Parental stress and toddler behaviour at age 18 months after pre-term birth

Acta Pædiatrica ISSN 0803–5253

REGULAR ARTICLE

Parental stress and toddler behaviour at age 18 months after pre-term birthKarin Jackson ([email protected])1, Britt-Marie Ternestedt1,2, Anders Magnuson3, Jens Schollin4

1.Department of Health Science, Orebro University, Orebro, Sweden2.Department of Health Care Sciences, Ersta Skondal University College, Stockholm, Sweden3.Clinical Research Centre, Orebro University Hospital, Orebro, Sweden4.Department of Paediatrics, Orebro University Hospital, Orebro, Sweden

KeywordsParental stress, Pre-term infant, Toddler behaviour

CorrespondenceKarin Jackson, Department of Health Science,Orebro University,S-701 82 Orebro, Sweden.Tel: + 46 19 303663 | Fax: + 46 19303639 |Email: [email protected]

Received9 May 2006; revised 9 May 2006; accepted 18May 2006

DOI:10.1111/j.1651-2227.2007.00015.x

AbstractAim: To describe the parent’s judgement of their own stress and the child’s behaviour at 18 months

after pre-term birth and if there are any correlations between these assessments, the morbidity in the

neonatal period, the gestational age at birth and the occurrence of twin/triplet births.

Method: Twenty-one mothers and 19 fathers of pre-term infants answered two questionnaires, The

Swedish Parenthood Stress Questionnaire (SPSQ) and The Toddler Behaviour Questionnaire (TBQ).

Results: Mothers scored somewhat higher than fathers concerning parental stress. Parents with

twins/triplets and of children born in gestational week 25–30 felt more stress, though the differences

were not statistically significant. High-risk diagnoses did not correlate to any of the dimensions. The

parents judged the behaviour of the children similar except that parents of children born in

gestational week 25–30 scored significantly higher for intensity/activity (p = 0.002). The correlation

between parental stress and judgement of their children’s behaviour did not show any significant

association except for the dimension regularity in TBQ (p = 0.016).

Conclusions: The mothers’ and fathers’ assessments of their own stress and of the children’s behaviour were

similar. Parents of very pre-term children felt more stress and judged the children somewhat delayed in their

social behaviours, probably due to their low gestational age.

INTRODUCTIONDuring the last decades great advances have been madein the perinatal care of mother and child. As a result thesurvival of pre-term infants, not least those born extremelyprematurely has increased (1). To become a parent is a ma-jor event for both the mother and father and is associatedwith both expectations and dreams. When a child is bornpre-term, the parents are faced with unexpected stresses,resulting in different stress experiences (2,3), especially inparents of twins or triplets (4). During the infant’s hospitalstay at the neonatal unit, the parents are affected by the spe-cific technological and psychosocial environment (5). Otherstress factors are anxiety about the child’s health and sur-vival (6,7) and their new parental role, which gives feelingsof alienship and imbalance in their daily life (8,9). It is im-portant that the parents are prepared for taking the childhome. To obtain this, the parents need information abouttheir child’s health and care and they should be supportedand given individual care (10–12).

During the child’s first year, the daily life is described asstressing, especially during the early period after dischargefrom the neonatal unit (13). Continued anxiety about thechild’s health, not least its future state of health, affects inparticular the mother’s relationship to the child and leads touncertainty in her care of the child (14,15). This can result,among other things, in increased health care consumption inthis group of children (16,17). The father’s reactions have notyet been fully investigated. Children born pre-term are re-ported to be at greater risk for behavioural disturbances and

the parents have more difficulty in interpreting the child’ssignals (18). This has a considerable impact on the parents,causing uncertainty in their treatment of the child (19,20).Thus, having a prematurely born child has great influence onfamily life. Several studies have shown, however, that this ef-fect decreases over time and that at the age of 2–4 years, thefamily life has become stable (8,21,22).

