychiatric unit (Butler, Hare, Walker, Wieck, & Wittkowski, 2014), and mothers suffering from postnatal depression (Tsivos, Calam, Sanders, & Wittkowski, 2015).

Many parents and practitioners continue to ask for the program, often noting that there simply are no available parenting programs for them. One randomised trial even had to be discontinued because parents so desperately wanted the information in the program (Popp & Schneider, 2015).

Parents of babies clearly want evidence-based parenting programs. Practitioners tell us that few options are available and are very keen to know when Baby Triple P will become available.

verticle babyHowever, the research evidence for all parenting interventions targeting new parents suggests that all existing approaches to date have had limited effects.

Systematic reviews of specifically targeted interventions have found limited evidence of positive effects for outcomes such as infant sleep for babies under 6 months of age (Douglas & Hill, 2013).

Our own recent meta-analysis of interventions targeting early infant and parenting behaviours (Mihelic, Morawska, & Filus, 2016a), found only five studies that examined parenting competence and confidence. This means that while parenting skill and their confidence in their own ability as parents are recognised as important (Mihelic, Filus, & Morawska, 2016), few interventions actually aim to help parents enhance these.

A meta-analysis of more than 140 early parenting interventions, starting during pregnancy or the first six-months postpartum, found very small to small intervention effects and only for some outcomes (Pinquart & Teubert, 2010). The authors found that shorter, more targeted interventions, and older studies tended to show stronger effects.

The fact that older studies tend to show larger effect sizes might suggest that parents these days have access to much more information at their fingertips, making it more difficult for modern-day studies to show effects. However, we are still a long way from knowing whether or not this is the case. What we do know that despite this abundance of information, parents still clearly want an intervention such as Baby Triple P.

So where to now for Baby Triple P, a program that has been much anticipated by many people familiar with the Triple P system of programs?

We think the theoretical approach we have taken is sound, and the specific strategies incorporated into Baby Triple P are appropriate, but we have begun rethinking how we design the intervention and how we target delivery to parents with specific needs.

Perhaps we have tried to target too many varied factors within the existing intervention, making the job of detecting the effects on a specific outcome, such as baby crying, too difficult? Our next efforts will involve more targeted interventions, focusing on parents with identified needs.

At the same time, we will continue to work with parents and examine the theoretical literature to determine how best to tailor the program.

Parenting in infancy matters and we need to make sure we design and test effective programs for parents. And although it can be tempting to disseminate a program that parents and practitioners are asking for, Baby Triple P has not yet been disseminated.

We will continue to develop and test interventions for parents of babies in an effort to support those fundamental early days and months of development.

 

Other references:

 

Mihelic, M., Morawska, A., & Filus, A. (2016a). Effects of early parenting interventions on parents and infants: A meta-analytic review. Under review.

Mihelic, M., Morawska, A., & Filus, A. (2016b, 22-25 June). How effective is Baby Triple P for parenting confidence and the mother-infant relationship? . Paper presented at the 8th World Congress of Behavioural and Cognitive Therapies, Melbourne, Australia.

Seah, C. K. F., & Morawska, A. (2016). Does Baby Triple P increase responsive parenting, efficacy and reduce parental stress? A randomized controlled trial of an early parenting intervention. Under review.

 

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How babies and a narrative of recovery might help mothers who experience postpartum psychosis

The role of the baby as both the cause and agent of recovery for women suffering from postpartum psychosis is part of the clinical and research work of Triple P Research Network member Dr Anja Wittkowski.

Two qualitative studies at the centre of this work were presented at the World Congress of Behavioural and Cognitive Therapies in Melbourne last month.

Dr Wittkowski’s research focuses on a time when most women anticipating the arrival of their baby are hoping to feel wonderful. But some may find themselves frightened, confused and, more than likely, sectioned under their country’s relevant Mental Health Act.

Dr Anja Wittkowski

Dr Anja Wittkowski

Rare but rapid onset

“Postpartum psychosis is quite rare, with around one in 1000 mothers giving birth experiencing it,’’ Dr Wittkowski said during a recent visit to UQ’s Parenting and Family Support Centre, following the World Congress. “It usually comes on very quickly within a few days of giving birth and it almost always requires an inpatient admission.

“It is an incredibly significant life event which can make the women who experience it question their very identity. But my impression is that many of these women go on to live normal, fulfilling lives as both women and mothers.’’

