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Promising Program Seal

Family Foundations

Blueprints Program Rating: Promising

A universal prevention program to improve mother, child, and birth outcomes through promoting coparenting quality among couples who are expecting their first child.

  • Mark E. Feinberg, Ph.D.
  • Pennsylvania State University
  • Prevention Research Center
  • S-109 Henderson Building
  • University Park, PA 16802
  • U.S.A.
  • mef11@psu.edu
  • www.famfound.net
  • Antisocial-aggressive Behavior
  • Anxiety
  • Conduct Problems
  • Depression
  • Externalizing
  • Internalizing
  • Prosocial with Peers

    Program Type

    • Parent Training
    • Skills Training

    Program Setting

    • Community (e.g., religious, recreation)
    • Hospital/Medical Center

    Continuum of Intervention

    • Universal Prevention (Entire Population)

    A universal prevention program to improve mother, child, and birth outcomes through promoting coparenting quality among couples who are expecting their first child.

      Population Demographics

      The program targets heterosexual couples expecting their first child.

      Age

      • Infant (0-2)
      • Adult

      Gender

      • Male and Female

      Gender Specific Findings

      • Male

      Race/Ethnicity

      • All Race/Ethnicity

      Race/Ethnicity/Gender Details

      Some child outcomes showed an intervention effect only for boys. These included internalizing, attention/hyperactivity, and relationship satisfaction collected at wave 4 and attention problems, aggressive behavior, and externalizing at wave 5. Supplemental analysis, gathered during the Blueprints review, also showed that anxious/depressed and Internalizing was only significant for the boys at wave 5. Some child outcomes showed intervention effects across gender, but stronger effects for boys. These included total behavior problems, externalizing, and aggression from wave 4.

      Family: Successful coparenting as a protective factor. Mother’s stress, mental health, and substance use during gestation.

      • Family
      Risk Factors
      • Family: Family conflict/violence, Parent aggravation*, Parent stress*, Poor family management, Psychological aggression/discipline, Violent discipline
      Protective Factors
      • Individual: Skills for social interaction*
      • Family: Attachment to parents, Non-violent discipline*

      *Risk/Protective Factor was significantly impacted by the program.

      See also: Family Foundations Logic Model (PDF)

      Family Foundations is a universal prevention program developed in collaboration with childbirth educators to enhance coparenting quality among couples who are expecting their first child. The program consists of four prenatal and four postnatal sessions, run once a week, with each two-hour session administered to groups of 6–10 couples. Sessions are led by a trained male-female team and follow the Family Foundations curriculum. The female leader is a childbirth educator and the male leaders are from various backgrounds, but experienced in working with families and leading groups. Ongoing observation of sessions facilitates regular supervision discussions.

      This program focuses on coparenting and the coparenting relationship, rather than other romantic relationship or parenting qualities. In assisting parents to work together supportively, the program content covers emotional self-management, conflict management, problem solving, communication, and mutual support strategies. Parenting strategies include an understanding of temperament, fostering children’s self-regulation, and promoting attachment security. The four prenatal classes introduce the couple to themes and skills, and the four postnatal classes revisit the themes once the couple has experienced life as parents and coparents. The delivery is psychoeducational and skills-based, with didactic presentations, couple communication exercises, written worksheets, videotaped vignettes of other families, and group discussion.

      Family Foundations is a universal prevention program developed in collaboration with childbirth educators to enhance coparenting quality among couples who are expecting their first child. The program consists of four prenatal and four postnatal sessions, run once a week, with each two-hour session administered to groups of 6–10 couples. Sessions are led by a trained male-female team and follow the Family Foundations curriculum. The female leader is a childbirth educator. Ongoing observation of sessions facilitates regular supervision discussions.

