Parenting Behavior Is Associated With the Early Neurobehavioral Development of Very Preterm Children Karli Treyvaud, Vicki A.

Anderson, Kelly Howard, Merilyn Bear, Rod W. Hunt, Lex W. Doyle, Terrie E. Inder, Lianne Woodward and Peter J. Anderson Pediatrics 2009;123;555 DOI: 10.1542/peds.2008-0477

The online version of this article, along with updated information and services, is located on the World Wide Web at:
http://pediatrics.aappublications.org/content/123/2/555.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2009 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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ARTICLE

Parenting Behavior Is Associated With the Early Neurobehavioral Development of Very Preterm Children
Karli Treyvaud, DPsycha,b, Vicki A. Anderson, PhDa,b, Kelly Howard, BSca,b, Merilyn Bear, RNa, Rod W. Hunt, PhDa,c, Lex W. Doyle, MDa,d,e, Terrie E. Inder, MDa,f, Lianne Woodward, PhDg, Peter J. Anderson, PhDa,b,d
aCritical Care and Neurosciences, Murdoch Childrens Research Institute, Victoria, Australia; bSchool of Behavioural Science and dDepartment of Obstetrics and Gynaecology, University of Melbourne, Victoria, Australia; cNeonatal Medicine, Royal Childrens Hospital, Victoria, Australia; eNewborn Research, Royal Womens Hospital, Victoria, Australia; fSchool of Medicine, Washington University, St Louis, Missouri; gDepartment of Psychology, University of Canterbury, Christchurch, New Zealand

The authors have indicated they have no nancial relationships relevant to this article to disclose.

Whats Known on This Subject

Preterm children are at risk for neurodevelopmental impairments, and parenting is a potential protective factor for children at risk. Certain parenting behaviors have been linked with better outcomes in preterm children.

What This Study Adds

This study includes a measure of social-emotional competence and examines the relationship between this outcome and parenting. There is a focus on parent-child synchrony, and the sample has a mean gestational age lower than that in many previous studies (ie, very preterm sample).

ABSTRACT
OBJECTIVE. There is an increasing focus on social and environmental factors that promote and support the early development of highly vulnerable children such as those born very preterm. The aim of this study was to assess the relationship between parenting behavior, parent-child synchrony, and neurobehavioral development in very preterm children at 24 months of age.

www.pediatrics.org/cgi/doi/10.1542/ peds.2008-0477 doi:10.1542/peds.2008-0477

Key Words prematurity, parent-child interaction, neurobehavioral, development, outcome Abbreviations MDIMental Developmental Index PDIPsychomotor Developmental Index ITSEAInfant Toddler Social and Emotional Assessment
Accepted for publication May 27, 2008 Address correspondence to Karli Treyvaud, DPsych, Parenting Research Centre, 24 Drummond St, Carlton, Victoria 3053, Australia. E-mail: ktreyvaud@parentingrc. org.au

1250 g birth weight) and their parents/guardians. At 2 years corrected age, parents/guardians and children completed a semistructured parent-child interaction task assessing dyad synchrony and parenting behavior (positive affect, negative affect, sensitivity, facilitation, and intrusiveness). Cognitive and motor development was assessed by using the Bayley Scales of Infant Development II, and the Infant Toddler Social and Emotional Assessment was used to assess socioemotional development (social-emotional competence and internalizing and externalizing behavior).
RESULTS. After controlling for social risk, most parenting domains were associated with

