psychological outcomes of a support intervention in mothers of children with ongoing health...

PSYCHOLOGICAL OUTCOMESOF A SUPPORT INTERVENTIONIN MOTHERS OF CHILDRENWITH ONGOING HEALTHCONDITIONS: THE PARENT-TO-PARENT NETWORK

Ellen J. Silver, Henry T. Ireys, Laurie J. Bauman,and Ruth E. K. SteinAlbert Einstein College of Medicine

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We compared depression, anxiety, anger, cognitive disturbance, and total scoreson the Psychiatric Symptom Index (Ilfeld, 1976) for 365 mothers of 5-to-8 year-olds with diverse health conditions who were randomized either to an experimen-tal (EG) or control (CG) group. EG mothers were offered a 12-month community-based support intervention; CG mothers received standard care. Posttest scores ofEG and CG mothers did not differ significantly. Although intervention effectswere not related to participation level or illness-related and sociodemographicfactors, a significant interaction with stressful life events (SLE) was found.Among mothers reporting more than five SLE in the past year, posttest anxietywas lower in the EG than in the CG, but no difference was found between EGand CG mothers having less than five SLE. The intervention also acted as amoderator variable, with correlations of SLE and posttest depression, anxiety,and total symptoms significantly lower in the EG than CG. Possible explanationsfor these findings are discussed. © 1997 John Wiley & Sons, Inc.

A R T I C L E

JOURNAL OF COMMUNITY PSYCHOLOGY, Vol. 25, No. 3, 249–264 (1997)© 1997 John Wiley & Sons, Inc. CCC 0090-4392/97/030249-16

Portions of this paper were presented at the Ambulatory Pediatrics Association Annual Meeting, Seattle, WA,May 3, 1994.

This work was supported in part by research grant aP50-MH 38280 to Dr. Ruth E. K. Stein from theBranch for Prevention Research of the National Institute of Mental Health. We gratefully acknowledge the co-operation of the New York City Health and Hospitals Corporation. We also would like to express our appreci-ation to Cheryl R. Koeber, Karen B. Savarese, and Stewart A. Ault for their important contributions to this proj-ect and thank the research and intervention staff and all participating families for their help. H. T. Ireyscurrently is at the Department of Maternal and Child Health, School of Hygiene and Public Health, JohnsHopkins University, Baltimore, MD.

Send correspondence to Ellen Johnson Silver, Albert Einstein College of Medicine/Montefiore MedicalCenter, Jack & Pearl Resnick Campus, 1300 Morris Park Avenue, NR 7S-15, Bronx, NY 10461.

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Mothers of children with ongoing health conditions appear to be at increased risk forpsychological distress, in part because they bear most of the responsibility for helpingtheir children adjust to the demands of the condition and for transactions within med-ical and educational settings (Breslau, Staruch, & Mortimer, 1982; Stein, Jessop, & Riess-man, 1983). A child’s entrance into a fulltime school environment is a particularly im-portant developmental transition in which changing roles and expectations affectingboth the parent and child can intensify their risks for mental health problems (Durlak& Jason, 1984). During this time, there may be an increased need for parents to interactwith clinics, school programs, and other institutions because of the child’s health con-dition. The dislocation and displacement of daily activities and the time needed to man-age the child’s care can grow substantially, and mothers may need extra help in negoti-ating these challenges.

The present study was designed to evaluate the psychological outcomes of the Par-ent-To-Parent Network (PTPN), a community-based support program for mothers of five-to-eight-year-old children with a variety of ongoing health conditions. We selected theearly school-age period because it has been identified as a time of strategic develop-mental transition that increases the vulnerability of both mother and child. This inter-vention was based on the presumption that mothers already have considerable skills inresponding to the needs of their children. Support programs must build on these skillsand help mothers adapt their own strategies to emerging developmental concerns. Pro-gram objectives were based on evidence suggesting that enhancing social support andincreasing access to services for the mother, child, and family can contribute to im-provements in maternal mental health (Dunst, Trivette, & Deal, 1994; Gottlieb, 1981;Stein & Jessop, 1984). Furthermore, the importance of using family-oriented interven-tions to meet the non-medical needs of children with ongoing physical illness and theirfamilies has been highlighted repeatedly (Dunst, Trivette, & Deal, 1994).