      This program focuses on coparenting and the coparenting relationship, rather than other romantic relationship or parenting qualities. In assisting parents to work together supportively, the program content covers emotional self-management, conflict management, problem solving, communication, and mutual support strategies. The program organizes material into three major domains: Feelings, Thoughts, and Communication. These domains help participants remember and utilize program tools. Parenting strategies include an understanding of temperament, fostering children’s self-regulation, and promoting attachment security. However, as the focus is on coparenting, these topics are examined in terms of whole-family dynamics. The prenatal classes introduce the couple to themes and skills, and the postnatal classes revisit the themes once the couple has experienced life as parents and coparents. The delivery is psychoeducational and skills-based, with didactic presentations, couple communication exercises, written worksheets, videotaped vignettes of other families, and group discussion. Skilled facilitators are able to maintain fidelity to the content while engaging parents in an interactive, supportive group learning context.

      Developed as a universal group-format program, ongoing research is assessing adaptations of delivery, content, and target population. For example, an adaptation for high-risk, home-visited mothers and partners is currently in a research trial; an adaptation for low-income teens has been piloted; an online version for military reserve and National Guard families is being developed; and an enhanced version for couples at risk of family violence is planned.

      This program is based on a theoretical model of coparenting as a key influence on parent adjustment, parenting quality, and child adjustment. Coparenting is defined as the way in which parents (or others in a caregiving role) coordinate and support each other in their roles as parents. Research indicates that the coparenting relationship is more strongly related to parenting and child outcomes than the general couple or marital relationship. As the coparenting construct includes couple conflict about issues related to the child, which is a strong risk factor for child externalizing and internalizing problems, the program directly addresses a central risk factor for child adjustment. Difficulties in coparenting have been found to be linked to a range of child outcomes in addition to internalizing and externalizing problems, including effortful control, peer relations, school adjustment, and substance use.

      Coparenting is distinguished from other aspects of the couple’s relationship such as romantic, friendship, legal, and financial domains (except as they impact coparenting per se). In this way, the program targets a circumscribed aspect of the couple relationship—which may be more malleable than the overall couple relationship. Moreover, coparenting is viewed as a protective factor (i.e., moderator) of other influences on parents and children. For example, supportive coparenting may reduce the detrimental effects of parent depression on parent-child relationship quality. Evidence from the research on Family Foundations supports this view, as the program buffered families from the negative effect of prenatal couple violence on harsh parenting toward the child.

      Because coparenting represents the overlap between the parent-child and parent-parent relationship spheres, coparenting is a key target with regard to a range of important outcomes. For example, as maternal stress and anxiety during pregnancy has been related to poor fetal development and outcomes, reducing maternal stress/anxiety during pregnancy through enhanced couple support may reduce adverse birth outcomes. As father involvement among both residential and non-residential fathers is linked to coparenting quality, a focus on coparenting may enhance responsible fathering. And as partner support is the strongest influence on maternal postpartum depression (after prior history of depression is controlled), enhanced coparenting may reduce levels of this problem with benefits for mothers and babies. Indeed, program evaluation data suggests that families enrolled in the program have demonstrated better birth outcomes (for mothers at risk due to levels of a stress hormone, cortisol), better father-infant relations, and decreased postpartum depression.

      • Cognitive Behavioral
      • Skill Oriented

      A randomized controlled design was used to evaluate Family Foundations. Couples were randomly assigned to an intervention (n=89) or to a no-treatment control condition (n=80), with the control condition consisting of receiving mailed literature on selecting quality childcare and developmental stages. Participants were primarily (81%) recruited from childbirth education programs at two hospitals located in small cities. Presumably, all couples responding to recruitment were enrolled, though no further details on recruitment procedures were provided.

      Data were collected on participants five times. Data from 4-5 couples were not utilized in analyses because of developmental difficulties, death of one of the parents, or congenital medical problems for the baby, resulting in a sample size of 164-165. The study gathered pretest data (Wave 1) on all 164-165 couples when mothers were pregnant. Posttest data collection (Wave 2) occurred after the intervention couples had completed the program, when babies were about 6 months old. Of the eligible enrolled couples, 147 mothers completed the posttest (Wave 2) and were included in the analytical sample for posttest results. The study administered a six-month follow-up (Wave 3), when babies were about one year old. For this wave, 93% of mothers and 88% of fathers participated. A two and a half year follow-up (Wave 4) was conducted when children were about three years old (N=137). Wave 5 took place when children were ages 6 to 7.5, or six to seven years after program conclusion. Ninety-eight families provided parent and/or teacher data on child development. Additional analysis was conducted on a subsample (N=123) of mothers consenting to baseline cortisol measurement and completing posttest data collection (Feinberg, Roettger et al., 2014).