METHODS. Participants were 152 very preterm children (30 weeks gestation or

cognitive development, with parent-child synchrony emerging as the most predictive. Greater parent-child synchrony was also associated with greater social-emoPEDIATRICS (ISSN Numbers: Print, 0031-4005; tional competence, as was parenting that was positive, warm, and sensitive. Parents Online, 1098-4275). Copyright 2009 by the American Academy of Pediatrics who displayed higher levels of negative affect were more likely to rate their children as withdrawn, anxious, and inhibited, but, unexpectedly, higher negative affect was also associated with more optimal psychomotor development. Parenting was not associated with externalizing behaviors at this age.
CONCLUSIONS. Specic parenting behaviors, particularly parent-child synchrony, were associated with neurobehavioral development. These ndings have implications for the development of targeted parent-based interventions to promote positive outcomes across different developmental domains during the rst 2 years of life for very preterm children. Pediatrics 2009;123:555561

younger gestational ages.1,2 Consequently, there is considerable interest in the long-term outcome of this population. Research indicates that very preterm children are at increased risk for a range of neurodevelopmental impairments, with 10% to 15% having a neurosensory impairment such as cerebral palsy, blindness, or deafness and another 50% having more subtle neurobehavioral impairments such as cognitive decits, learning disabilities, or emotional-behavioral problems.3 A number of risk factors have been associated with poor neurobehavioral outcome, including medical complications such as bronchopulmonary dysplasia, infection, and brain injury.2 Not surprisingly, social and environmental factors, such as low socioeconomic status and parenting style, have also been reported to inuence the development of preterm children.47
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ECENT DECADES HAVE seen a signicant increase in the number of very preterm infants surviving, especially at

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Fewer researchers have investigated protective factors that promote and support the early development of very preterm children. Improving our understanding of the key protective factors in this population may partially explain variable outcomes observed with children born very preterm, but more importantly, this knowledge may guide the content of preventive and early intervention programs. Two factors known to inuence child development are the caregiving behaviors of parents and the quality of the early parent-child relationship. Theorists such as Bowlby8 proposed that when the parent is perceptive of the childs signals and responds promptly and appropriately, the childs development and the parent-child relationship thrives. Not only are specic parenting behaviors such as responsiveness and sensitivity important inuences, synchrony is a vital component of the parent-child relationship and contributes to development. Core features of parent-child synchrony are the dyads capacity to share and match each others affect and behavior, which in turn serves to provide the child with a secure base from which they can explore their environment, grow, and develop.9 The parent-child relationship has been suggested as 1 factor that may moderate or mediate longer-term outcomes for children born very preterm.10 Specically, there is some evidence to suggest that prematurity may pose challenges for early parent-child synchrony,11 which may in turn inuence child development. Conversely, parenting that is warm (eg, displays positive affect, provides praise) and sensitive (eg, displays appropriate and prompt reactions to the childs cues) and consistently provides these aspects of support in an ongoing way that matches the childs developmental level and needs has been found to have a protective effect on the development of preterm children.12,13 More research is needed to examine the protective role of parenting, particularly parent-child synchrony, in this population; previous research has tended to involve unrepresentative cohorts such as parents with emotional difculties,14 populations at high social risk,7,13 and infants at low biological risk.13 With this study we aimed to investigate the relationship between specic parenting behaviors, early parent-child synchrony, and neurobehavioral development in a large representative sample of very preterm children and their parents/guardians. Considering the link between social factors and childrens outcomes,4,5 a measure of social risk was included in the analyses. It was predicted that warm, sensitive, facilitative, and highly synchronous parenting would be associated with more optimal development, whereas negative and intrusive parenting would be associated with less optimal development in very preterm children. PATIENTS AND METHODS Participants were families with infants who were born at 30 weeks gestation or with a birth weight of 1250 g at the Royal Womens Hospital (Melbourne, Australia) between 2001 and 2003. Informed parental consent was necessary for family participation, and the study was approved by the Royal Womens Hospital Ethics Committee. Two hundred twenty-nine children were initially
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TABLE 1 Medical and Sociodemographic Characteristics of the Very Preterm Sample (N 152)
Characteristic Male, n (%) Gestational age, mean (range), wk Birth weight, mean (range), g Multiples, n (%) Days in hospital, mean (range) Bronchopulmonary dysplasia, n (%)a Conrmed infection, n (%)b Conrmed necrotizing enterocolitis, n (%) Grade III/IV intraventricular hemorrhage, n (%) Cystic periventricular leukomalacia, n (%) Maternal age at birth of child, mean (range), yc Social risk category (moderate/high), n (%) Value 85 (56) 27.4 (2232) 954.7 (4141395) 66 (44) 88.0 (32235) 54 (36) 73 (48) 8 (5) 6 (4) 7 (5) 31.9 (2046) 88 (58)

a Bronchopulmonary dysplasia is dened as the requirement for supplemental oxygen at 36 weeks corrected age. b Infection in the infant is dened by positive blood culture or more than 1 abnormal marker of sepsis. c n 133.

