Background
Parenting and the home learning environment
Early childhood parenting interventions for disadvantaged families
The current study
Development of the Smalltalk programs
Developmentally appropriate, evidence-informed content
Key Parenting Strategies (active skills training in-session and exemplified in DVDs)
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1. Quality parent–child interactions: Responsive interactions characterised by parental sensitivity, warmth and cognitive stimulation |
• Tuning in: refers to moments when the parent is fully focussed on what the child is doing, saying and possibly feeling. This creates the opportunity for the parent to be sensitive and responsive to the child’s needs. |
• Following the child’s lead: involves paying attention to and building on the child’s interests. This provides opportunities for teachable moments |
• Listening and talking more: involves increasing exposure to language (both the frequency and variety of words) in a way that promotes ‘conversation’ (e.g., interactive turn-taking that involves both listening and talking). This is a powerful driver of language development from a very young age. |
• Using teachable moments: involve capitalising on everyday opportunities for learning. Children are most open to learning when they are interested in something. A teachable moment arises when a parent encourages a child to extend their knowledge or experience of something with simple comments and questions (e.g., “Yes, it’s a car – what colour is that car?”). |
• Being warm and gentle: relates to the tone or quality of the interaction. The expression of affection and acceptance strengthens the relationship between parent and child and has powerful effects on child development and wellbeing. |
2. Stimulating home learning environment: An environment rich in language and age-appropriate play activities |
• Shared reading: a dialogic (shared) approach to reading that is interactional and relationship-building and promotes the use of both book and non-book literacy resources. Where parents have low literacy themselves, they are encouraged to ‘tell a story’ based on the pictures. |
• Learning through everyday routines: predictable, positive daily routines that help children feel secure and provide a daily ‘infrastructure’ for parent–child interactions that promote learning and development (e.g., a bedtime routine that involves reading to children). |
• Supporting children’s play: provision of developmentally appropriate play objects and activities essential for child development. Emphasis is given to the use of inexpensive, safe household objects that make excellent toys for learning. |
• Using community resources: involves introducing parents to activities and resources in the community such as libraries and toy libraries. |
• Monitoring use of media: emphasis is given to choosing age appropriate programs and limiting exposure to advertising and ‘background’ television (e.g., television that is on in the background, which interrupts and distracts children from their activities). |
Supporting Information Provided on strategies to build parents’: |
• Personal agency: building confidence, efficacy and reflective practice around parenting • Self-care: enhancing/maintaining wellbeing, accessing practical, emotional & informational support, stress management • Community connectedness: increasing parental awareness of and ability to access needed services, being supported by and involved with their community |
The service context
Aims and hypotheses
Methods and design
Approval and registration
Design
Site recruitment
Allocation
Intervention delivery
Smalltalk program development and content
Program delivery formats—infants
Program delivery formats—toddlers
Facilitator training and support
Participant recruitment and eligibility criteria
Measures
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Parent-report data were collected via computer assisted telephone interviews (CATI) to allow inclusion of parents with low literacy. These were conducted at pre, post (12 weeks), and follow-up (32 weeks) by trained interviewers, independent of the research team and blinded to participant allocation. As summarised in Table 2, the CATI included a number of brief, validated measures of parent and child outcomes (all time points), parent, child and family characteristics (baseline only), and ratings of satisfaction with the program and barriers to participation (post only; asked at the end of the interview to avoid unblinding the interviewer during the collection of outcomes data). Included measures were primarily sourced from the Longitudinal Study of Australian Children [40] or other evaluation studies [39]. Parents also completed a pencil and paper version of the Communicative Development Inventory (CDI) during the home visit (see below), or over the telephone with a research staff member.Table 2Summary of Study MeasuresVariableMeasureData collectionMethodaCollectedbPrimary outcomesParental verbal responsivityStimQ-T [47]: 4 items on a 4-point scale