      Key outcome measures included pregnancy-related indicators, attitudes and behaviors of mothers and fathers, coparenting and parenting behaviors, and child developmental outcomes.

      Across posttest and follow-up analyses, 9 of 22 child outcomes and 24 of 40 parent outcomes showed significant program effects. One of seven pregnancy-related outcomes assessed at mid-program showed improvement.

      At Wave 2 (posttest, when children were six months old), two of four child outcomes and 6 of 12 parent outcomes showed significant improvement. Mothers and fathers’ coparental support, fathers’ parent-child dysfunctional and parenting-based closeness, mothers’ depressive symptoms and anxiety, father-reported infant soothability, and child duration of orienting all showed significant differences. Mothers’ and fathers’ coparental undermining, mothers’ parent-child dysfunctional interaction and parenting-based closeness, fathers’ depressive symptoms and anxiety, mother-reported infant soothability, and child sleep habits did not show a significant program effect.

      Of the 18 parenting, couple, and coparenting variables tested at wave 3 (six-month follow-up, when children were one year old), 12 showed significant improvements for the intervention participants. The study reported a program effect for one of two child outcomes. Mothers and fathers in the treatment group showed reduced competition and triangulation in coparenting, increased warmth to partner, and increased parenting positivity. Mothers, but not fathers, improved on coparenting inclusion and negative communication to partner, while fathers significantly increased coparenting warmth and reduced parenting negativity. Neither maternal nor paternal active coparenting cooperation showed a significant effect. For child outcomes, self-soothing improved significantly, but sustained attention did not.

      Wave 4 (2.5-year follow-up, when children were about three years old) analyses indicated a significant program effect on six of ten parent, interparental relationship, and parenting outcomes and on four of seven child outcomes. Intervention participants improved parental stress, parental efficacy, coparenting quality, parenting overreactivity, parenting laxness, physical punishment, total behavior problems, child externalizing problems, child aggression, and child social competence. No significant effect emerged for parental depression, relationship satisfaction, child internalizing problems, child attention/hyperactivity, or child emotional competence (Feinberg et al., 2010), or for partner psychological aggression or parent-child physical aggression (Kan & Feinberg, 2013b). Additional analyses showed that among boys, the program had an effect for male children on internalizing, attention/hyperactivity, and relationship satisfaction and showed a stronger effect on total behavior problems, externalizing, and aggression for boys.

      Main effects analyses indicated that, of the two parent-reported and nine teacher-reported child academic and behavioral outcomes measured at wave 5 (six-year follow-up, when children were 6-7.5), two showed significant improvements for the intervention group: teacher-reported anxious/depressed and internalizing problems. In looking at program effects by child gender, boys showed significant improvement for attention problems, aggressive behavior, and externalizing. Parent- and teacher-reported conduct problems and emotional problems and teacher-reported classroom participation and academic participation showed no direct or gender moderated program effects.

      Pregnancy-related outcomes assessed mid-program (four of eight classes) indicated one main effect of the intervention (fewer Caesarian births). Birth weight, number of weeks born premature, premature status, the number of days the child was in the hospital, pregnancy complications, and the number of days the mother was in the hospital showed no program effects for the full sample.

      Moderation analyses indicated the greater effectiveness of the program for high-risk couples. Significant moderators included low parental education, high maternal and paternal attachment insecurity, unmarried mothers, high baseline negative communication levels, high baseline cortisol levels, baseline psychological partner aggression, baseline physical partner aggression, and baseline intimate partner violence, all of which strengthened the relationships between intervention status and different outcomes.