This study is part of a larger descriptive longitudinal re-search project with both interviews and questionnaires. Theaim of the project was to study parenthood in pre-term birth,partly in the context of health care. The principal aim of thisstudy was to describe the stress experienced by mothers andfathers of a pre-term child when the child has reached theage of 18 months. A further aim was to determine how thetwo parents assessed their child at that age and to find outwhether there was any relation between this assessment andself-perceived parent stress. Additional purposes were to in-vestigate whether the morbidity in the neonatal period, thegestational age at birth and the occurrence of twin/tripletbirths influenced the degree of stress and the parents´ as-sessment of the child.

MATERIAL AND METHODSThe study was performed at the neonatal unit, a level IIIunit, at Orebro University Hospital and at child health cen-tres (CHC) in the county. It was started after the birth ofthe infant, and the family and the newborn infant were thenfollowed up until the child was 18 months old. During theperiod April 1999–February 2000, parents with a newborn

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Parental stress after pre-term birth Jackson et al.

child born at a gestational age of ≤34 weeks were given writ-ten and verbal information about the project and asked ifthey would participate. This information and request werepresented to the parents between 1 and 2 weeks after theinfant’s birth. Study questionnaires were distributed whenthe infants were 18 months old. The choice was to includeparents of children born before gestational week 34 in orderto recruit enough children and parents in a reasonable time.The Research Ethical Committee at the hospital approvedthe project.

Criteria for inclusion of the children were that they shouldnot have any congenital defect and that their parents shouldspeak Swedish and live in the county of Orebro. Twenty setsof parents and one single mother, with a total of 28 infants(15 singletons, 5 sets of twins and 1 set of triplets), wereincluded. In all there were 21 mothers and 20 fathers whoreceived questionnaires and these were answered by all ex-cept 1 father (40 parents). Eleven of the mothers and 11of the fathers were first-time parents. The mean age of themothers was 33.4 (26–44) years and that of the fathers 34.4(29–40) years. Five mothers gave birth by a normal delivery,1 mother by vacuum extraction and 15 by caesarean sec-tion. The mean birth weight of the children was 1595 (range660–2480) g and the mean gestational age at birth was 30.9(25–34) weeks. The mean length of hospitalization was 49.1(14–121) days. Three newborns needed mechanical venti-lation and six continuous positive airway pressures. Fournewborns were very sick with extremely low birthweight, respiratory distress syndrome, sepsis and cerebralhaemorrhage.

To further analyse the impact of gestational age on par-enting stress and infant behaviour, gestational age was cate-gorized as 25–30 weeks or 31–34 weeks. The first categorycomprised 11 children, 8 mothers and 7 fathers, and the sec-ond one 17 children, 13 mothers and 13 fathers.

We also categorized children with regard to high-risk di-agnoses in the neonatal period: gestational week <28, respi-ratory distress syndrome, sepsis and cerebral haemorrhage.Children with one or more of these diagnoses (16 children,11 mothers and 9 fathers) were compared with children whohad none of them (12 children, 10 mothers and 10 fathers).The number of children with high-risk diagnoses and whowere born in gestational week 25–30 was nine (of those therewere three sets of twins). Of those born in gestational week31—34, seven had high-risk diagnoses.

The Swedish Parenthood Stress QuestionnaireData were collected from the Swedish Parenthood StressQuestionnaire (SPSQ) (23). This questionnaire was devel-oped from the parent domain of the American ParentingStress Index, PSI (24) and has been tested for validity andstability (23,25,26). The questionnaire estimates the levelof stress experienced by the parents and the perceived re-sources to cope with the experienced stress. The SPSQconsists of 34 items focusing on the parental domain withpositively worded items. There are five interrelated sub-scales: incompetence regarding parenthood, role restric-tions, social isolation, spouse relationship problems and

health problems. Example of questions of incompetence,‘More difficult than expected to foster child’; of role restric-tions, ‘Child takes all time’; of social isolation, ‘Feeling ofloneliness’; of spouse relationship problems, ‘More problemsin relationship with spouse’ and of health problems, ‘Moretired than before’. The questionnaire is assessed by a 5-pointLikert-type scale from 1 (disagree) to 5 (agree completely).High scores represent a level of high stress experiences in aparticular area of the parent–child relationship (23).