E.g. “Talk about the day while your child is eating”, summed to produce a total score between 4 and 16.CATIPre, post, FUHome learning activitiesHome activities with child: 5 items on a 4-point scale assessing parental engagement of child in home activities that stimulate development [48] E.g. “Read books to your child”, summed to produce a total score between 4 and 20.CATIPre, post, FUSecondary outcomesParent–child interactionsParental warmthWarmth: 6 items on a 5-point scale scale from the Longitudinal Study of Australian Children (LSAC) [40], “Thinking about the last 6 months, how often do you…” E.g. “Hug or hold your child for no reason”, summed to produce a total score between 6 and 30.CATIPre, post, FUParental irritabilityIrritability: 5 items on a 5-point scale from LSAC [40], “Thinking about the last 4 weeks, how often have you…” E.g. “Lost your temper with your child”, summed to produce a total score between 5 and 25.CATIPre, post, FUParent interactionsIndicator of Parent – Child Interaction: Caregiver interactions coded as ‘facilitators’ or ‘interrupters’ [42] E.g. “conveys acceptance and warmth” and “uses criticism or harsh voice”. Interactions are rated on a 4-point scale of relative frequency, from 0 = never to 3 = often/consistently.ObservedPre, post, FUHome environmentHome literacyHome Literacy Environment Scale: 6 items on various scales, [49], E.g. “How many books does your child own?”, summed to produce a total score ranging from 0 to 11.CATIPre, post, FUDisorganisationCATIPre, post, FUParent focussed outcomesPsychosocial distressKessler-6 (K6): 6-item psychosocial screener on a 5-point scale assessing emotional distress in the last 4 weeks [52]. “About how often did you feel:” E.g. “nervous”, summed to produce a total score between 0 and 24.CATIPre, post, FUWellbeingSF-12: 12-item health related quality of life [53] on various scales E.g. “How much does your health limit you in climbing several flights of stairs?” and “How much of the time during the past 4 weeks have you felt calm and peaceful?”, producing a Physical Health summary score and a Mental Health summary score.CATIPre, postPsychological adjustmentI-PANAS-SF: 5-item positive affect subscale on a 5-point scale [54], “Thinking about yourself in the last 4 weeks, about how often did you feel…E.g. “alert?”, summed to produce a total score between 5 and 25.CATIPre, post, FUParent confidence1 item on a 5-point scale, overall efficacy as a parent from LSAC [55], “Overall, as a parent, do you feel that you are…” E.g. “a better than average parent”, producing a score between 1 and 5.CATIPre, post, FUParental self-efficacy4 items on a 5-point scale, infant and toddler versions of parental self-efficacy from LSAC [39], “In general, do you feel that you are…?” E.g. “Very good at keeping your child amused”, summed to produce a total score ranging from 5 to 20.CATIPre, post, FUCommunity connectednessUse of early childhood services: 6 items on a yes/no scale, study-developed to assess past, current or intended use of similar early childhood programs. “Have you or your child ever attended any other services or programs to assist you and your child?” E.g. “early intervention program”.CATIPostContact with other parents: 2 items assessing contact with other parents outside the program [39] “Have you had contact with any of the other parents outside the sessions?” and if so, “Do you think this contact will continue?”CATIPostChild focussed outcomesCommunication skillsAges and Stages Questionnaire (ASQ) Communication subscale [56]: 6 items on a 3-point scale. E.g. “Does your child point to, pat, or try to pick up pictures in a book?” Scored yes = 10, sometimes = 5, not yet = 0; summed to a total score between 0 and 60.CATIPre, post, FUVocabularyMacArthur-Bates Communicative Development Inventory (CDI) [57, 58]. Three age versions of the Short Form vocabulary checklists. Level I, up to 18 months: 89 words the child “understands” or “understands and says” (e.g. “mummy” and “meow”). Level II, 19–30 months: 101 words (e.g. “book” and “finish”) and 1 item assessing use of word combinations. Level III, 31 months and older: 100 words (e.g. “then” and “today”), 12 sentence pairs to evaluate complexity of language use, and 12 yes/no items assessing language comprehension.Parent-reportPre, post, FUEarly Communication Indicator (ECI) [59]: frequency of gestures, vocalisations, single words and multiple words generated for each minute of 6-min play activity. Instances of communication are tallied, with weightings for single words (multiplied by 2) and multiple words (multiplied by 3) to produce a total communication score.ObservedPre, post, FUSocio-emotional skillsASQ Personal-Social subscale [56]: 6 items on a 3-point scale, E.g., “Does your child play with a doll or stuffed animal by hugging it?” Scored yes = 10, sometimes = 5, not yet = 0; summed to a total score 0–60.CATIPre, post, FUGeneral developmentASQ Fine Motor subscale: [56] 6 items on a 3-point scale, E.g. “Does your child stack three small blocks or toys on top of each other by