      Feinberg et al. (2015) found no direct effects of the program on parent-reported birth weight, neonatal length of stay in hospital, or maternal length of stay in the hospital. They did find that the program helped several subgroups, specifically those with high levels of pretest parental economic strain, depression, and anxiety.

      At wave 2 (posttest, when children were about six months), the study (Feinberg & Kan, 2008) reported a significant intervention effect for:

      • Fathers’ coparental support, parenting-based closeness, and parent-child dysfunctional interaction
      • Mothers’ coparental support, depressive symptoms, and anxiety
      • Father-reported infant soothability
      • Child duration of orienting

      At wave 3 (six-month follow-up, when children were about one year old), intervention participants showed improved (Feinberg et al., 2009):

      • Mothers’ coparenting competition, coparenting triangulation, warmth to partner, parenting positivity, coparenting inclusion, and negative communication
      • Fathers’ coparenting competition, coparenting triangulation, warmth to partner, parenting positivity, coparenting warmth, and parenting negativity
      • Observed child self-soothing

      At wave 4 (2.5-year follow-up, when children were three years old), intervention participants showed program effects for (Feinberg et al., 2010):

      • Parent-reported parental stress, parental efficacy, coparenting quality, parenting overreactivity, parenting laxness, and physical punishment
      • Mother-reported child total behavior problems, externalizing problems, aggression, and social competence
      • Mother-reported child internalizing problems and attention/hyperactivity (boys only)

      At wave 5 (six year follow-up, when children were 6-7.5 years old), intervention participants showed improvements in the following child outcomes (Feinberg, Jones et al., 2014)

      • Teacher-reported anxious/depressed and internalizing problems
      • Teacher-reported attention problems, aggressive behavior, and externalizing problems (boys only)

      Pregnancy-related outcomes from mid-program showed a significant intervention effect (Feinberg, Roettger et al., 2014):

      • Reduced levels of Caesarian birth

      In Feinberg et al. (2015), the program had no main effects on birth weight, maternal length of hospital stay, or neonatal length of hospital stay, but it did help some subgroups by improving

      • birth weight at low gestational age among parents with high economic strain or maternal depression
      • newborn length of stay among parents with high economic strain, depression, or anxiety
      • maternal length of stay among parents with high economic strain

      In Solmeyer et al. (2014), coparenting competition mediated the effect of the intervention on wave 4 child adjustment problems for mother-son and father-child relationships, but not mother-daughter relationships. The proportion of total effects mediated by coparenting competition was 39% for mothers and sons and 55% for fathers. Coparenting positivity did not mediate program effects for mothers or fathers.

      Moderated intervention effects:

      • Wave 2 posttest outcomes of maternal depression, mother report of coparental support, and child sleep habits were moderated by parental education (Feinberg & Kan, 2008)
      • Wave 2 posttest outcomes of maternal depression, mother’s coparental support, coparental undermining, maternal dysfunctional interaction, and paternal dysfunctional interaction were moderated by father’s insecurity, and maternal depression was moderated by mother’s insecurity (Feinberg & Kan, 2008)
      • Parental depression across waves 2-4 were moderated by parent gender and marital status (Feinberg et al., 2010)
      • Maternal and paternal positivity and negativity toward daughters and reactivity to distress at wave 3 were moderated by baseline intimate partner violence perpetration (Kan & Feinberg, 2013a)
      • Fathers’ psychological partner aggression was moderated by baseline psychological partner aggression and physical partner aggression and mothers’ aggression toward the child was moderated by baseline psychological partner aggression (Kan & Feinberg, 2013b)
      • Parent-reported emotional problems and teacher-reported behavioral outcomes at wave 5 (classroom total participation, academic motivation, conduct problems, emotional problems, anxious/depressed, aggressive behavior, internalizing, and externalizing), were moderated by baseline negative communication levels (Feinberg, Jones et al., 2014)
      • Pregnancy-related outcomes of birth weight, number of weeks born premature, newborn hospital length-of-stay and maternal length-of-stay in hospital were moderated by baseline cortisol levels (Feinberg, Roettger et al., 2014)

      As there were many effects across the different outcomes and analyses, the sizes ranged from small to large. Coparenting outcomes generally had small-medium or medium effect sizes, child behavior outcomes generally had medium to medium-large effect sizes, and the adverse birth outcome effect was small.