Dr Wittkowski said any pregnant woman could be at risk of developing the condition but an underlying bipolar disorder, or a previous postpartum psychosis, appears to increase the risk of experiencing it.

Dr Wittkowski is a senior lecturer in clinical psychology at The University of Manchester, the current Research Director for the Clinical Psychology Doctorate program at The University of Manchester as well as a clinical psychologist at the 10-bed Mother and Baby Unit (MBU) on Andersen Ward at Wythenshawe Hospital operated by the Manchester Mental Health and Social Care Trust.

Mothers who are admitted to Andersen Ward may be experiencing problems such as postnatal depression, postpartum psychosis or an exacerbation of an existing mental health problem, such as psychosis or bipolar affective disorder.

Dr Wittkowski’s first study involved conducting qualitative interviews with 12 women and was aimed at developing a theoretical understanding of recovery from psychosis following childbirth. This study was published in the journal BMC Psychiatry.

“We know from our first study that the first step in recovering from a postpartum psychosis is gaining an initial understanding of what you have experienced,’’ Dr Wittkowski said. “We know someone has a sense of realisation when they ask their friends or family, ‘what did I say, what did I do’, and can’t believe they did what their friends and family are telling them they did.

“Once they realise that they had very unusual (often psychotic) experiences, these women experience a great sense of loss. They had been anticipating that after giving birth they were going to experience the best feeling in the world but the next minute they are frightened and confused.

Losing a piece of themselves

“This period of experiencing acute psychotic symptoms is not viewed by these women as representative of what they are normally like. As part of recovery, they have told us that they had to accept that they have lost a little bit of themselves, such as their sense of security, their knowledge of being a stable persoverticle babyn or just time. But the women we interviewed told us that they used those experiences positively.

“In my clinical experience I can begin to see women recover when they start to develop a narrative about their experiences, partly as a way of explaining to others what happened to them – and why they had to b
e admitted to a psychiatric unit – but mostly so they have a way of explaining those very unusual experiences to themselves.’’

One of the women I worked with expressed this process of acceptance really nicely. She told me that she really liked musical animation. She explained that during her acute illness phase she was found hiding away in her room but singing these songs. She later said to me that singing these songs ‘helped me through the darkest moments in my life’.”

Because of the importance of psychosocial factors in the role of recovery, Dr Wittkowski said the research team asked the women in their first study about the things that had helped their recovery and the women identified that their relationships with family members and mental health staff had been very helpful.

“When these women talked about their relationships with others, one very strong theme emerged: none of these women mentioned their baby,’’ Dr Wittkowski said. “We were thinking about how odd that was and that informed the design of the second study. As the baby is a reason why women become extremely unwell in the first place, we wanted to know about the role of the baby in their recovery from postpartum psychosis.

Mothers who took part in the second qualitative study told us that the baby is central to their recovery and the baby was perceived a facilitator but the baby was also a barrier to recovery. These findings reflected what we had seen in clinical practice on the unit.

“The mothers also told us they felt they had to sacrifice their own wellbeing for the sake of the baby.’’

The second as yet unpublished study underlined the value of the work of the Mother and Baby Unit which centres around mothers’ wellbeing but also encouraging mothers to look after their babies and bond with them.

“We know that by looking after the baby, these women achieve a greater sense of self-confidence which helps their recovery,’’ she said.

Baby Triple P

Dr Wittkowski and fellow researchers are about to embark on a new study in which the Baby Triple P program will be offered at the Mother and Baby Units in Birmingham and Manchester. Funded by a National Institute of Health Research for Patient Benefit grant in the UK, they will be working with women who have been admitted for a range of mental health difficulties, including psychosis, postnatal depression, having thoughts of harming their child, stress, bonding problems, or existing problems, such as OCD, anxiety and/or depression.

“Baby Triple P just fits in so well with what we are doing,’’ Dr Wittkowski said. “When I first came across Baby Triple P I liked the fact that it had two sessions on dealing with the relationship between mother (or parent) and baby, two sessions for coping and building social support and four sessions for skill implementation via phone support.

“It’s really nice that there are four weeks of phone support so we get to see how the women manage the transition from having been on the unit to being back at home.”

“When we ran our mini-pilot, one of the women told me she really liked the idea of knowing that she could ring me after having been discharged from the Mother and Baby Unit.

“The study is a feasibility study looking at the possibility of recruiting women in this setting, whether they would be ok with being randomly allocated to treatment as usual plus the intervention or treatment as usual only and whether we can retain them throughout the study.’’