recruited as part of the Victorian Infant Brain Studies cohort. Given the nature of the parent-child interaction task, children with signicant neurosensory or medical problems (n 13) or from nonEnglish-speaking households (n 13) were excluded from this study. At the 2-year follow-up, 5 children were not able to be followed up within 4 weeks of their second birthday (corrected for prematurity), and 2 families refused followup. From a potential sample of 196 participants (86% of original cohort), parent-child interaction data were unavailable for 44 children, 33 interactions were unable to be lmed because of technical difculties (eg, camera not working, assessment was completed in the participants home), and 11 children were uncooperative (ie, distressed, inhibited). The sociodemographic and neonatal characteristics of the nal sample of 152 families (66% of original cohort) are listed in Table 1. No sociodemographic or neonatal differences were observed between families with and without parent-child interaction data, with the exception of the proportion of children experiencing at least 1 episode of sepsis, which was higher in families included in the study who had parent-child interaction data (48% vs 30%; 2 [n 196] 4.73; P .05). Families with twins and triplets were less likely to be categorized as high social risk (55% lower risk, 45% higher risk) than families with singletons (33% lower risk, 67% higher risk; 2 [n 152] 7.41; P .01). Procedure Children were assessed at 2 years corrected age. Assessments were conducted at the Royal Childrens Hospital (Melbourne, Australia) and included administration of a parent-child interaction measure,15 a questionnaire, and the Bayley Scales of Infant Development II (BSID-II).16 The parent-child interaction measure was not administered to families assessed off-site. Social risk was assessed by using a composite measure17 composed of 6 aspects of social status: family structure (0: 2 caregivers [nuclear]; 1: separated parents

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with dual custody, or cared for by other intact family; 2: single caregiver); education of primary caregiver (0: tertiary educated; 1: 1112 years of formal schooling; 2: 11 years of formal schooling); occupation of primary income earner (0: skilled/professional; 1: semiskilled; 2: unskilled); employment status of primary income earner (0: full-time employment; 1: part-time employment; 2: unemployed/pension); language spoken at home (0: English only; 1: some English; 2: no English); and maternal age at birth (0: 21 years old; 1: 18 21 years old; 2: 18 years old). Each family was categorized as lower social risk (social-risk score of 0 or 1) or higher social-risk (social-risk score of 2). This cut point was derived from other composite social-risk scales used in follow-up studies of very preterm infants.18,19 Parenting behaviors and parent-child synchrony were measured by using a parent-child observation procedure developed for use with very preterm infants and preschoolers.15 This measure was based on previous work with the Dunedin longitudinal study20 and the Eunice Kennedy Shriver National Institute of Child Health and Human Development early child care study.21 The measure consisted of 3 tasks that the parent/guardian and child dyad were to complete or explore together in a set order. The rst task was a puzzle board for which the aim was to match the colors of the puzzle pieces to colors in a tray. The second task was a posting box puzzle for which the aim was to t 2 differently shaped blocks into their correct hole in a box. The third task involved a long, clear plastic box with a lever inside for which the aim was to gure out that a weight must be used to hold down 1 end of the lever so that the child could reach a small toy on the other end of the lever. The measure was completed by 139 mother-child dyads and 13 fatherchild dyads. In general, the measure took 10 minutes in total to administer, with the dyads spending 3 to 4 minutes with each task. Parents were informed that they would be lmed through a 1-way mirror and that they should play and interact with their child as they would at home. The performance of the child in solving these tasks was irrelevant, and not scored, because the objective of this measure was to observe the behaviors of the parent, as well as the synchrony between the parent and child, during this structured play session. The extent and quality of 6 parenting behaviors were examined, including positive affect, negative affect, sensitivity, facilitation, intrusive/overcontrolling, and parent-child synchrony. Positive affect reected the quality and frequency of positive expressions toward the child such as smiling or playfulness. Negative affect reected the quality and frequency of disapproval, anger, and negativity toward the child. Greater expressions of positive regard and praise, as well as being warm, available, and emotionally supportive, were represented by high scores on sensitivity. Facilitative behaviors involved parents providing scaffolding and support to help the child control his or her emotions and behavior and actively and positively engage with the task. Scoring highly on the intrusive/overcontrolling domain reected physical behaviors and verbal instructions that seemed ill-timed, intrusive, or excessively or inappropriately controlling.