The Toddler Behaviour QuestionnaireData were also collected from the Toddler BehaviourQuestionnaire (TBQ), which has been tested for validityand stability (27–29). The questionnaire estimates thelevel of individual behaviour of the child from theparents’ perspective. The TBQ consists of 37 itemsincluding 6 subscales: intensity/activity, regularity, ap-proach/withdrawal, sensory/sensitivity, attentiveness andmanageability. The dimensions intensity/activity (energyoutput), approach/withdrawal (tendencies in social situa-tions) and sensory/sensitivity (reactivity to strong stimu-lation) are seen as temperamental qualities. Regularity isseen as the rhythmicity of the biological needs of sleep,food and elimination. Attentiveness is related to the infant’sperceptual-cognitive function and manageability to the in-fant’s behavioural dispositions to the caretaking routines.Example of questions of intensity/activity; ‘Activity duringdiaper changing’; of regularity, ‘Regularity in times of fallingasleep’; of approach withdrawal, ‘Adaptability in new situa-tions/places’; of sensory sensitivity, ‘Intensity of reactions tostrong sounds’ and of attentiveness, ‘Differential reactionsto adults and children’. The questionnaire is assessed by a5-point Likert-type scale with endpoints defined by the par-ents’ descriptions of the behaviour of the infant. Accordingto Hagekull and Bohlin (28), during the period between 4and 13 months, the infant in general becomes more activeand intense, more regular, more withdrawing in new situa-tions, less sensitive, more attentive and less manageable.

Statistical methodsDescriptive measures of data are presented as mean andstandard deviation. Analysis of variance (ANOVA) was usedto analyse data with the six different dimensions from SPSQand six dimensions from TBQ as outcome variables. Foreach outcome a model was constructed with four explana-tory factors: (i) mother or father, (ii) singlet or twins/tripletsborn, (iii) gestational age categorized as 25–30 or 31–34weeks, (iv) children having at least one high-risk diagno-sis or no high-risk. Because of the sparsity of the data, as-sumption regarding normality and the linear assumption onthe scale we also analysed the significant findings from theANOVA with Mann–Whitney U test. A p-value <0.05 wastreated as statistical significant. The computation was madein SPSS for Windows version 13.0. To further analyse theassociation between SPSQ and TBQ, we used linear regres-sion with total score in SPSQ as the outcome variable andthe different dimensions in TBQ as explanatory variables.The last dimension in TBQ was not included because of the

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Jackson et al. Parental stress after pre-term birth

missing data. Parents to twins or triplets have answered onceon the SPSQ questionnaire and two or three times, one foreach child, on the TBQ questionnaire (five sets of twins andone set of triplets = 54 questionnaires). To come around thisproblem, we calculated the mean of each dimension in TBQfor each parent of twins and triplets.

RESULTSSPSQThe results of the different dimensions are summarized inTable 1. Mothers scored somewhat higher than fathers on alldimensions except social isolation, although the differenceswere minor and not statistically significant. Parents of single-born children scored lower then parents of twins/triplets onall dimensions, but only the dimension spouse relationshipproblems was significant (p = 0.030). Parents of childrenborn in gestational week 25–30 scored higher on every di-mension than parents of children born later. The total scoresfor theses two subgroups differed significantly in ANOVA(p = 0.031) but could not be confirmed in the Mann–Whitney U test (p = 0.125). The dimensions social isolation(p = 0.035) and spouse relationship problems (p = 0.015)both showed a significant difference, and these results wereconfirmed in the Mann–Whitney U test. High-risk diagnosisdid not correlate to any of the dimensions.