One effective method of providing a family-centered social support intervention isthrough the use of lay counselors. Because of their cultural affiliation and nonprofes-sional status, lay intervenors often can be powerful agents for creating a relationshipwithin which different types of support can be offered (Larner & Halpern, 1987). In ad-dition, our program elected to use lay intervenors who had had the experience of rais-ing children with ongoing health conditions. The “experiential knowledge” (Borkman,1976) they brought to this relationship was viewed as adding legitimacy to this role andfacilitating their acceptance. We also chose a community-based rather than a hospital-based approach to delivering this intervention to families. Home visiting with parents ofyoung children has been employed in a number of other contexts and is considered apromising approach in improving pregnancy outcomes, influencing parent and child in-teraction, and reducing risk of child abuse (Olds & Kitzman, 1993). Olds and Kitzman(1993) also reviewed three effective randomized control trials of home visiting programsfor parents of children with developmental disabilities or chronic health conditions.However, these programs were conducted by nurses rather than parents or other lay in-tervenors, and they were not specifically designed to enhance maternal social supportor psychological adjustment.

Nevertheless, we did identify several prior attempts to provide assistance through layintervenors to parents whose children had ongoing health conditions or disabilities.These involved home visiting alone or combined with hospital-based support. For exam-ple, both Pless and Satterwhite (1972) and Miller and Diao (1987) initiated interventionsin which volunteers visited parents of disabled children on a weekly basis to offer emo-

250 • Journal of Community Psychology, May 1997

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tional support, help with family interactions, and guidance in accessing community re-sources. Pless and Satterwhite (1972) found positive effects on the children’s psycho-logical status compared with a control group, but they did not assess potential mentalhealth benefits for mothers. Miller and Diao (1987) interviewed parents following theintervention and found that parents felt better, more relaxed, and more able to copewith stress. Parents also reported that their children’s behavior had improved. Pitel, Pi-tel, Richards, Benson, Prince, and Forman (1985) described a hospital staff positioncalled “Parent Consultant” in which the parent of a child who had an ongoing illnessworked with other parents inside and outside the hospital. The Parent Consultant of-fered help with practical problems, such as understanding a ward’s organization or re-solving billing difficulties, and provided emotional support. Participating parents viewedthe Parent Consultants more as friends than professionals and reported that they weremore accessible, more understanding, and more involved with the family than hospitalsocial workers. Iscoe and Bordelon (1985) conducted a survey of programs using the ti-tle “Pilot Parents.” These were self-help groups geared toward advice and emotional sup-port in which parents of children with developmental disabilities were paired with par-ents of newly diagnosed youngsters. Comments from participants indicated theyparticularly liked receiving personal support from someone who understood what it waslike to “have been there” and who could assist them with problems that the helper hadalready encountered.

Several of these projects evaluated their efforts informally and, as noted, they re-ported generally positive findings. However, closer examination of these evaluations re-veals major methodological problems, including biased selection procedures, inade-quate sample sizes, lack of a conceptual framework and reliance on unstandardizedmeasures. The study by Pless and Satterwhite (1972) was well designed, but focused itsefforts on the children’s psychological status and did not evaluate maternal mentalhealth. The present project was designed to address these issues by implementing amethodologically sound evaluation of an intervention’s mental health effects on moth-ers through a randomized, controlled, pretest/posttest design. Mothers of children withongoing health conditions were assigned to either an experimental group that was of-fered a support intervention provided by lay counselors or to a control group that re-ceived standard care. This paper describes mental health outcomes of the support in-tervention by comparing posttest symptoms of psychological distress in mothers assignedto these two groups.

In addition to overall program effects, we investigated whether some subgroups ofmothers benefited more than others. It is unlikely that intervention programs will haveequal impact on all participants, yet evaluation studies typically provide little informa-tion about who benefits most (Olds & Kitzman, 1993). A “moderator” variable in out-come research specifies when a certain effect will hold; it affects the direction or strengthof a relationship between a predictor and an outcome variable (Baron & Kenny, 1986).We examined the potential moderating influences of one program-related factor, levelof participation in the intervention, and several demographic or context variables (timesince diagnosis, presence of illness-related functional impairment, socioeconomic status,family structure, and stressful life events) to determine if these factors defined specificgroups of mothers for whom the PTPN program was particularly successful.

Finally, maternal and child mental health are known to be inter-related; therefore,any interventions affecting the adjustment of the mother are likely to influence the childas well. We also examined the relationship of our maternal support intervention to dif-

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ferences in the children’s behavior and psychological adjustment. Findings from theseanalyses will be described elsewhere.

METHODS

Sample

Recruitment occurred from March 1990 to April 1992 at two large urban medical cen-ters that serve a predominantly inner-city, low-income, minority population. Names offive-to-eight-year-old children who had ongoing health conditions were drawn from therecords of the pediatric inpatient units and the primary care and subspecialty clinics. Anongoing health condition was defined as one that had lasted or was expected to last forat least three months or had required hospitalization for 30 days or more in the previ-ous year (Pless & Douglas, 1971). Because of the demands of the intervention, the moth-er had to speak at least conversational English, live with her child in the Bronx or low-er Westchester, and have consistent access to a telephone. A family was excluded if thechild was moderately or severely mentally retarded or had a life expectancy under 18months.

