Aim: To determine whether a strength-based home-visiting program enhances parent–child interaction during the first year at home for children born extremely preterm (gestational age < 28).

Methods: A randomised controlled trial of 130 infants born extremely preterm 2018–2021 in Stockholm, allocated to either the Stockholm preterm interaction-based intervention (SPIBI) (n = 66) or an extended follow-up program (n = 64). The intervention group received ten home visits during the first year by a trained interventionist following SPIBI guidelines: an interaction-based intervention supporting sensitive parental responses to infants' signals. The primary outcome of emotional availability was assessed at 12 months corrected age (CA) using the emotional availability scales (EAS).

Results: At 1-year CA, data were collected from 115/130 (89%) of the included children. There were no significant group differences in emotional availability at 12 months CA. A secondary analysis showed an effect modifier in families with mothers self-rated as depressed at discharge, with the outcome favouring intervention in the EAS dimension of child involvement.

Conclusion: The SPIBI had no significant main effect on emotional availability at 12 months CA. Children of self-reported depressed mothers displayed superior involvement behaviour in the intervention group, prompting further research on risk groups and potential modifications of post-discharge interventions.

The first thousand days from conception are crucial for future learning and development throughout life. During the infant year, several sensitive periods for sensorimotor, cognitive and social development coincide, making the period particularly suitable for early intervention (EI). From a special educational perspective, the social and physical environment of a child may either support or hinder future growth. Optimal early learning environments include environmental enrichment, reduced toxic stress and strengths-based support of parent-child interaction.

Being born extremely preterm (EPT <28 gestational weeks) is a biological risk factor, increasing the risk for future disability, academic difficulties and social challenges. The parents are also negatively affected by prematurity. Sweden offers highly specialized neonatal care from 22 GW, resulting in a new population of surviving children.

The aim of this thesis is to evaluate an interaction-based and strengths-based EI for infants born EPT and their parents in a Swedish context. The Stockholm Preterm Interaction-Based Intervention (SPIBI) consists of 10 home visits led by a trained interventionist during the first year at home, focusing on parent-child interaction, family strengths and reduction of toxic stress. The control group received an extended treatment as usual follow-up program (TAU⁺). The thesis has a mixed methods design and includes three studies.

Study I presents the protocol, including a description of the planning, formulation, theoretical background, theory of change, interventionist training, recruitment, randomization and implementation of the SPIBI. Study II reports the primary outcome of the RCT (N=130, intervention=66 vs. controls=64) and their parents regarding parent-child interaction as measured with the Emotional Availability Scale (EAS) at 12 months corrected age (CA). The EAS consists of the six dimensions: sensitivity, structuring, non-intrusiveness, non-hostility, child responsiveness and child involvement. No significant effect of the EAS at 12 months CA related to the SPIBI was found. In the secondary analysis, analysis of covariances for all EAS dimensions were tested with predefined medical, social, and psychological moderators. The model with the best fit was one for the EAS dimension child involvement (adj R²=.463). A significant effect modifier shows that the SPIBI enhances child involvement in families where the mothers rate themselves as depressed at discharge (F(1, 65)=5.499, p=.023).The parental experience during the first year at home with or without the SPIBI was qualitatively analyzed and reported in Study III (n=17). The results showed that child-related medical concerns were still present a year post-discharge, and that the premature birth experience still affected the parental inner state and family dynamics. Parents in the intervention group (n=8) also pointed out the security the knowledgeable interventionists gave them, while some parents described the SPIBI as important but not necessary.

Overall, this thesis adds to the understanding of the first year at home with a child born EPT. An interaction-based intervention in the home environment is feasible in Sweden. It is possible to unite different professions in an EI in a special educational context. The tested intervention does not affect the emotional availability at 1 year CA, but findings from secondary analyses prompt further research on specific subgroups, particularly families with depressed mothers. 

Abstract: Extremely preterm born children and their parents is a vulnerable group with a high risk of developmental delays, academic challenges and parental mental health difficulties. Previously interventions have been medical focusing of increasing survival, but recently post-discharge interventions improving long-term development have been presented. This abstract concerns a novel multiprofroessional intervention, Stockholm Preterm Interaction-Based Intervention (SPIBI) aiming at consolidation of expertise from educational, behavioral and medical fields in benefit of the child development and family well-being.  

Rationale and purpose: SPIBIs purpose is to enhance the parent-child interaction, child cognitive and motor development, child preschool social participation and parental mental health in families with extreme preterm born infants.

Description of methods, results, or modes of inquiry: In a novel RCT a strengths-based post-discharge intervention targeting extreme preterm born (EPT= born before 28 gestational weeks) infants and their parents is being tested. 130 EPT born children and their parents have been randomly allocated to an intervention group receiving 10 home visits during the first year at home, or a control group receiving treatment as usual with an extended follow-up program. The novel intervention is named Stockholm Preterm Interaction-Based Intervention (SPIBI).

Innovation: The field of long-term development of extremely born infants is innovative in itself, since the field consist of a severely vulnerable population on the verge of viability, who did not survive twenty years ago. The innovation in SPIBI is its consolidation of practical knowledge as well as research concerning the challenges of extreme prematurity from a medical (brain developmental), special educational (preschool behavioral), physiotherapeutic (motor), psychological (parent-child-interactional and cognitive) perspective. Working together will benefit the child and family as a whole, since extreme prematurity is a nuanced field with implications for several aspects of development. Despite this, previous international research from the field is almost always unidisciplinary.