TBQThe results are summarized in Table 2. No major differenceswere found between father and mother regarding any di-mension except for a tendency for mothers to score higherthan fathers regarding attentiveness (p = 0.070). Therewere no major differences between parents of single-bornchildren and those of twins/triplets except that parents ofsingle-born children tended to score higher in the dimensionsensory/sensitivity (p = 0.057). Parents of children born in

Table 1 Results from six different ANOVA with total scores and five different dimensions in the SPSQ as outcome variables. Values can vary between 1 and 5∗

n Total score Incompetence Role restriction Social isolation Spouse relationship problems Health problems

(parents) mean p-value mean p-value mean p-value mean p-value mean p-value mean p-value(SD) (SD) (SD) (SD) (SD) (SD)

Mother 21 2.45 p = 0.456 2.25 p = 0.080 3.52 p = 0.767 1.84 p = 0.208 2.21 p = 0.436 2.49 p = 0.773(0.61) (0.76) (0.76) (0.66) (1.05) (0.76)

Father 19 2.34 1.89 3.49 2.08 2.04 2.43(0.37) (0.43) (0.47) (0.57) (0.54) (0.66)

Single-born 28 2.32 p = 0.145 2.07 p = 0.829 3.44 p = 0.189 1.83 p = 0.119 1.91 p = 0.030 2.40 p = 0.383(0.47) (0.63) (0.64) (0.56) (0.79) (p = 0.003) (0.64)

Twins/triplets 12 2.59 2.12 3.66 2.24 2.63 2.60(0.55) (0.71) (0.62) (0.69) (0.76) (0.85)

Gestational week25–30 15 2.64 p = 0.031 2.28 p = 0.152 3.63 p = 0.161 2.27 p = 0.035 2.62 p = 0.015 2.57 p = 0.432

(0.64) (p = 0.125) (0.88) (0.61) (0.80) (p = 0.046) (0.78) (p = 0.003) (0.80)31–34 25 2.26 1.96 3.43 1.76 1.83 2.40

(0.34) (0.43) (0.64) (0.39) (0.74) (0.65)High-risk diagnosis

No 20 2.30 p = 0.431 2.02 p = 0.687 3.53 p = 0.172 1.79 p = 0.764 1.84 p = 0.763 2.44 p = 0.564(0.34) (0.44) (0.68) (0.41) (0.48) (0.68)

Yes 20 2.50 2.15 3.49 2.11 2.42 2.49(0.62) (0.81) (0.60) (0.75) (1.02) (0.74)

∗Higher values indicate more stress.

p-value in parenthesis refers to the Mann–Whitney U test.

gestational week 25–30 scored significantly higher for in-tensity/activity (p = 0.002) than parents of children bornlater. A tendency towards lower scores for regularity and ap-proach/withdrawal and higher scores for attentiveness wasnoted for parents of children born in gestational week 25–30. Parents of children with at least one high-risk diagnosisare tended to score higher for the dimensions regularity andapproach/withdrawal but lower for attentiveness.

Correlation between SPSQ and TBQThe correlation between parental stress and judgement oftheir children’s behaviour did not show any significant as-sociations with one exception, see Table 3. There is a signif-icant association between SPSQ total score and dimensionregularity in TBQ (p = 0.016), higher regularity correlatesto lower parental stress. The proportion of the variances inparents’ stress explained by the five dimensions in the mul-tivariate analyses is 22%, R2 = 0.22.

DISCUSSIONWhen a child is born pre-term, we know that this has animpact on the whole family. The experiences in the neonatalunit leave their mark both on the parents and on the sib-lings, and in different studies, it has been shown how thewhole family is affected for a varying length of time (2,3). Itis true that our study comprised a relatively limited numberof families and their children, but this study is part of a largerresearch project and the parents were followed up from theirchild’s birth to the age of 18 months, with several interviewsand investigations.