A list of 1195 children was compiled from hospital records. We were unable to con-tact 443 families either by mail or telephone. Of the 752 families we reached, 240 failedto meet eligibility requirements. In addition, 86 mothers refused, and 61 were unable toschedule an interview during the recruitment period. We enrolled 365 mothers. Studyparticipants did not differ from nonparticipants with regard to the child’s age, sex, ordiagnosis. The children in the sample had a variety of ongoing health conditions that in-cluded asthma (35%), sickle cell anemia, epilepsy, and congenital heart disease (8%each), and cleft lip or palate, cancer, and endocrine disorders (5% each). Spina bifidaand various other congenital anomalies each occurred in 2% of the sample. All other di-agnoses occurred in 1% or fewer of the children; 15% had multiple health conditions,mostly asthma in combination with another disorder.

Table 1 shows that the sample consisted primarily of minorities of lower socioeco-nomic status. Almost half of the families received public assistance; the largest ethnicgroup was Hispanic. Both parents were present in fewer than half of the households; inmore than one-third, no other adult lived in the household. The experimental (EG) andcontrol (CG) groups did not differ significantly on any of these variables. They also didnot differ at baseline in years since the diagnosis, visits to medical providers, hospital-izations, mother’s ratings of the child’s health status and difficulty of care, or presenceof illness-related functional impairment.

Procedure

Data were obtained from mothers through structured interviews that were administeredby trained research assistants. Mothers were paid $20 for each one hour interview. Theywere given the option of being interviewed in English or Spanish; 19 mothers chose theSpanish interview. Baseline interviews were conducted in person, with a signed informed-consent form obtained from each participant. Followup interviews were conducted at 6,12, and 18 months. This report focuses on outcome data collected 12 months after re-cruitment, as this corresponded to the time when mothers in the EG completed the in-tervention and we expected that any demonstrated effects would be strongest. We had


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very high retention in the study; 343 mothers (94%) completed the 12-month posttestinterview. Of these, there were 174 EG mothers (95%) and 169 CG mothers (93%).About one quarter (26.5%) of these followup interviews were conducted by telephone.Interviewers were blind to mothers’ intervention status at the posttest.


Table 1. Comparisons of Baseline Demographic and Medical Characteristicsin Experimental (EG) and Control (CG) Groups

EG (n 5 183) CG (n 5 182)

MeansChild’s age 7.2 7.0Mother’s age 34.7 34.0Years since diagnosis 5.1 5.0Medical visits in last year 11.1 11.9

PercentagesChild’s sex

Males 55 53Females 45 47

Family typeBoth parents in home 40 42Mother alone 33 41Mother with partner unrelated to child 7 6Mother and other adult relative 16 11Foster/grandparent 5 0

Mother’s ethnicityHispanic 43 46Black 41 32White, not Hispanic 11 17Mixed/Other 5 6

Mother’s educationLess than high school 23 21High school graduate 34 38Attended some college 31 35College graduate 10 5Graduate school 3 2

Mother employed 41 42Family receives welfare 48 48Hospitalizations in last year

None 65 60One 21 20Two or more 14 20

Child’s health ratingExcellent 14 14Very Good 18 23Good 33 32Fair 26 22Poor 9 9

Difficulty of child careNot particularly 63 70Somewhat difficult 26 24Very difficult 11 7

Functional limitation 63 60

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At baseline, all mothers were invited to enroll in a longitudinal study to help doc-tors and other health professionals understand how parents were meeting the challengesof raising a child with special health care needs. Following the initial interview, motherswere assigned to the EG and CG using a preestablished randomization procedure by amember of the research team, who was unaware of baseline responses and had no rolein the intervention. Mothers in the EG were mailed a letter and brochure describing thesupport program, and the lay intervenors then called to answer questions and invitethem to participate. A separate signed informed consent form for the intervention wasobtained from those who agreed. This procedure was reviewed and approved by the hos-pital’s Institutional Review Board.

Measure s

The pre- and posttest structured interviews provided data on a wide range of variablessuch as the child’s health, functional status and adjustment, family and demographic fac-tors, and maternal social support, internal psychological resources, and mental health.Data on program participation were obtained from forms that the intervenors complet-ed to document their contacts with mothers. Several variables used in the analyses wereassessed using standardized measures, as described below.

