Early Human Development 90 (2014) 119–124

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Early Human Development

journal homepage: www.elsevier.com/locate/earlhumdev

Associations between parental psychological well-being and

socio-emotional development in 5-year-old preterm children
Mira Huhtala a,b,⁎, Riikka Korja c, Liisa Lehtonen b, Leena Haataja d, Helena Lapinleimu b, Päivi Rautava e,f,
on behalf of the PIPARI Study Group
a
Department of Public Health, University of Turku, Turku, Finland
b
Department of Pediatrics, Turku University Hospital, Turku, Finland
c
Department of Child Psychiatry, Turku University Hospital, Turku, Finland
d
Department of Pediatric Neurology, Turku University Hospital and University of Turku, Turku, Finland
e
Turku Clinical Research Centre, Turku University Hospital, Turku, Finland
f
The Department of Public Health, University of Turku, Turku, Finland

a r t i c l e i n f o a b s t r a c t

Article history: Background: Preterm children are at risk for developing behavioral and emotional problems, as well as being less
Received 8 November 2013 socially competent. Premature birth causes chronic distress in the parents.
Received in revised form 19 December 2013 Aims: The aim of the paper is to discover whether parental psychological well-being is associated with the social,
Accepted 24 December 2013 behavioral, and functional development of very low birth weight (VLBW, ≤1500 g) children at 5 years of age.
Study design: A longitudinal prospective cohort study.
Keywords:
Subjects: A cohort of 201 VLBW infants (≤1500 g, b37 weeks of gestation) born during 2001–2006 in Turku Uni-
Depression
Distress
versity Hospital, Finland was studied.
Parenting stress Outcome measures: At 4-year chronological age of their child, parents independently completed validated ques-
Preterm tionnaires (Beck Depression Inventory, Parenting Stress Index and Sense of Coherence Scale). At 5 years, parents
Sense of coherence and day-care providers evaluated the development of the child by completing the Five to Fifteen questionnaire.
Results: The parents of VLBW children reported significantly more problems in child development compared to
the Finnish normative data. Depressive symptoms and weaker sense of coherence in mothers, but not in fathers,
were associated with more problems in child development. Parenting stress, for both mothers and fathers, was
associated with developmental problems in their child at 5 years of age.
Conclusions: Maternal depressive symptoms and parenting stress of both parents may be risk factors for the
social, behavioral, and functional development of 5-year-old preterm children. On the other hand, stronger
maternal sense of coherence may be a protective factor.
© 2013 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Improved prognosis for survival of very preterm infants has led to
increasing concerns about their neurobehavioral and socio-emotional
development during childhood and adolescence. Previous findings
highlight preterm infants' increased risk for behavioral and emotional
problems [1–6], as well as being less socially competent [1,7]. Deficits
in executive functions have been reported in very low birth weight
(VLBW, birth weight ≤ 1500 g) children even after controlling for
cognitive development [8,9]. Neurodevelopmental problems can be
Abbreviations: BDI, Beck Depression Inventory; FTF, Five to Fifteen questionnaire; MDI,
Mental Development Index; PSI, Parenting Stress Index; SOC, sense of coherence; SOC-13,
Sense of Coherence Scale; VLBW, very low birth weight, ≤1500 g.
⁎ Corresponding author at: Department of Pediatrics/PIPARI, Turku University Hospital,
Kiinamyllynkatu 4-8, 20520 Turku, Finland. Tel.: +358 405941606; fax: +358 23131460.
E-mail address: mira.huhtala@utu.fi (M. Huhtala).
detected even before school attendance [10] but deficits in socio-
emotional development [11] and executive functions [12] may persist
into adolescence and later complicate academic achievement. There is
thus a need to explore factors predisposing for later developmental
problems in preterm infants, in order to prevent or alleviate them.
Previous evidence suggests that parenting and home environment
are important modulators of the psycho-emotional development and
the development of social competence of preterm children [1,13–19].
Apart from acute distress, premature birth itself also causes chronic dis-
tress in parents [20–23] because of their prolonged concerns about
well-being and development of the child [15,24–26]. In the 2000s,
family-centered intervention programs have reduced maternal distress
and improved parent–infant interactions in families with a preterm
infant [27,28]. Maternal distress in particular has been associated with
later behavioral problems [18,19], and recent studies have revealed
parallel results in fathers of preterm children [17]. Still, there is a paucity
of studies that have investigated paternal distress and resilience in the
families of preterm infants.