Finally, parent-child synchrony assessed the responsivity, coordination, and mutual focus between parent and child and particularly focused on shared affect and eye contact and physical closeness. A score ranging from 1 to 5 was given for each domain at the end of each task, and these scores were summed over the 3 tasks to form a total score for each domain. Higher scores on positive affect, sensitivity, facilitation, and synchrony reected more optimal parenting behaviors, but higher scores on negative affect and intrusive/overcontrolling domains reected less optimal parenting behaviors. Each parentchild interaction was coded by the primary coder (Dr Treyvaud). A set of 24 (17%) interactions was randomly selected and recoded by the primary coder to calculate intrarater reliability, with generalizability coefcients (Cronbachs ) ranging from .67 to .88. A subset of interactions (n 20 [14%]) was also coded by a second coder, with generalizability coefcients ranging from .70 to .81, apart from negative affect (20 0.42). Interrater and intrarater reliability were considered satisfactory, because coefcients above .70 are considered acceptable for reliability analysis.22,23 Cognitive development was assessed by using the Mental Developmental Index (MDI), and psychomotor development was assessed by using the Psychomotor Developmental Index (PDI) of the BSID-II.16 The MDI and PDI were calculated by using age-based norms and have means of 100 (SD: 15), and range 50 to 150. Consistent with procedures used previously,24,25 children who failed to meet the criteria for the basal MDI or PDI score of 50 were assigned a score of 45 (MDI: n 8; PDI: n 3), whereas children who were unable to be formally assessed (eg, signicant developmental delay) were assigned an MDI or PDI score of 40 (MDI, PDI: n 3). Social-emotional development was assessed by using the prepublication version of the Infant Toddler Social and Emotional Assessment (ITSEA).26 The ITSEA is a parent-report questionnaire developed to assess socialemotional difculties and competencies in 12- to 36month-old children. The domains of social-emotional competence (compliance, attention, imitation/play, mastery motivation, empathy, prosocial peer relations), externalizing behaviors (activity/impulsivity, aggression/deance, peer aggression), and internalizing behaviors (depression/withdrawal, general anxiety, separation distress, inhibition to novelty) were assessed in this study. An advantage of the ITSEA is that it assesses behavioral difculties and competencies. This version of the ITSEA had age- and gender-specic t scores (mean: 50 [range 25 80]; SD: 10), which were based on data collected from a sample of 7433 children in Connecticut. Children in the extreme 10th percentile of each domain were considered to be at risk and were categorized as such. Statistical Analysis The data were analyzed by using Stata 9.1 (Stata Corp, College Station, TX). Regression models were used to examine relationships between parenting measures and a range of neurobehavioral outcomes. The twins and
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TABLE 2 Bivariate Relationships Between Parenting Domains (n 152)

Positive Negative Sensitivity Facilitation Intrusiveness Affect Affect Negative affect 0.16 Sensitivity 0.59a Facilitation 0.29a Intrusiveness 0.32a Synchrony 0.63a
a b