Outcomes in this analysis were mothers’ subscale and total symptom scores on the29-item Psychiatric Symptom Index (PSI; Ilfeld, 1976). The PSI is multidimensional andincludes several elements believed to be related to maternal capacity to provide care, in-cluding depression, anxiety, anger, and cognitive disturbance. The PSI measures inten-sity of 29 common symptoms. Its subscale scores are standardized based on percentages,yielding a possible range from 0 to 100. Although not intended to distinguish psychiatricdiagnoses or to define “caseness,” PSI total scores of 20 or greater are considered to re-flect “high” symptom levels. Concurrent validity with other criteria indicating emotion-al distress has been well established, and the internal reliability of the PSI total scale andits subscales are high. Other studies also have used the PSI successfully with urban, mi-nority populations (Stein & Jessop, 1984; Jessop, Riessman, & Stein, 1988). The PSI wasadministered as part of the pre- and posttest maternal interviews.

Children’s illness-related functional impairment was assessed in the baseline inter-view using the 14-item version of the Functional Status II(R) [FS II(R); Stein & Jessop,1990, 1991]. The FS II(R) has good internal consistency reliability as demonstrated by aCronbach alpha of .85, correlates well with other indicators of children’s health status,and has been used with disadvantaged and ethnic minority populations (Stein & Jessop,1990, 1991). The scale measures level of appropriate behavioral functioning and providesa total score that may range from 0 to 100. For this analysis, we considered only whetherthe child’s baseline FS II(R) score indicated any functional limitation (i.e., was less thanthe maximum of 100).

Stressful life events were measured by a scale that was a modification of the list usedin the Psychiatric Epidemiology Research Interview (PERI; Dohrenwend, Krasnoff, Aske-nasy, & Dohrenwend, 1978). This scale was included in the posttest interview. It askedthe mother to indicate if any of 46 listed events had been experienced in the previousyear and to rate whether each experienced event had been a good or bad event on thewhole. The mother’s stressful life events (SLE) score was the number of “bad” events re-ported.


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Program Description

The lay intervenors were women who had raised children with ongoing health condi-tions. They were recruited through advertisements in neighborhood newspapers. Tenwomen were selected and received a 40-hour training program that focused on listening,reflection, and communication skills, and on the special issues that mothers of childrenwith ongoing conditions experience. Six were chosen to participate in a second inten-sive training program that covered practical topics such as home visiting, coordinatingschedules, and how to describe the program to newly recruited mothers. Of these, threewomen accepted jobs as lay intervenors and continued throughout the project. Theyworked approximately 21 hours per week during the intervention, and were supervisedby a clinical psychologist and a social worker.

The intervention offered to the EG mothers lasted 12 months. It was designed toprovide an expected schedule of six face-to-face meetings in the home (or at the hospi-tal if preferred by the mother) with at least biweekly telephone calls. Families also wereinvited to three group activities with food and entertainment (e.g., picnics, holiday par-ties) that brought mothers and their children together with others in the program. Ourmain goal was to improve the mother’s psychological status by increasing her social sup-port and access to relevant information, services, and knowledgeable advisors. In thisway, we hoped to make mothers feel more empowered and active participants in theirchildren’s health care. Although the mother and her intervenor met to discuss specificissues related to the child’s health condition, they also attempted to identify and addressthe needs and concerns of other family members as well. In addition, all aspects of theintervention sought to reinforce the concept that parents have a great deal of experi-ence in raising a child with an ongoing health condition and that this experience is bothvaluable in itself and potentially useful to other mothers in similar situations. Thus, theprocess by which the intervenor developed a relationship with each mother began by of-fering the mother the chance to participate in a program that might be of some use toher in her role as a mother. Mothers also were provided the opportunity to share theirexperiences and expertise to inform other mothers in similar situations as well as en-lighten and educate professionals who care for children with chronic health conditionsand their families. Mothers were encouraged to identify and discuss issues that con-cerned them. The intervenors also were provided with a set of core topics that could beused to guide conversations and identify unmet needs. Through their talks with moth-ers, intervenors attempted to: (1) link families with existing community resources andencourage them to talk with the child’s health care providers; (2) share informationabout child health and behavior, parenting, and coping among mothers in the program;(3) enhance maternal confidence in parenting and reassure the mother about the ap-propriateness of her concerns; (4) provide a source of emotional support by being avail-able to listen, communicating that she understood the mother’s feelings, and standingby the mother in times of crisis, such as a child’s hospitalization; and (5) help identifysources of support within a mother’s naturally occurring network of family and friends.