herself?” Scored yes = 10, sometimes = 5, not yet = 0; summed to a total score 0–60.CATIPre, post, FUProcess measuresParent engagementAttendance checklist and facilitator ratings of parent engagement [39] E.g. “Parent engagement with other parents” on a 5-point scale from 1 = did not talk with other parents to 5 = talked to many other parents.Staff ratingsEach sessionProgram deliveryProgram quality and integrity: 6 items rated by facilitators [39], E.g. “Level of rapport and engagement established” on a 5-point scale from 1 = much less than expected to 5 = much better than expected.Staff ratingsEach sessionProgram intensityStudy designed, facilitator checklist of content coverage.Staff ratingsEach sessionParent satisfaction6 items on a 4-point scale assessing parents satisfaction with the program, staff and knowledge gains [38] E.g. “Overall, how satisfied or dissatisfied were you with the program?”CATIPostParticipation barriers13 items on a yes/no scale assessing barriers to program participation [38] E.g. “difficulties relating to other parents”, “work commitments”.CATIPostStaff trainingRatings of program quality (2 items: clarity, usefulness), preparedness to deliver it (3 items: confidence, well-prepared, difficulty), and satisfaction with training (5 items: clarity, usefulness of materials/presentation) on 5-point scales.Staff ratingsAfter trainingStaff self-assessment6 skills for program delivery with the target population, E.g. “Identifying specific needs of families” on a 5-point scale from 1 = ‘no level of skill/knowledge in the area’ to 5 = ‘advanced level of skill/knowledge’.Staff ratingsBefore, after trainingCovariatesDemographicsParent age, ethnicity, language spoken, education, income, employment status family structure and sizeCATIPreChild characteristicsChild age, ethnicity, general health, disability, special health services, birth weightCATIPreChild temperamentCATIPre, post, FUParent depressionSingle item yes/no rating from LSAC, “In the past year, have you had 2 weeks or more during which you felt sad, blue or depressed, or lost pleasure in the things that you usually cared about or enjoyed?” (0 = no; 1 = yes).CATIPreParent copingSingle item on a 5-point scale from LSAC, “How well do you think you are coping?” producing a score 0–5.CATIPre, post, FUStressful life eventsList of Threatening Experiences (LTE-Q): 7-item yes/no list of life adverse life events in last 12 months, [61] E.g. “You had a major financial difficulty”, producing a total score between 0 and 7.CATIPre, post, FU
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Observational data were collected in the parent’s home by trained and accredited research staff or home coaches, at pre, post and follow-up (Table 2). Data were collected according to standardised protocols for two ‘Individual Growth and Development Indicators’ assessment procedures (described below) [41]. These assessments provide good capture of the parent and child outcomes targeted by the smalltalk programs, have been validated for use with parents of children aged 2–42 months, and have demonstrated reliability and validity among disadvantaged populations [41, 42].
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The Indicator of Parent–Child Interaction (IPCI) assesses the extent to which parents respond to their child in ways that promote positive communication and social-emotional behaviours during 8–10 min of: free play (4 min); looking at books (2 min); a dressing task (2 min); and a distraction task (2 min; only for children 12 months and older). Interactions were videotaped for later frequency coding. Six parent behaviours (four ‘facilitating’ and two ‘interrupting’ behaviours) were tallied for each task and then an overall rating was made for all tasks combined (behaviours coded as ‘0 = never occurs’ to ‘3 = occurs often). Scores are the frequencies for each behaviour separately and summed for the facilitators (warmth and acceptance; descriptive language; follows child’s lead; maintains child’s interest) and interrupters (harsh comments; restrictions) [42].
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The Early Communication Indicator (ECI) assesses four child communication skills (use of gestures, vocalisations, single words and multiple word utterances), demonstrated during a 6-min parent–child play activity with standardised toys. Later coding involved tallying the number of skills demonstrated per minute. The final score was a weighted sum that gives greater weight to more advanced communication skills (a weighting of two for single words and three for multiple word utterances) and allows for comparisons between children of different ages [41].
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Coding was undertaken by two accredited, expert coders according to standardised protocols. Coders were blind to the study design, participant allocation and the data collection time point. Twenty percent of observations were independently coded by both assessors to determine inter-rater reliability (percent agreement).