0378-3782/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved.
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120 M. Huhtala et al. / Early Human Development 90 (2014) 119–124

In this study, we investigated the role of parental psychological well- Table 1

being in relation to the development and behavior of their VLBW child. Infant and family characteristics of children born with very low birth weight (VLBW).

We hypothesized that the parents' depressive symptoms, parenting Characteristics VLBW infants
stress, and weak sense of coherence (SOC) are associated with social, n = 201
behavioral, and functional deficits in very low birth weight (VLBW) Birth weight (grams), mean ± SD [min, max] 1076 ± 283 [400, 1500]
children at 5 years of age. Gestational age (weeks), 28.8 ± 2.8 [23, 35.9]
mean ± SD [min, max]
Small for gestational age (SGA), n (%) 79 (39)
2. Methods
Days in level III hospital, mean ± SD 61 ± 32 [3,183], missing data n = 7
Multiple birth, n (%) 59 (29)
2.1. Participants Male, n (%) 107 (53)
Neurodevelopmental impairment, n (%) 23 (12), missing data n = 6
A regional cohort of 261 VLBW preterm children (birth weight Mental development indexa b70 6 (3), missing data n = 6
Cerebral palsy 12 (6), missing data n = 2
≤ 1500 g and gestational age b 37 weeks) who were admitted to a
Severe visual impairment 0
level III neonatal intensive care unit in Turku University Hospital, Severe hearing deficit 10 (5), missing data n = 2
Finland, between January 2001 and December 2006, were invited to Mental development indexa b85, n (%) 23(12), missing data n = 6
participate in this study as part of a larger prospective longitudinal Mother, n (%)
Education, missing data n = 5
cohort study on the development and functioning of VLBW preterm
≤9 years 24 (12)
infants from infancy to school age (the PIPARI Study [29]). We excluded over 9–12 years 53 (27)
eight infants (four infants lived outside the catchment area of the N12 years 119 (61)
hospital, two had anomalies or a syndrome, and language problems Smoker 37 (20), missing data n = 15
prevented participation of two families). In total, 97% of eligible children Employed 99 (52), missing data n = 11
Father, n (%)
were recruited. Forty-one of the infants died during the neonatal period
Education, missing data n = 6
and 11 families refused to participate after receiving oral and written ≤9 years 18 (9)
information about the study leaving 201 children and their parents in over 9–12 years 114 (59)
the final study group. The PIPARI Study protocol was approved by the N12 years 63 (32)
Smoker 59 (32), missing data n = 16
Ethical Committee of the Hospital District of Southwest Finland.
Employed 177 (94), missing data n = 13
Parents gave their informed consent after receiving written and oral Married/living with a partner, n (%) 182 (98), missing data n = 15
information.
SGA is defined as a birth weight of b−2.0 SD according to age- and gender-specific Finnish
growth charts.
2.2. Design a
Bayley N. Bayley scales of infant development — II. 2nd ed. San Antonio, TX:
Psychological Corporation; 1993.
At 4 years of age, parents independently completed validated
questionnaires (Beck Depression Inventory [BDI], Parenting Stress
Index [PSI], and Sense of Coherence Scale [SOC-13]). At 5 years, parents
and day-care providers evaluated the development of the child by parents were asked to complete self-reporting questionnaires, indepen-
completing the Five to Fifteen (FTF) questionnaire. We studied the dently from each other. Their depressive symptoms were examined
associations between the measures of parental psychological well- using the modified 13-item Finnish translation [34] of the original 21-
being and child development. item BDI [35]. The Finnish translation of the PSI [36] was used to
The characteristics of the study participants and their families are measure the stress related to parenting caused by either child character-
presented in Table 1. Parental background data were obtained from istics (the child domain) or parents' functioning (the parent domain).
the parents when the child was born. Neonatal background data on Higher scores in these two questionnaires indicated more symptoms.
the VLBW infants were prospectively collected from the medical The Finnish translation of the SOC-13 [37] was used to assess the
records. At 2 years corrected age, the children were invited for outpa- parents' global orientation to view the world; to comprehend, manage,
tient appointments to conduct medical and neurological examinations and find meaning in their individual lives. Higher scores in this
by a pediatrician and standardized developmental testing (Bayley questionnaire indicated better SOC. The questionnaires were mailed
Scales of Infant Development, II [30]) by a psychologist. Neuro- one month before the child's fourth birthday and no reminders were
developmental impairment of the child was considered to be present sent. The BDI and PSI questionnaires were used to estimate psychological
if the child exhibited one or more of the following factors: cognitive burden and the SOC-13 questionnaire was used as a measure for
disability (mental development index [MDI] b 70), cerebral palsy resilience.
(determined during systematic follow-up to 2 years corrected age
using the classification proposed by Himmelmann et al. [31] and Bax 2.4. The evaluation of the VLBW infants' social, behavioral, and functional
et al. [32]), severe visual impairment (blindness or visual acuity below development (5 years)
0.3), or severe hearing deficit (hearing loss requiring amplification at
least in one ear or a hearing impairment with a cut-off point of 40 dB). The parents rated their children at 5 years of age using the FTF
In order to exclude the confounding effect of neurodevelopmental parent questionnaire, which is a validated [38,39] questionnaire
impairment of the child on parental psychological well-being we studied comprising 181 questions grouped into eight problem domains
the associations also excluding the children with neurodevelopmental (motor skills, executive functions, perception, memory, language, learn-
impairment. ing, social skills, emotion/behavior) of child development and behavior.
The FTF questionnaire was developed by a multidisciplinary group of
2.3. Parental psychological well-being measures (4 years) Scandinavian clinical researchers for detecting developmental deficits
in 5 to 15-year-old children [40]. The questionnaire was originally
Parental psychological well-being was measured using scores of created in Swedish, but Korkman et al. have conducted a pilot study
depressive symptoms, parenting stress, and the level of their sense of with the Finnish translation [39]. Instead of establishing diagnoses the
coherence. The questionnaires had previously been well validated, and FTF questionnaire was developed to gain information about the relevant
used internationally; they have been described in detail elsewhere problem areas of the child as perceived by the parents [40]. The items
[33]. When VLBW children reached 4 years of chronological age, the were scored (0) “does not apply”, (1) “applies sometimes or to some
 M. Huhtala et al. / Early Human Development 90 (2014) 119–124 121