RESULTS

Program Participation

More than three quarters (77%; n 5 141) of the EG mothers participated in the inter-vention in some way. However, few EG mothers (18%; n 5 33) had all six planned face-


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to-face meetings with their intervenors. The mean number of face-to-face meetingsamong the 183 EG mothers was 2.9 (SD 5 2.8); the highest total number was 14. Thetotal amount of time spent in face-to-face meetings averaged 4.7 hours (SD 5 5.1) acrossthe full EG. However, the mean among the 141 EG mothers who met at least once withan intervenor was 4.1 meetings (SD 5 2.4), which lasted an average of 6.7 hours in total(SD 5 4.8). Given six one-hour contacts as the expected dose, this was slightly more thanprojected for total time in face-to-face contact. Thus, meetings were fewer but longerthan anticipated. Several active program participants could not complete the interven-tion protocol: one died, one moved to a shelter for abused women, three moved to oth-er states. Five mothers never responded to numerous telephone messages and lettersfrom the intervenors inviting them to participate in the PTPN, but they all continued inthe research interviews. All mothers randomized to the EG were included in outcomeanalyses.

Mothers also received an average of 17.9 (SD 5 13.6) telephone contacts, rangingfrom none (as described above) to one mother who spoke to her intervenor on the tele-phone more than 80 times over the year. Total time of telephone contact averaged 4.1hours (SD 5 3.8), and ranged up to 20 hours. Excluding the nonparticipants, numberof telephone contacts averaged 22.0 (SD 5 12.8), lasting about 5.1 hours (SD 5 3.8) intotal. On the average, the interveners talked to each participating mother approximate-ly twice a month for about 25 minutes in total per month. Twelve mothers accepted tele-phone calls although they never had an individual face-to-face session with a lay inter-venor; five of these 12 mothers also attended one or more PTPN group activities.

Outcomes in Experimental and Control Groups

Table 2 shows the means and standard deviations of maternal PSI scores for the EG andCG at the baseline and postintervention assessments. Despite random assignment, oneway ANOVAs of baseline scores demonstrated that EG mothers performed significantlyworse than CG mothers on all PSI subscales except Depression. Therefore, posttestcomparisons of the groups were made using ANCOVA to control for these initial dif-ferences in scores. Table 2 also provides a second set of posttest scores for each groupthat show the treatment effects after variation due to baseline differences was taken intoaccount using multiple classification analysis (Norusis, 1992). Using ANCOVA, we foundno significant differences between the groups in the PSI Total or any of the subscalescores at the one year assessment. However, the analysis showed that all adjusted posttestscores other than Depression were directionally lower in the EG than the CG. Changesin PSI scores thus consistently favored the EG, except for the Depression subscale, whereboth groups improved over time. In particular, we noted that Anger scores for the EGshowed a significant decrease compared with a commensurate increase in symptoms forthe CG.

Level of Program Participation

We next attempted to determine whether program effects were restricted to subgroupsof mothers defined by amount of intervention received. We examined the degree of con-tact between a mother and intervenor using the combined pattern of telephone callsand face-to-face meetings, as shown in Table 3. In inspecting the distribution of face-to-face meetings, we detected two points where fairly large increments in telephone con-


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Table 2. Pretest and Posttest Means and Standard Deviationson Psychiatric Symptom Index (PSI) Subscales for Experimental (EG)and Control (CG) Groups

Adjusteda

Pretest Posttest Posttest

PSI Subscale Mean (SD) Mean (SD) Mean

DepressionEG 23.8 (17.5) 22.1 (17.5) 21.3CG 20.8 (16.6) 19.6 (16.9) 20.5

AnxietyEG 21.4 (18.0)* 19.4 (17.5) 18.2CG 17.6 (17.4) 17.3 (18.0) 18.5

AngerEG 29.0 (19.8)** 26.7 (19.2) 25.3CG 23.9 (16.5) 25.8 (19.0) 27.3

Cognitive disturbanceEG 27.1 (19.7)* 25.0 (19.5) 23.8CG 22.7 (18.7) 23.2 (18.3) 24.5

Total scoreEG 24.1 (15.5)* 22.1 (15.4) 20.9CG 20.3 (14.3) 20.1 (14.7) 21.4

aPosttest means adjusted for baseline using multiple classification analysis; no adjusted SD available.*p , .05; **p , .01; (differences betwen groups); n 5 343.

Table 3. Number and Total Length in Minutes of Telephone Contacts Between Intervenors andExperimental Group Mothers by Level of Participation Based on Face-to-Face Meetings

Participation in Number of Minutes ofFace-to-Face Meetings N Telephone Contacts Telephone Contact

Mean (SD) Mean (SD)

NonparticipantsRefused 25 3.6 (2.9) 34.0 (25.0)Passive 17 4.6 (4.5) 56.9 (62.2)

Participants (N of Meetings)None 12 12.7 (3.2) 145.7 (43.5)One 20 12.0 (6.3) 152.1 (81.7)Two 20 17.3 (10.3) 239.6 (214.7)Three 19 19.9 (10.8) 267.8 (135.8)Four 15 20.3 (10.8) 296.7 (292.5)Five 22 28.7 (15.2) 424.7 (267.6)Six 14 26.9 (6.3) 366.1 (150.9)Seven 8 29.8 (10.7) 457.8 (219.3)Eight 6 34.2 (7.8) 460.8 (203.2)Nine or more 5 44.8 (15.2) 584.6 (262.2)

Note. “Passive nonparticipants” never directly refused invitation to be in the intervention, but did not attend any face-to-face meetings or events; “Participants” with no face-to-face meetings agreed to be in the intervention (all had telephonecontact and 5 of the 12 also attended group events).