0.31a 0.15 0.41a 0.24b

0.62a 0.46a 0.74a

0.17b 0.54a

0.45a

tional competence, 9% (13 of 135) within the at-risk range for externalizing difculties, and 11% (16 of 135) within the at-risk range for internalizing difculties. Boys (mean: 80.2, SD: 19.9) had signicantly lower MDI scores than girls (mean: 87.8, SD: 17.0; F1,150 6.3; P .01), and gender was included as a possible confounding factor in equations including MDI. No other signicant gender differences were found. Parenting Behaviors Parenting behavior was not associated with the gender of either the child or parent; thus, all remaining analyses involved the entire sample. The relationships between the different parenting domains varied from weak to moderate (see Table 2). Results from the regression analyses predicting neurobehavioral development by parenting behaviors are presented in Table 3. The analyses revealed that regardless of social risk, higher levels of parental positive affect and sensitivity were related to more optimal cognitive development (P .05 and P .05, respectively) and greater social-emotional competence (both P .01). Increased levels of parental negative affect were related to higher psychomotor scores as well as increased internalizing problems such as withdrawal, inhibition to novelty, and anxiety (P .05). Increased facilitation was signicantly associated with more optimal cognitive development (P .01), whereas greater parent-child synchrony was associated with more optimal cognitive development (P .01) and social-emotional competence (P .01). DISCUSSION This study reinforces the view that parenting plays a central role in the early development of children, even those who are exposed to signicant biological and environmental risks such as being born very preterm. Our ndings indicate that parenting has quite a specic inuence on early development in that different parenting behaviors are related to different developmental outcomes at 2 years of age over and above any impact that social risk factors may have on the relationship. For example, parental affect (positive and negative) had a signicant role across several developmental domains, whereas facilitative parenting seems to have a more

P .001. P .01.

triplets in the sample resulted in within-family clustering in the data, which was addressed by tting linear regression models by using generalized estimating equations and using the information-sandwich method to obtain SEs for the regression coefcients that are robust to the (incorrect) assumption of independence made by ordinary least-squares regression. An exchangeable correlation structure was specied for the generalized estimating equations analyses, under which it was assumed that all subjects from the same family were equally correlated. This is the preferred regression modeling technique for correlated/clustered data such as twin data.27,28 Social-risk classication was included in regression analyses exploring relationships between parenting and child outcomes. Model adequacy checks were performed and deemed satisfactory. RESULTS Neurodevelopmental Assessment (2 Years Corrected Age) The very preterm sample had a mean MDI score of 83.5 (SD: 19.0), which was within the upper end of the mildly delayed range, and a PDI score of 88.4 (SD: 15.9), which was within the average range. Sixteen percent of the sample (n 25) had a signicant cognitive delay (MDI score 70), and 11% (n 16) had a signicant motor delay (PDI score 70). On the ITSEA scales, all group means fell within the normal (mean 1 SD) range (social-emotional competence: mean: 46.2, SD: 10.4; externalizing: mean: 49.3, SD: 9.6; internalizing: mean: 49.2, SD: 11.6). Eighteen percent (27 of 135) of children scored within the at-risk range for social-emo-

TABLE 3 Bivariate Relationships Between Parenting Behaviors and 2-Year Neurobehavioral Outcomes
MDI (n 152) Coeff Positive affect Negative affect Sensitivity Facilitation Intrusiveness Synchrony 1.09a 0.56 1.29a 1.83b 0.84 2.43c 95% CLs (0.13, 2.05) (2.54, 3.70) (0.25, 2.33) (0.45, 3.22) (2.09, 0.41) (1.45, 3.42) PDI (n 152) Coeff 0.89 3.27a 0.40 0.48 0.36 0.98 95% CLs (0.31, 1.80) (0.61, 5.93) (0.60, 1.41) (1.04, 2.01) (0.57, 1.28) (0.06, 2.02) Social-emotional Competence (n 135) Coeff 1.37b 1.75 0.90b 0.66 0.39 0.87b 95% CLs (0.57, 2.17) (3.88, 0.38) (0.25, 1.54) (0.30, 1.58) (1.11, 0.34) (0.21, 1.52) Externalizing (n 135) Coeff 0.39 1.74 0.38 0.01 0.58 0.40 95% CI (1.08, 0.29) (0.07, 3.55) (0.96, 0.20) (0.95, 0.92) (0.03, 1.20) (1.04, 0.25) Internalizing (n 135) Coeff 0.07 2.49a 0.31 0.52 0.38 0.01 95% CLs (0.7, 0.91) (0.40, 4.59) (0.44, 1.06) (0.64, 1.69) (0.57, 1.32) (0.72, 0.74)

95% CLs indicates 95% condence limits; Coeff, regression coefcient. a P .05. b P .01. c P .001.