extent”, or (2) “definitely applies”. The sum of the scores of each domain Table 2
was divided by the number of items in order to obtain the mean value. Maternal and paternal mean scores for inventories indicating parental psychological well-
being when the child was 4 years old.
Higher scores indicated more problems. The norms for 5-year-old
children have been obtained from the Finnish study population, which Mothers Fathers p
included 769 children [39]. n Mean (SD) n Mean (SD)
In the present study, the evaluation was limited to three domains of
Beck Depression Inventory 144 8.4 (6.9) 118 5.7 (5.8) b0.001
FTF assessing social skills, emotional/behavioral problems (including Parenting Stress Index
subdomains of internalizing symptoms, externalizing symptoms, and Child domain 149 91.7 (24.2) 124 92.0 (22.8) ns
obsessive–compulsive behavior), and executive functions (including Distractibility/hyperactivity 150 21.0 (6.1) 124 21.6 (5.1) ns
subdomains of attention, hyperactivity/impulsivity, hypoactivity, and Adaptability 149 22.5 (6.5) 124 22.8 (6.5) ns
Reinforces parent 150 9.2 (3.2) 124 9.3 (3.3) ns
planning/organizing) covering aspects of everyday functioning. The Demandingness 149 18.3 (5.8) 124 17.3 (5.9) b0.01
FTF questionnaire was mailed one month before the child's fifth Mood 150 9.5 (3.1) 124 9.5 (2.6) ns
birthday. The parents completed and returned the questionnaire by Acceptability 151 11.3 (4.4) 124 11.5 (4.1) ns
mail. No reminders were sent. In order to explore whether the parents' Parent domain 147 117.8 (29.2) 123 108.2 (25.1) b0.001
Competence 148 27.4 (7.6) 123 25.8 (6.2) b0.01
own psychological well-being influenced the way they perceived their
Isolation 148 12.9 (4.4) 124 12.0 (3.6) ns
child's development and behavior, we also asked the day-care providers Attachment 149 12.1 (3.2) 123 12.6 (3.7) b0.01
to complete the FTF questionnaire. Health 150 12.1 (3.6) 124 10.4 (2.9) b0.001
Role restriction 148 17.0 (5.2) 123 15.7 (4.9) b0.01
Depression 148 19.3 (6.4) 124 16.4 (5.1) b0.001
2.5. Statistical analysis Spouse 149 17.1 (5.5) 124 15.3 (4.9) b0.001
Total score 147 209.6 (50.5) 123 200.3 (45.6) b0.01
Life stress 150 1.8 (1.5) 124 1.3 (1.6) b0.01
The statistical analyses were performed with SAS for Windows
Sense of Coherence Scale 140 67.9 (11.7) 112 71.4 (10.1) b0.001
(version 9.2; SAS Institute, Cary, NC). P-values b0.05 were considered
to be statistically significant. The associations between parental well- ns: non significant.
p-value defines the significance between the maternal and paternal mean scores.
being measures and child development measures were studied twice:
including and excluding the children with neurodevelopmental impair-
ment. The associations between continuous predictor variables (mater-
nal and paternal scores for BDI, PSI and SOC-13 questionnaires) and
The infants of the non-responding parents were hospitalized for
continuous outcome variables (FTF scores) were analyzed using a
longer in level III hospitals than the infants of the participating families
generalized linear model with a negative binomial distribution and
(mean 75 days vs. 60 days, p b 0.05). Furthermore, the non-responding
log-link. The logarithm of the number of answered questions was
fathers smoked more often (17% vs. 6%, p b 0.05) than the responding
used as the offset variable. First, these negative binomial regression
fathers. The non-responding mothers were more often unemployed
models were used to study if any of the background characteristics
(20% vs. 4%, p b 0.01) and had fewer educational years (p b 0.01)
were possible predictive variables for the selected FTF domains. Associ-
than the responding mothers.