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tact time occurred, and used these to divide EG mothers into four groups as follows: (1)55 mothers who met five or more times with an intervenor formed the “high” partici-pation group; (2) 53 mothers who had from two-to-four meetings were the “moderate”participation group; (3) 32 mothers who completed one face-to-face session or accept-ed telephone contact only were the “low” participation group; and (4) the remaining 42mothers comprised the “nonparticipant” group.

Posttest PSI scores were compared for these four intervention subgroups and the CGmothers using ANCOVA to control for baseline scores. There appeared to be no patternof posttest differences in PSI scores related to level of participation.

Investigation of Other Moderating Variables

As noted earlier, we also sought to determine if program effects were dependent on sev-eral illness-related or sociodemographic variables measured at the initial interview. Eachof these additional analyses examined posttest scores by group assignment and by a po-tential moderating variable as a second factor influencing outcome. We controlled forvariation due to baseline scores through two-way ANCOVAs. The following sections de-scribe the results that were obtained.

Medical and Demographic Variables. Other potential moderating variables examined were:(1) illness-related characteristics, including presence or absence of condition-relatedfunctional impairment and time since diagnosis (more or less than two years), and (2) de-mographic factors of socioeconomic status (receives public assistance or not) and familystructure (single mother households compared with other types). We explored whetherany of these five variables moderated program effects on maternal psychological out-comes by looking for significant interaction terms in two-way ANCOVAs with posttestsymptom scores as the dependent measures and baseline scores controlled. These analy-ses revealed no significant interactions of group assignment with any medical or demo-graphic characteristics. Thus, none of these variables moderated intervention effects.

High Life Stress. In comparing their one-year reports of stressful life events (SLE), wefound that EG mothers had experienced slightly more negative life events than CG moth-ers (3.4 vs 3.0, respectively). We wondered whether their differential exposure to lifestress, although not statistically significant, could have limited the program’s ability toachieve changes in symptoms among the intervention mothers. Therefore, we investi-gated SLE score as a potential moderator and compared posttest psychiatric symptomsfor high- and low-stress mothers. Mothers scoring in the top third on the SLE scale re-ported five or more negative life events during the year, and we defined “low” and “high”stress in the sample based on this cut-off. Two-way ANCOVAs were conducted to exam-ine posttest PSI scores by group and life stress while controlling for baseline scores.

A significant interaction effect of group assignment and SLE was found for posttestscores on the Anxiety subscale (p , .05). The pattern of mean scores suggested that theintervention effectively reduced anxiety symptoms in the subgroup of mothers who re-ported relatively higher life stress. That is, among mothers reporting fewer than five SLEin the past year, posttest Anxiety scores did not differ significantly between the twogroups; in the low stress group, mean Anxiety scores were 17.6 for the EG (n 5 118) and13.5 for the CG mothers (n 5 128). However, among mothers with greater life stress (i.e.,five or more SLE), posttest Anxiety was significantly lower in the EG (23.1; n 5 56) than


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in the CG (29.1; n 5 41), F(1,94) 5 4.61, p , .05. No other posttest differences betweenEG and CG mothers emerged in these analyses.

Buffering Effects of Intervention

It has been suggested that social support can moderate or “buffer” effects of negativelife stressors on mental health (Cohen & Wills, 1985; Wheaton, 1985). That is, supportis hypothesized to protect individuals from the potentially adverse influence of stressfullife events (Cohen & Wills, 1985). Therefore, we also examined whether our support in-tervention might work in this capacity. We examined the correlations between numberof negative life events reported and posttest PSI scores and compared their relativestrengths in the EG and CG using Fisher Z tests.

As shown in Table 4, correlations of life stress and posttest psychiatric symptomscores were significant within each of these two groups; however, the correlations of SLEand symptoms were significantly higher in the CG than in the EG for the PSI Total scoreand for the Depression and Anxiety subscales (p . .05). Although significant group dif-ferences in correlation magnitude were not found for the Anger and Cognitive Distur-bance subscales, the correlations between SLE scores and posttest scores on these twosubscales were fairly low in both groups. These findings suggest that: (1) participating inthe intervention reduced the likelihood that stressful life events would be associated withmaternal distress at the posttest, and (2) that the intervention had particular effects onthe relationship of SLE scores to anxiety and depression symptoms.