Implications for policy or practice: The outcome will influence practice at a regional and possible national level, concerning how a low cost early intervention may improve several outcomes and reduce challenges for a group of children with a high risk of developmental delays.

Relationship to principles of diversity, equity, and inclusion: The extreme preterm born population often has double challenges, both concerning developmental delays and socioeconomic hardships, both internationally and in a Swedish context. Giving this vulnerable population initial extra support is ultimately a question of equity, increasing the chance of participating in fully inclusive learning environments ahead.

Methods used to encourage audience engagement When presenting the poster, these 3 questions will be continuously discussed with researchers passing by:

1.     What do parents to medically fragile infants who have been balancing on the verge of death, need when the family comes back home from the hospital?

2.     What are the key elements of multidisciplinary and multiprofessional co-operation between medicine, psychology and special education?

3.     What may be the different needs of different groups of families with extreme preterm born children, regarding socioeconomic background, severity of prematurity and migration statues?

Bakgrund: Stockholm Preterm Interaction-Based Intervention (SPIBI) är ett nytt styrkebaserat tidigt interventionsprogram för samspelsstöd till föräldrar och barn i familjer där barnet föddes mer än tre månader för tidigt. Forskning visar att dessa barn löper ökad risk att stöta på problem i sin utveckling vad avser kognition, koncentrationsförmåga, skolgång och social situation. Det finns också ökad risk för att föräldrarna ska drabbas av psykisk ohälsa. SPIBI består av 10 hembesök under första året hemma, där fokus ligger på att stärka ett lyhört föräldra-barn samspel, bejaka lekfullhet och stötta barnets nyfikna utforskande. 130 extremt prematurfödda barn från 122 familjer har rekryterats och randomiserats till interventionsgrupp (n=66) och kontrollgrupp (n=64). Studien är i linje med FNs globala hållbarhetsmål för god hälsa och välbefinnande samt minskad ojämlikhet då den riktar sig till en grupp som riskerar drabbas av ohälsa och utsatthet även i vår kontext, med tillgång till avancerad neonatalvård och utbyggd välfärd.

Syftet med detta bidrag är att redovisa erfarenheter av interventionens genomförande i hemmiljö från oktober 2018 till december 2022. 

Metod: Samtliga intervenerare (n=6) och 17 av de deltagande föräldrarna har intervjuats om sina erfarenheter från SPIBI. Föräldraintervjuerna är tidigare publicerade (Baraldi et al., 2020).

Resultat: Deltagande familjer varierar mycket vad avser barnens medicinska behov, hur svår sjukhusvistelse familjen har bakom sig, familjens socioekonomiska situation och tidigare föräldraerfarenhet. Vissa familjer har dubbel belastning både i form av kvarstående behov av frekventa sjukhusbesök efter ett års ålder, och utsatt familjesituation med exempelvis trångboddhet, otrygg boendemiljö eller bristande socialt nätverk. Således varierar också behoven som familjerna önskar få tillfredsställda av interventionsprogrammet, från utökat behov av stöd i att läsa barnets signaler till behov av socialt stöd i föräldrarollen. De familjer vars barn har störst funktionsnedsättning är inte nödvändigtvis i störst behov av SPIBI, eftersom de ofta redan har extra vårdkontakter. Coronapandemin drabbade deltagande familjer hårt, då hygienfrågor alltid är viktiga i omsorgen om svårt sjuka barn. Detta påverkade i sin tur SPIBI både avseende hembesöksmodellen och rekrytering. Trots olika förutsättningar uppger samtliga behandlare att det varit lätt att hitta styrkor att fokusera på i familjerna och att hembesöksupplägget överlag fungerat väl.

Slutsats: Implementeringen av SPIBI under studieperioden har fungerat väl, men delvis störts av pandemin. Framtida vidareutveckling av SPIBI skulle kunna inkludera en flernivåmodell, där stödets intensitet men även fokusområden anpassas till den enskilda familjen.

Background

Parental responsiveness is of great importance for positive effects of behavioral and cognitive development in preterm infants and the Emotional availability scales (EAS) is a clinically relevant assessment measure, for early neurodevelopment. The EAS is an observational measure which reflects the quality of parent–child relationship and the child’s socio-emotional development. It has 4 adult domains (sensitivity, structuring, non-intrusiveness, non-hostility) and 2 child domains (responsiveness, involvement) (Biringen 2014). In an ongoing RCT of an intervention for extremely preterm (EPT) born infants and their parents, the Stockholm Preterm Interaction-Based Intervention (SPIBI), the primary outcome measure is EAS used at 12 months corrected age (CA). The aim for this sub-study is to evaluate the inter-rater reliability of EAS in this cohort.

Method

During the first year after discharge, ten home visits were carried out from specially educated interventionists of our multidisciplinary team. 130 EPT infants were recruited and 115 have been filmed and assessed at 12 months CA. The parent was instructed to play with the infant for 10 minutes. Dyads were filmed, videos assessed and scored by a trained EAS-accredited team member. 20% of the videos (23/115) were assessed by an additional EAS-accreditor to evaluate inter-rater-reliability. Interclass Correlation Coefficient (ICC) were used. To obtain authenticity with real-life, the videos were filmed in a home setting with opportunity to choose study parent. Interaction were encouraged to proceed in an ordinary pattern.

Results

ICC values range 0,86 - 0,96 within all dimensions, all individual values, 95%CI (Table 1). This indicates high inter-rater reliability, although some of the subscales had lower ICC (0,73-0,98). 

Conclusion

The SPIBI study corresponds well with EAS scoring assessment method for reflection of parent-infant interaction at 12 months CA in EPT born infants.