ations between each parental variable and the FTF scores were then
studied, controlling for the background variables which had a significant
univariate association with the FTF score. The adjusted models are pre-
3.2. Social, behavioral and functional development of the children (5 years)
sented in Table 4. The FTF scores given by the parents and the day-care
providers were compared using a paired samples t-test. Pearson's
A total of 161 (80%) FTF questionnaires were returned. The respond-
correlation was used to study the association between the parents'
er was the mother (n = 133), the father (n = 5) or the mother and
psychological well-being and the difference between the FTF scores
father together (n = 20). The responder was not indicated in three
given by the parents and the day-care providers.
questionnaires. Day-care providers completed questionnaires for 124
Proportions of parental FTF-scores above the 90th percentile were
(62%) children. Fifteen children did not need day-care services as they
compared with the Finnish norm population using a Chi-Square test.
were taken care of by a parent. This explained the lack of the day-care
For analysis of non-participation, two nominal variables (Table 1)
giver's questionnaire for these children. When completing the FTF
were compared with the χ2-test or Fisher's exact test, as appropriate.
questionnaire, the day-care givers had known the children an average
Associations between parental education and dropout status were
of 17 months.
studied using χ2-test for trend. The t-test for independent samples
The mean FTF scores for the VLBW children are shown in Table 3,
was used for comparing the continuous background variables of
showing also the proportion of parental scores over the 90th percentile,
responders and non-responders. An MDI of b85 was used in the dropout
according to the Finnish normative data [41]. The VLBW children were
analysis, because our population included only six children with an
reported to have significantly more problems in all of the domains
MDI of b70.
compared to the normative data.
The day-care providers reported more problems in social skills than
3. Results did the parents (p b 0.001). In the subdomain level, the day care
providers reported more problems than the parents in attention and
3.1. Parental psychological well-being (4 years) hypoactivity (p b 0.05 and p b 0.001, respectively). The correlations be-
tween the psychological well-being of the parents and the difference
Of the 201 participating families, 176 (88%) returned at least one of between the FTF domain scores given by the parents and the daycare
the questionnaires assessing parental psychological well-being when providers were not statistically significant.
the child was 4 years of age. The mean scores defining parents' The mother not returning the FTF questionnaire had completed
depressive symptoms, parenting stress and sense of coherence, as well fewer years of education than the mothers who returned FTF question-
as the number of responding parents are presented in Table 2. The naire (p b 0.001). The FTF questionnaire was more often returned for
mothers reported significantly more symptoms of depression and children whose MDI at 2 years corrected age had been ≥85, compared
weaker SOC, compared to the fathers. The mothers also reported more with the children with MDI b85 (92% vs. 74%, p b 0.05). We did not
parenting stress due to the stress caused by the parental functioning have background information of those day-care providers who did not
(the parent domain) than the fathers. return the FTF questionnaire.
122 M. Huhtala et al. / Early Human Development 90 (2014) 119–124