Our main finding is that there were no statistical signifi-cances when comparing mothers and fathers regarding theirperceived stress and their assessment of the child. With re-spect to perceived stress, we know that families can be af-fected for a long time after the birth of the infant (2). In our



Table 2 Results are available for 54 questionnaires of 28 children, then categorized to four factors and used by ANOVA with the different dimensions from TBQ asoutcome variables∗

n Intensity/activity Regularity Approach/withdrawal Sensory/sensitivity Attentiveness Manageability (n = 46)

(questionnaires) mean p-value mean p-value mean p-value mean p-value mean p-value mean p-value(SD) (SD) (SD) (SD) (SD) (SD)

Mother 28 3.88 p = 0.413 3.53 p = 0.921 3.46 p = 0.184 2.82 p = 0.747 3.76 p = 0.070 3.34 p = 0.979(0.50) (1.01) (0.91) (1.11) (0.53) (p = 0.056) (0.54)

Father 26 3.78 3.55 3.71 2.88 3.49 3.36(0.41) (0.80) (0.81) (1.11) (0.67) (0.65)

Single born 28 3.94 p = 0.169 3.31 p = 0.202 3.50 p = 0.429 3.13 p = 0.057 3.30 p = 0.193 2.70 p = 0.728(0.44) (0.94) (0.75) (1.00) (p = 0.043) (0.61) (0.61)

Twins/triplets 26 3.72 3.79 3.66 2.55 3.40 2.60(0.46) (0.81) (0.98) (0.91) (0.57) (0.57)

Gestational week25–30 21 4.03 p = 0.002 3.22 p = 0.003 3.33 p = 0.001 3.06 p = 0.121 3.81 p = 0.003 3.46 p = 0.420

(0.28) (p = 0.005) (0.91) (p = 0.063) (0.75) (p = 0.071) (1.27) (0.53) (p = 0.117) (0.55)31–34 33 3.71 3.74 3.73 2.72 3.52 3.28

(0.51) (0.85) (0.91) (0.76) (0.64) (0.61)High-risk diagnosis

No 22 3.87 p = 0.234 3.37 p = 0.083 3.33 p = 0.002 2.95 p = 0.738 3.78 p = 0.037 3.26 p = 0.959(0.48) (0.72) (p = 0.165) (0.84) (p = 0.069) (0.84) (0.56) (p = 0.140) (0.62)

Yes 32 3.81 3.66 3.75 2.78 3.52 3.39(0.45) (1.01) (0.85) (1.10) (0.64) (0.58)

∗Values can vary between 1 and 5.

p-value in parenthesis refers to Mann–Whitney U test.

study, we found that the mothers generally had somewhathigher stress scores than the fathers, especially with regardto incompetence regarding parenthood and spouse relation-ship problems, while the fathers had somewhat higher scoresconcerning social isolation. The father’s perceived stressregarding social isolation may be due to the change in sit-uation resulting from the child’s birth. Our results are inagreement with those of Tommiska et al. (22). In the study byOstberg (25), where parental stress was measured when par-ents were consulting the paediatric department, the mothershad higher stress scores than the fathers for all dimensionsexcept for health problems. The somewhat higher scoresof stress for the mothers may be due to the fact that theyhad spent more time together with the child after the child’shomecoming and probably also at the neonatal clinic. Themothers had been more involved in its care, which mighthave resulted in greater feelings of responsibility and stressin the parental role (8,13,14,15). The fathers, on the otherhand, had returned to work early after the child’s dischargeand thus had not come so close to the child and not de-

Table 3 Regression analysis on 40 parents with parental stress total score in SPSQ as outcome variable and infant behaviour (TBQ) with respect to intensity/activity,regularity, approach/withdrawal, sensory/sensitivity and attentiveness as explanatory variables

Univariate Multivariate (R2 = 0.22)

�� (95% CI)∗ p-value �� (95% CI) p-value

Intensity/activity −0.21 (−0.59 to 0.18) p = 0.278 −0.23 (−0.64 to 0.19) p = 0.274Regularity −0.19 (−0.37 to −0.02) p = 0.032 −0.23 (−0.41 to −0.05) p = 0.016

(p = 0.220)∗∗ (p = 0.221)∗∗

Approach/withdrawal −0.10 (−0.31 to 0.10) p = 0.304 −0.11 (−0.31 to 0.10) p = 0.298Sensory/sensitivity 0.05 (−0.12 to 0.22) p = 0.552 0.06 (−0.12 to 0.24) p = 0.473Attentiveness −0.04 (−0.32 to 0.25) p = 0.790 −0.16 (−0.52 to 0.20) p = 0.381