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signicant effect on cognitive development than other outcomes. Importantly, parent-child synchrony has a strong positive inuence on cognitive development and social-emotional competence. These ndings are important, because environmental factors such as parenting represent potentially modiable inuences that can promote the development of very preterm children in the face of signicant medical and developmental risks.10,29,30 Very preterm children are at risk for delayed cognitive development, and this is a major concern for parents. Our results suggest that parents can be reassured that they can play a key role in their childs cognitive development. We found that early cognitive development was positively inuenced by warm, positive, sensitive, and facilitative parenting, which is consistent with previous research that reported a positive relationship between cognitive development and sensitive parenting that provides scaffolding7,13,31 or conceptual links between objects, persons, activities, or functions32 and is low in restrictive and overly controlling behavior.13,33 The synchronicity of the interactions between the parent and the child was found to be very important to the childs development. This relates to how well the child and parent respond to each other and depends on the parent having a good understanding of how to effectively communicate with and respond to (verbally and nonverbally) his or her child. Not surprisingly, we found that increased parent-child synchrony was related to more optimal cognitive development, which is consistent with results reported by others.7 Unexpectedly, increased parental negative affect was associated with more optimal psychomotor development in very preterm children. Although this nding is difcult to explain, an earlier study reported a similar relationship in term children in whom higher levels of maternal warmth and sensitivity were associated with less optimal motor development at 12 months of age.34 Displays of negative affect by parents in this study were rare, with higher scores on this domain tending to reect low-level negative behaviors such as using a rm voice or saying no frequently. It could be speculated that rm and restrictive parenting is a response to children who are very active and mobile, or represents a parenting style that values and promotes activity and motor development. Replication of these results is needed not only because the relationships may change with development but also because of the low frequency of parents exhibiting negative affect and the limitations associated with the poorer interrater reliability of this variable. There have been few studies that have examined the link between parenting and social-emotional competence in very preterm children. Findings presented here support and build on previous work with term children reporting an association between higher levels of parental warmth or positive affect and increased child socialemotional competence.35,36 Our results demonstrate that when parenting was sensitive and in synch with the child, social-emotional competence was greater. Considering that almost 20% of this sample was in the at-risk range for social-emotional competence, knowledge of factors that might have a positive effect on aspects of