Table 3
The mean (SD) scores of the Five to Fifteen (FTF) questionnaire. The comparison of the parental and the day-care providers' scores and the proportion of parental scores above the 90th
percentile of the normative scores are presented.

FTF domains Parental scores Day care providers' Difference Parental scores N90th percentile according to the FTF manuala
scores

n = 161 n = 124 Estimate (95% CI) n (%)

Social skills 0.20 (0.24) 0.34 (0.42) −0.11 (−0.17 to −0.05)⁎⁎⁎ 34 (21)⁎⁎⁎
Emotional/behavioral problems 0.17 (0.18) 0.17 (0.21) 0.02 (−0.02 to 0.06) 24 (15)⁎
Internalizing symptoms 0.14 (0.16) 0.15 (0.20) −0.007 (−0.04 to 0.03) (No valid norms)
Externalizing symptoms 0.25 (0.29) 0.22 (0.31) 0.06 (−0.002 to 0.12) (No valid norms)
Obsessive–compulsive 0.09 (0.15) 0.13 (0.28) −0.03 (−0.07 to 0.02) (No valid norms)
Executive functions 0.43 (0.33) 0.53 (0.51) −0.07 (−0.15 to 0.005) 33 (21)⁎⁎⁎
Attention 0.44 (0.39) 0.58 (0.58) −0.11 (−0.20 to−0.02)⁎ (No valid norms)
Hyperactivity/impulsivity 0.52 (0.43) 0.53 (0.58) 0.02 (−0.08 to 0.13) (No valid norms)
Hypoactivity 0.21 (0.30) 0.44 (0.54) −0.20 (−0.30 to−0.11)⁎⁎⁎ (No valid norms)
Planning and organizing 0.42 (0.47) 0.53 (0.60) −0.09 (−0.19 to 0.02) (No valid norms)
⁎ p 0.05.
⁎⁎ p b 0.01.
⁎⁎⁎ p b 0.001.
a
Korkman M, Kadesjö B, Trillingsgaard A, et al., eds. Viivi (5–15)-käsikirja [FTF manual in Finnish] kyselylomake vanhemmille 5–15 -vuotiaiden kehityksestä ja käyttäytymisestä 1st edn. ed.
Helsinki: ADHD-liitto r.y.; 2005.