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Due to the high costs of coding, an initial 600 observations (100 participants each from the maternal child health and playgroups services assessed at three time points) were randomly selected, stratified by location (to preserve the clustered design) for coding.
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Administrative records: Numbers of parents who expressed interest, were recruited and retained at each phase of the study were collected via administrative reporting procedures and tracking databases.
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Program staff ratings: Program fidelity, program quality, participant attendance and participant engagement in sessions were rated using standardised checklists by facilitators and home coaches at the end of each group or home coaching session (see Table 2). Reliability was checked by comparison with the independent ratings by research members attending a sample of group sessions.
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Sample size
Data analyses
Trial status and baseline data
Recruitment and participant characteristics
Characteristics | Maternal and Child Health (infant) RCT | Facilitated Playgroups (toddler) RCT | ||||||
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standard N = 312 | smalltalk group-only N =312 |
smalltalk plus
N = 362 | Total N = 986 | standard N = 350 | smalltalk group-only N = 410 |
smalltalk plus
N = 440 | Total N = 1200 | |
Child | ||||||||
Female, n (%) | 164 (52.6) | 144 (46.2) | 182 (50.3) | 490 (49.7) | 169 (48.3) | 210 (51.3) | 240 (54.3) | 619 (51.5) |
Child age in months, mean (SD) | 7.9 (2.4) | 8.1 (2.2) | 8.0 (2.2) | 8.0 (2.3) | 21.7 (7.5) | 22.3 (7.2) | 22.8 (7.1) | 22.33 (7.2) |
Indigenous, n (%) | 7 (2.3) | 8 (2.6) | 10 (2.8) | 25 (2.5) | 3 (0.9) | 9 (2.2) | 8 (1.8) | 20 (1.7) |
Parent | ||||||||
Male, n (%) | 4 (1.3) | 4 (1.3) | 3 (0.8) | 11 (1.1) | 19 (5.4) | 19 (4.7) | 13 (2.9) | 51 (4.3) |
Parents' age in years, mean (SD) | 30.5 (5.1) | 31.2 (5.7) | 31.1 (6.0) | 30.9 (5.6) | 33.3 (5.9) | 33.5 (5.8) | 33.2 (6.2) | 33.33 (6.0) |
Aged ≤ 25 years, n (%) | 60 (19.2) | 57 (18.3) | 70 (19.3) | 187 (19.0) | 34 (9.7) | 39 (9.5) | 41 (9.3) | 114 (9.5) |
Indigenous, n (%) | 5 (1.6) | 3 (1.0) | 5 (1.4) | 13 (1.3) | 0 (0.0) | 6 (1.5) | 6 (1.4) | 12 (1.0) |
Single parent family, n (%) | 39 (12.5) | 41 (13.1) | 45 (12.4) | 125 (12.7) | 48 (13.7) | 38 (9.3) | 50 (11.3) | 136 (11.3) |
Born overseas, n (%) | 50 (16.0) | 38 (12.2) | 48 (13.3) | 136 (13.8) | 122 (34.9) | 128 (31.3) | 137 (31.0) | 387 (32.2) |
Non-English Language, n (%) | 41 (13.1) | 34 (10.9) | 50 (13.8) | 125 (12.7) | 120 (34.3) | 146 (35.7) | 130 (29.4) | 396 (33.0) |
No parent employed, n (%) | 32 (10.3) | 47 (15.1) | 58 (16.0) | 137 (13.9) | 47 (13.4) | 51 (12.4) | 64 (14.6) | 162 (13.5) |
Did not complete high school (year 12), n (%) | 41 (13.1) | 47 (15.1) | 57 (15.8) | 145 (14.7) | 42 (12.0) | 47 (11.5) | 50 (11.3) | 139 (11.6) |
Main income from pension/benefit, n (%) | 50 (16.1) | 67 (21.5) | 69 (19.1) | 186 (18.9) | 69 (19.7) | 65 (15.9) | 77 (17.4) | 211 (17.6) |
Low income (≤$36,400 AUD), n (%) | 58 (19.3) | 69 (22.8) | 75 (21.5) | 202 (21.2) | 79 (23.8) | 80 (20.4) | 90 (21.0) | 249 (21.6) |