DISCUSSION

This study was designed to evaluate mental health outcomes related to participating inthe Parent-To-Parent Network, a community-based program of support provided by layintervenors to mothers of five-to-eight-year-old children with diverse chronic health con-ditions. Contrary to expectation, the experimental and control groups did not differ sig-nificantly in self-reported psychiatric symptoms at the posttest. However, compared withthe control group, the experimental group reported more symptoms at baseline, and


Table 4. Comparisons of CorrelationsBetween Number of Stressful Life Eventsand Psychiatric Symptom Index (PSI)Posttest Scores in Experimental (EG)and Control (CG) Groups

PSI Subscale EG CG

Depression* .21 .41Anxiety* .21 .42Anger .18 .26Cognitive disturbance .25 .21Total score* .25 .44

*Z-test of difference in correlations between groups, sig-nificant p , .05.

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their improvement relative to their initial status suggests that the intervention may haveplayed some positive role. In particular, intervention mothers experienced a significantreduction in anger as compared with a commensurate increase in symptoms for the con-trol group. Posttest measures in other PSI subscales consistently favored mothers in theintervention, except for depression (which improved over time in both groups). Never-theless, any effects were modest and some portion of this change is likely to reflect re-gression to the mean. In a previous study, Michielutte, Patterson, and Herndon (1981)evaluated a program in which a pediatric nurse provided home visits to families of chil-dren with cancer. Similar to our findings, they demonstrated that parents who partici-pated in the program felt more able to control feelings of anger, but their emotional re-actions in terms of anxiety and depression were not affected. On the other hand, ourintervention appeared to diminish maternal anxiety, although primarily in mothers whoreported experiencing relatively higher life stress.

In addition, the intervention acted as a buffer between negative life events andposttest symptoms of emotional distress, particularly those of depression and anxiety. Weconsidered whether the differences in correlations that we found could have been in-fluenced by statistical problems such as restricted range (Baron & Kenny, 1986). How-ever, we determined that the variance characteristics of the subscales were similar in theEG and CG, and were confident in ruling out this alternative explanation for our find-ings. One objective of this program was to develop an ongoing relationship so that theintervenor would be perceived as someone available to the mother in times of crisis. Ourfindings regarding the relationship between negative life stress and maternal mentalhealth at the posttest suggested that the intervention may have served this purpose rea-sonably well.

Nevertheless, we still seek to better understand the pathways by which an interven-tion such as this may influence maternal mental health. It is highly unlikely that a sin-gle intervention strategy will appeal to, or be effective with, all the members of a targetgroup. Thus, an important part of our evaluation included an attempt at ascertainingwhich mothers would benefit from their participation. Introducing moderating variablessometimes can improve the ability of one variable to predict another by helping to de-termine if a relation holds in one subpopulation but not another (Baron & Kenny, 1986).However, other than stressful life events, our analyses did not identify any medical or de-mographic variable that might define subgroups of mothers for whom the interventionwas particularly effective. Very importantly, level of participation among the interventionmothers did not appear to be a critical factor in this respect.

In trying to explain the lack of stronger program effects, we speculated whether tim-ing the posttest assessments of maternal psychological status so close to the point whereEG mothers completed the intervention may have influenced their responses. We hadhypothesized that the strongest effects would occur immediately following the comple-tion of the program and focused our evaluation on this time point. However, if programtermination increased distress in EG mothers, we probably did not measure the maxi-mal effects of the intervention on mental health. As we developed and implemented thePTPN program, we became concerned that it might be conceptually inconsistent to of-fer support to mothers and then withdraw it. The essence of social support is “availabil-ity,” the notion that people will be there for you if you need help. Although motherswere clearly told at recruitment by the intervenor that the program would be one yearin length, there was an intrinsic tension in building a relationship only to terminate it.Intervenors used the technique of a “positive review” of the mother’s year experience in


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the program to help achieve a sense of empowerment and closure. The intervenors alsotried throughout the year to help mothers develop support resources among their owncircles of family and friends. However, in several instances, mothers did not have ade-quate support systems, and the intervenor had little hope of helping to recruit someonefrom the mother’s own network as a resource. Even mothers who reported that they al-ready had adequate support obtained unique kinds of support from the intervenors.Specifically, the lay intervenor was like a “friend” in that there was emotional sharing,but the relationship differed from friendship in that the intervenor did not use the moth-er for support in return. This non-reciprocal relationship is socially rare. Thus, despitecareful planning and various attempts to soften the experience, withdrawal of the inter-vention was difficult. As noted, we cannot know what influence, if any, this had on ourability to detect program effects at the 12-month posttest. Data collected at six monthspostenrollment were not suitable for addressing this question because mothers’ involve-ment varied greatly midway through the intervention and often did not reflect their fi-nal participation status. Therefore, it seemed inappropriate to examine midyear effects.In addition, data obtained at the 18-month assessment (six months postintervention)originally were intended to be used to determine if any effects lasted beyond the inter-vention’s termination. The lack of short-term differences made this additional analysisunnecessary, yet we still compared the groups to explore the possibility of “sleeper” ef-fects. However, no new differences emerged at this later time point. (Results of theseanalyses are available from the authors upon request.)