3.3. Parental psychological well-being in relation to the social, behavioral
and functional development of the child
The adjusted associations between the measures defining parental
psychological well-being and the social, behavioral, and functional
development of the child are presented in Table 4. Mothers' depressive
symptoms were associated with more problems in all the examined
developmental areas i.e. social skills, emotional/behavioral problems,
and executive functions. However, fathers' depressive symptoms did
not associate with any of the developmental areas.
Maternal parenting stress (PSI total, child, and parent) was associat-
ed with more problems in all the selected developmental areas. Total
parenting stress and parenting stress of the fathers because of the child's
characteristics (PSI child) was associated with all the developmental
domains of the child.
The SOC of the mothers was associated with all of the three develop-
mental areas while fathers' SOC did not associate with any of them.
The associations remained essentially similar (data shown in
Supplemental Table S1) if we excluded the children with neuro-
developmental impairment.
4. Discussion
The parenting stress experienced by both the mothers and the
fathers of 4-year-old preterm children was associated with social,
behavioral, and functional developmental problems in the same
children at 5 years of age. This finding is in line with our previously
reported associations between parental psychological well-being and
cognitive development at 2 years corrected age [33] as well as behavior-
al problems at 3 years of chronological age [17]. Together these findings

Table 4
Adjusted associations between scores defining parental variables and child development scores (negative binomial regression).

FTF at 5 years Social skillsa Emotional/behavioral problems b

Executive functionsc

RR (95% CI) RR (95% CI) RR (95% CI)

BDI
Mothers 1.06 (1.02 to 1.09)⁎⁎⁎ 1.06 (1.03 to 1.09)⁎⁎⁎ 1.05 (1.03 to 1.07)⁎⁎⁎
Fathers 1.02 (0.97 to 1.06) 1.01 (0.98 to 1.05) 0.99 (0.96 to 1.02)

PSI
Mothers
Total 1.01 (1.01 to 1.02)⁎⁎⁎ 1.01 (1.01 to 1.01)⁎⁎⁎ 1.01 (1.00 to 1.01)⁎⁎⁎
Child domain 1.02 (1.02 to 1.03)⁎⁎⁎ 1.02 (1.01 to 1.03)⁎⁎⁎ 1.02 (1.01 to 1.02)⁎⁎⁎
Parent domain 1.02 (1.01 to 1.02)⁎⁎⁎ 1.01 (1.01 to 1.02)⁎⁎⁎ 1.01 (1.00 to 1.01)⁎⁎⁎
Fathers
Total 1.01 (1.01 to 1.02)⁎⁎⁎ 1.01 (1.00 to 1.01)⁎⁎ 1.00 (1.00 to 1.01)⁎
Child domain 1.03 (1.02 to 1.04)⁎⁎⁎ 1.02 (1.01 to 1.02)⁎⁎⁎ 1.01 (1.00 to 1.02)⁎⁎
Parent domain 1.02 (1.01 to 1.03)⁎⁎⁎ 1.01 (1.00 to 1.02)⁎ 1.01 (1.00 to 1.01)

SOC-13
Mothers 0.95 (0.94 to 0.97)⁎⁎⁎ 0.96 (0.95 to 0.98)⁎⁎⁎ 0.97 (0.96 to 0.98)⁎⁎⁎
Fathers 0.99 (0.96 to 1.01) 0.99 (0.97 to 1.01) 1.00 (0.98 to 1.01)