∗CI is confidence interval of the slope, �.∗∗p-value in parenthesis after exclusion of one observation.

veloped the same feeling of responsibility for its care (8).Ostberg discusses the same hypothesis, which was also con-firmed by Abidin (19). There is an ongoing discussion inSweden as to whether parental leave should be divided be-tween the parents (30). Traditionally, in Sweden, the motheris at home with the child most of the time. Participation ofthe father in the child’s care is in the best interest not onlyof the child but also of the father himself. That it is of greatimportance that the father spends sufficient time with thechild after its homecoming, and that the health care person-nel support the fathers in this respect cannot be emphasizedstrongly enough.

The parents of singlets exhibited less stress than those whohad had twins or triplets, but it was only spouse relationshipproblems that differed significantly between these groups.This conclusion is supported by the finding of a previousreport (4), which shows that relationship problems betweenparents are probably more common in families with morethan one child, when the care of the children takes so muchtime that the parents have insufficient time for each other.


Jackson et al. Parental stress after pre-term birth

Glazebrook (4) found that first-time mothers who had givenbirth to more than one child had high stress levels in theirdaily lives. The same phenomenon may explain why parentsof very premature infants had higher stress levels than thoseof less premature ones. Both spouse relationship problemsand social isolation were more pronounced in those parentswith a child born in gestational week 25–30 compared toweek 34, although it was not statistically significant.

Regarding the parents’ assessments of their child’s be-haviour at 18 months of age, overall the parents gavesimilar scores, except for the child’s capacity for percep-tion/cognition (attentiveness). Although not statistically sig-nificant, the fathers’ assessment was lower, which raises thequestion if this could be due to that the fathers had spentless time with the child/children. Parents of very pre-termchildren gave higher scores concerning their children’s be-haviour in energy output (intensity/activity, p = 0.002). Thismight be explained by the actual behaviour but also by thatthese children might receive more attention regarding bothtime and content. Parents of children with high morbiditygave higher scores with respect to both regularity (not sta-tistical significant) and to withdrawal (p = 0.002) in newsituations. The question is whether this also may be dueto greater demands by these children for their parents’ at-tention or whether the parents feel some uncertainty in theevaluation of the child. Several studies (18,20) have shownthat it can be difficult for the parents to assess prematurechildren as the behavioural pattern and signals of these chil-dren are not always so distinct as those of full-term chil-dren. If the child is still affected by its neonatal morbidity,this may increase the difficulties for the parents in interpret-ing the child’s behaviour. In this study, however, most of thechildren were in good health at the age of 18 months, eventhough several had been very sick in the neonatal period.But the early morbidity may still have had an effect on theparents at 18 months. In the correlation analysis, no rela-tion was found between the child’s behaviour and parentalstress, except for lower stress levels in parents whose childshowed greater regularity in its daily rhythm (p = 0.016). Ithas been noted in several studies (21,22) that when the dailylife becomes more stable and both the child and parents finda rhythm, the stress experienced in parenthood diminishes.It was interesting in the present study that an increased in-tensity in the child showed no relation to high scores forparental stress, but rather the opposite. Hagekull (29) foundthat children who were difficult to manage had a low degreeof intensity, whereas an easily managed child had a higherdegree of activity and intensity. Our results might be inter-preted in a similar way.

In summary, we found that the mothers’ and fathers’ as-sessments of their children and of their own stress at thechild’s age of 18 months were very similar. Parents of chil-dren who were born very pre-term and who had had adifficult neonatal period were not more stressed than par-ents of children born somewhat less prematurely and nothaving major problems in the neonatal period. However,parents of children born very prematurely assessed theirchildren somewhat delayed in their development of social

behaviours, probably due to their low gestational age com-pared to the other children of the study.

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Parental stress and toddler behaviour at age 18 months after pre-term birth