We considered other threats to our ability to achieve expected mental health effects.For example, Prieto-Bayard (1993) suggests that low participation and dropouts fromparent programs are typical, and that programs may undermine effective engagement byinadvertently increasing demands on mothers with few resources and social supports, aproblem often found among low-income, minority parents. However, as noted, our sup-port intervention was reasonably successful in engaging these mothers in that more thanthree quarters of the experimental group participated in the intervention to some ex-tent and extremely few either dropped out or reduced participation over the year. Al-though telephone calls and meetings are difficult to complete for many families in lightof multiple demands, busy home and work schedules, and repeated health care visits,contact time with mothers averaged about what we intended. Also, participation ratesamong mothers did not seem to be an important factor in determining mental healthchanges.

We also speculated as to whether an intervention with six face-to-face visits and tele-phone contact was too modest to accomplish planned effects. However, we believe thatthe most important intervention ingredient was not the number of visits per se, but therelationship building that was intended to occur between the lay intervenors and themothers; the face-to-face meetings and telephone calls were the strategies used to ac-complish that objective. A diversity of approaches was employed precisely because of oursensitivity to the needs of mothers in our ethnically and culturally diverse community.We responded to the mothers’ cues that they were uncomfortable with a more intensiveface-to-face intervention. Evidence from comments on interviews, testimonial letters sentto intervenors, and post-hoc ethnographic interviews nevertheless suggested that theserelationships were strong and painful to sever.

We also believed that individualizing our approach was critical in meeting the needsof mothers in our study. Because many mothers do not see their children or themselvesas needing a great deal of help, we tried to tailor the intervention to mothers’ perceived


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need for contact and to reduce the feeling of burden by not presenting the lay inter-venors simply as “helpers.” The intervenors’ capacity to connect with the mothers aroundconcerns that they both shared, their ability to present themselves as knowledgeablesources of information about complex medical, educational, and social service systems,and their emphasis on the value of the mother’s experiences facilitated their entree intothe social systems of the participants. As noted, qualitative feedback from participantsand intervenors collected after the intervention was over did indicate that the programprovided a positive, meaningful, and supportive social relationship for mothers. Manymothers anecdotally reported changed perspectives on being the parents of childrenwith ongoing health conditions, and said they felt more understood, more hopeful aboutthe future, and more empowered. Although these mental health changes did not appearto be reflected in our measures, the task of diagnosing why an intervention performeddifferently than expected is extremely complex.

As we have noted, mothers of young children often are faced with unexpected eventsthat can prevent them from coming to appointments. Also, we did not restrict the studyrecruitment to patients in active treatment or to those with long-term ties to our facility.Indeed, some children with ongoing conditions who appeared on the patient rosters andwere eligible for the study may only have been seen at or admitted once to these hospi-tals. Despite these circumstances, the research study itself successfully retained nearly allof its extremely mobile and high-risk sample. This level of success in retaining the re-search sample caused us to consider another possible explanation for small interventioneffects. In examining mothers’ evaluative comments in the final research interview (sixmonths posttermination of the intervention), we noticed that many control group moth-ers, as well as those in the experimental group, said they felt that participating in the re-search itself (as distinct from the intervention) had been helpful because it allowed themto express their feelings about their children’s illnesses and showed that someone caredabout their experiences and opinions. Although one certainly would not have expectedthe interviews alone to increase a mother’s positive self-image or diminish her negativefeelings about the parenting role, their statements suggested that being part of the studyitself could have had some unintended beneficial effects that may have masked some ofthe intervention’s impact. Depression symptoms, in particular, showed improvement forboth groups. Thus, participating in the research interviews may have mimicked a low-dose support intervention. Van Dongen-Melman, Pruyn, DeGroot, Koot, Hahlen, andVerhulst (1995) identified a similar phenomenon in studying late psychosocial conse-quences among parents whose children had survived cancer. The authors noted that dur-ing the interviews a number of parents spontaneously reported beneficial effects of hav-ing had the opportunity to talk about their experiences. Nevertheless, this can only beone very small part of the explanation. We hope that future investigations will be ableto provide additional information about the mechanisms behind the mental healthchanges that will help to target those mothers who are most at risk as well as suggest re-finements in the program that can be incorporated into a more powerful and effectiveintervention.

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