RR: rate ratio; e.g. one point increase in mother's BDI score was associated with 1.06-fold increase in FTF social skills score.
Associations are significant when 95% confidence interval does not include value 1. Significant associations are bolded.
FTF: Five to Fifteen parent questionnaire; BDI: Beck Depression Inventory; PSI: Parenting Stress Index; SOC-13: Antonovsky's Sense of Coherence Scale.
Higher scores on BDI and PSI indicate more depressive symptoms and stress, respectively. Higher scores on SOC-13 indicate better sense of coherence.
⁎ p b 0.05.
⁎⁎ p b 0.01.
⁎⁎⁎ p b 0.001.
a
Adjusted for gestational age, birth weight, days of hospitalization in a level III hospital, and mental development index.
b
Adjusted for maternal education.
c
Adjusted for birth weight, gender, days of hospitalization in a level III hospital, and maternal education.
 M. Huhtala et al. / Early Human Development 90 (2014) 119–124
add important information of the long-term impact of parental psycho-
logical well-being for the development of preterm children.
As the mothers of preterm infants have an increased risk of
postpartum depression [22,42], there is a growing interest in discover-
ing how depression might affect the development of preterm children.
We found that maternal, but not paternal, depression correlated with
the social, behavioral, and functional development of preterm children
at 5 years. Our finding is supported by the study of Silverstein et al.
[43], which showed that maternal depression was associated with
negative maternal perceptions of the child's social skills and abilities
in preterm-born preschoolers. Previously, our own studies have
shown that paternal depressive symptoms are associated with internal-
izing, but not externalizing, behavioral problems at 3 years of age [17].
Based on the present study, the effect of paternal depressive symptoms
may decrease over time. In families with a depressive father, there
might be other persons in the expanding social network, or maybe the
mother, compensating for the effect on the development of the child.
Previous studies have shown that fathers may leave the major
responsibilities of routine child care to the mothers [44,45] as the
fathers of preterm children may want to work and provide financial
security for their family [46]. Therefore, depression in mothers may
have a stronger effect on the development of a preterm child, as the
mothers are more present and closer to the child than the fathers.
Our results show a robust association between both maternal and
paternal parenting stress and the social, emotional and functional
development of the child. Our study is supported by a previous study
showing that 4-year-old children, born preterm or full-term, had more
social and attention problems if their mothers had reported emotional
stress one year earlier [47]. Several intervention programs supporting
parenting in neonatal care have reduced later parenting stress [48,49]
and improved parent–child interaction [27,49]. Interestingly, some of
these interventions have also been associated with better cognitive
development [50,51].
There is a paucity of research on the protective factors concerning
parental psychological characteristics on the development of a preterm
infant. Our study provides an interesting finding suggesting that SOC is a
protective factor in mothers. We assume that the mothers who believe
that they can control their own lives may also be better able to support
their child in their developmental challenges. As the developmental
outcomes of the child were not affected by the SOC of the father, we
speculate that a father's weak SOC may be compensated by the mother
or other persons in the child's social network.
As the developmental impairments of preschool-age children tend
to be diffuse, before becoming more specific later, we used the FTF
questionnaire, which is not developed to establish a diagnosis but
instead to cover any concerns the parents might have about the devel-
opment of their child. As a more comprehensive assessment than
other methods which aim to detect clinical disorders, the FTF highlights
more minor problems which can later affect the academic performance
of preterm children. The FTF demonstrated that preterm children have
more problems in all of the studied developmental areas compared to
the normative population of Finnish children of same age [39]. In this
study, child outcome was reported both by the parents and day-care
providers. Some authors have suggested that the mothers' mental