social-emotional competence such as compliance, motivation, and empathy in very preterm children is important for the development of interventions for this population. Although young preterm children are sometimes rated as being hyperactive or overactive,37 rarely are other externalizing symptoms reported. More commonly, preterm children and adolescents score higher on internalizing domains such as anxiety and depression.3,38 Such behavioral problems may be linked to specic parenting characteristics; previous research has linked behavioral difculties with parenting that is highly intrusive and lacking in warmth and responsiveness.8,37,39 Although the mean scores for this sample on the externalizing and internalizing domains were within the average range, internalizing behaviors were related to certain parenting domains. More specically, symptoms of internalizing problems were increased in children of parents who demonstrated higher levels of negative affect. The causality of this relationship is unclear and is likely to be bidirectional and reciprocal. For example, a child may withdraw in response to intrusive, negative parenting,40 but a parent may also display more negative affect in response to a child who is temperamentally inhibited and difcult to engage.41 Understanding the link between parenting and internalizing behavior in very preterm children is particularly important, because previous research has suggested that internalizing symptoms can have a detrimental effect on later development and behavior for term children,42,43 and the effect on children at risk for poorer developmental outcomes could be even greater. Although we found little evidence that parenting was associated with externalizing problems, this may change later in development. Positive affect, sensitivity, and parent-child synchrony emerged from this study as particularly important for cognitive development and social-emotional competence. The positive affective system has been proposed as a motivational system that works to facilitate connected and rewarding family relationships,44 and it may be through this motivational system that positive affect also facilitates the cognitive and social-emotional development of children. The mechanisms by which parent-child synchrony are believed to inuence development have also been described in a recent review,11 in which it was suggested that parent-child synchrony helps to introduce children to the use of symbolic representations as well as self-regulatory experiences, both of which are important building blocks of cognitive and social-emotional development. The results from this study not only t well with established theories of child development, but they support the application of these theories to a population of children at increased neurobehavioral risk. It is generally accepted that parenting behavior needs to adapt over time in response to the childs changing developmental level and needs.45,46 Although the ndings presented here are important because they provide a snapshot of the relationships between parenting and neurobehavioral development in very preterm children at 2 years of age, the cross-sectional design means that
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any claims regarding the causality and direction of these relationships need to be interpreted with caution. The role of parenting behavior with this sample of children will become clearer over time and may change as other environmental factors increase in importance, and longitudinal follow-up of these children and their families is underway. In addition, considering the important role of parental affect in promoting more or less optimal development reported here, additional exploration of the relationship between parental mental health and parenting within the very preterm population is particularly important for future research. CONCLUSIONS These ndings suggest that parent-based interventions are likely to affect the developmental outcomes of very preterm children. A recent intervention that focused on parental responsiveness reported benets for preterm infants.47 This intervention encouraged maternal warmth and contingent responsivity, which are similar to the domains of positive affect and parent-child synchrony described here. Thus, the ndings from the current study further support the notion that parents of very preterm children should be encouraged to smile, laugh, and try to sensitively and responsively share eye contact and the same emotional state with their very preterm child to promote optimal outcomes for their child. Importantly, ndings from this study also suggest that although the early attachment processes may be disrupted for parents of very preterm children because of lengthy hospitalization and invasive medical procedures, parents can be reassured that they retain the capacity to positively inuence their childs development through infancy and early childhood. ACKNOWLEDGMENTS This study was funded by the National Health and Medical Research Council (project grant 237117; training research fellowship [PJA] 284568), the Royal Womens Hospital Research Foundation, and the Brockhoff Foundation. This study received support from the Murdoch Childrens Research Institute. We thank the entire Victorian Infant Brain Studies Team and, in particular, K. Johnson for assistance with the interrater reliability analysis. We also thank Drs O. Ukoumunne and P. Dudgeon for statistical advice and assistance, and we acknowledge the important contribution to research made by the families who participated in the study. REFERENCES
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PEDIATRICS Volume 123, Number 2, February 2009

561

Parenting Behavior Is Associated With the Early Neurobehavioral Development of Very Preterm Children Karli Treyvaud, Vicki A. Anderson, Kelly Howard, Merilyn Bear, Rod W. Hunt, Lex W. Doyle, Terrie E. Inder, Lianne Woodward and Peter J. Anderson Pediatrics 2009;123;555 DOI: 10.1542/peds.2008-0477
Updated Information & Services References including high resolution figures, can be found at: http://pediatrics.aappublications.org/content/123/2/555.full.ht ml This article cites 43 articles, 10 of which can be accessed free at: http://pediatrics.aappublications.org/content/123/2/555.full.ht ml#ref-list-1 This article has been cited by 5 HighWire-hosted articles: http://pediatrics.aappublications.org/content/123/2/555.full.ht ml#related-urls This article, along with others on similar topics, appears in the following collection(s): Premature & Newborn http://pediatrics.aappublications.org/cgi/collection/premature _and_newborn Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://pediatrics.aappublications.org/misc/about.xhtml#permis sions Information about ordering reprints can be found online: http://pediatrics.aappublications.org/misc/addir.xhtml#reprint sus

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2009 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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