health may affect the way they report child's behavioral prob-
lems [52,53]. In our study, the psychological well-being of the parents
did not affect the amount of problems they reported by the FTF
questionnaire when compared to the day-care providers' reports. As
expected, the day-care providers reported more social problems, atten-
tion deficits, and hypoactivity in the preterm children than did the
parents. The challenging group situation of a daycare environment
may provoke problems in social skills and executive functions even if
the child can compensate for them in their home environment.
Our data were based on a representative cohort of VLBW infants
from a defined geographical area. To be able to generalize our results,
we did not exclude multiples or SGA-children since they are important
123
subgroups in preterm populations. The study methods were standard-
ized, internationally used and validated. Furthermore, we analyzed
maternal and paternal associations with child behavior separately and
collected paternal data directly from the fathers. The response rate of
80% can be considered acceptable as no reminders were sent to the
participants. More FTF questionnaires were missing if the child had an
MDI b85 at 2 years of age. We believe that adding these responses to
the analyses would have strengthened the results, especially for the
fathers whose poorer psychological well-being has been associated
with a lower MDI in a preterm child [33].
Finally, it is important to emphasize that the longitudinal design of
the present study can suggest, but not determine, causal directions.
The associations between parental psychological well-being and child
development reflect multifactorial processes. The directions of these
associations are unclear and may well be bi-directional, as also stated
by other authors [54]. We may also assume that the problems in child
development already evident at the age of 4 years can cause depressive
symptoms and parenting stress in the parents. However, we found that
the associations between parental psychological well-being and child
development existed even in the children without neurodevelopmental
impairment. Similarly, previous evidence from family-based interven-
tion studies suggest that it is possible to improve the developmental
outcome of preterm children by supporting the parent–infant relation-
ship and mother–infant interaction [50,51].
5. Conclusions
Based on our findings we suggest that maternal depressive symp-
toms and parenting stress of both parents may be risk factors for the
social, behavioral, and functional development of 5-year-old preterm
children. On the other hand, a stronger sense of coherence in the
mothers may be a protective factor. The implication of our study
results is to address parental psychological well-being in the follow-
up of preterm children in addition to alleviate their developmental
problems.
Conflict of interest statement
This study was supported by personal grants to the first author from
the South-West Finnish Fund of Neonatal Research, Alli Paasikivi Foun-
dation, Emil Aaltonen Foundation, and the Turku University Hospital
EVO Funds. The funding sources had no role in the study design; the
collection, analysis, or interpretation of data; the writing of the article;
or the decision to submit it for publication. The authors declare no finan-
cial interest, arrangement or affiliation with a commercial organization
that may have direct or indirect interest in the subject matter.
Supplementary data to this article can be found online at http://dx.
doi.org/10.1016/j.earlhumdev.2013.12.009.
Acknowledgments
We acknowledge the following members of the PIPARI Study group:
Mikael Ekblad, M.D.; Satu Ekblad, R.N.; Eeva Ekholm, M.D., Ph.D.; Pentti
Kero, M.D., Ph.D.; Virva Lepomäki, M.Sc.; Marika Leppänen, M.D.;
Annika Lind, Ph.D.; Hanna Manninen, M.D.; Jonna Maunu, M.D., Ph.D.;
Jaakko Matomäki, M.Sc.; Petriina Munck, Ph.D., Pekka Niemi, Ph.D.;
Anna Nyman, Psych.Lic.; Pertti Palo, M.D., Ph.D.; Riitta Parkkola, M.D.,
Ph.D.; Liisi Rautava, M.D., Ph.D.; Katriina Saarinen, Physiotherapist;
Elina Savonlahti, M.D.; Sirku Setänen, M.D.; Matti Sillanpää, M.D.,
Ph.D.; Suvi Stolt, Ph.D.; Päivi Tuomikoski-Koiranen, R.N.; Timo
Tuovinen, B.A.; Milla Ylijoki, M.D., Ph.D.; and Tuula Äärimaa, M.D., Ph.D.
Special thanks to Jaakko Matomäki for help and advice in data
analyses.
124 M. Huhtala et al. / Early Human Development 90 (2014) 119–124
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