      Feinberg et al (2015) did not report effect sizes.

      The sample appears to have limited generalizability. It was composed of a high proportion of couples who were white, married, and of high socioeconomic status and was limited geographically to two small U.S. cities. Moderation analyses indicated the greater effectiveness of the program for high-risk couples. Most of the child outcomes were found only for boys and not for girls.

      • Program participation rates were not very high. Most couples (66% of mothers and 63% of fathers) attended 5 or more sessions.
      • The sample appears to have limited generalizability.
      • Of the several dozen outcomes tested, only 11 were independently measured and related to the development of children (two in wave 3 and nine in wave 5), three of which showed significant improvements across the whole sample. In addition, two of these significant findings (wave 5) are from a substantially reduced sample.
      • The moderation analyses found stronger results for high-risk families but also that the program did not work as well universally.
      • Some parent-reported child outcomes were not independent, but teacher reports and researcher observations were.
      • Some coparenting outcomes were closely related to program content, but the child outcomes were more general.
      • Low reliability of some teacher measures.

      Feinberg et al. (2015)

      • Excluded those who did not attend enough sessions
      • No significance tests for baseline equivalence
      • Not possible to control for baseline outcomes
      • Likely no differential attrition but wording is ambiguous
      • No main effects of the treatment on outcome measures

      • Blueprints: Promising
      • SAMHSA: 3.6-3.7

      Feinberg, M. E., Jones, D. E., Kan, M. L., & Goslin, M. C. (2010). Effects of Family Foundations on parents and children: 3.5 years after baseline. Journal of Family Psychology, 24(5), 532-542.

      Feinberg, M. E., Jones, D. E., Roettger, M. E., Hostetler, M. L., Sakuma, K.-L., Paul, I. M., & Ehrenthal, D. B. (2015). Preventive effects on birth outcomes: Buffering impact of maternal stress, depression, and anxiety. Maternal Child Health Journal, published online 21 July 2015.

      Feinberg, M. E., Jones, D. E., Roettger, M., Solmeyer, A., & Hostetler, M. L. (2014). Long-term follow-up of a randomized trial of Family Foundations: Effects on children’s emotional, behavioral, and school adjustment. Journal of Family Psychology, 28(6), 821-831.

      Feinberg, M. E., & Kan, M. L. (2008). Establishing Family Foundations: Intervention effects on coparenting, parent/infant well-being, and parent-child relations. Journal of Family Psychology, 22(2), 253-263.

      Feinberg, M. E., Kan, M. L., & Goslin, M. (2009). Enhancing coparenting, parenting and child self-regulation: Effects of Family Foundations one year after birth. Prevention Science, 10, 276-285.

      Feinberg, M. E., Roettger, M. E., Jones, D. E., Paul, I. M., & Kan, M. L. (2014). Effects of a psychosocial couple-based prevention program on adverse birth outcomes. Maternal Child Health Journal, published online 27 June 2014.

      Kan, M. L., & Feinberg, M. E. (2013a). Links between pre-birth intimate partner violence and observed parenting among first-time parents? Unpublished manuscript.

      Kan, M. L., & Feinberg, M. E. (2013b). Can strong family foundations prevent parent and partner aggression among couples with young children. Unpublished manuscript.

      Solmeyer, A. R., Feinberg, M. E., Coffman, D. L., & Jones, D. E. (2014). The effects of the Family Foundations prevention program on coparenting and child adjustment: A mediation analysis. Prevention Science, 15, 213-223.

      Mark E. Feinberg
      Prevention Research Center
      Pennsylvania State University
      S-109 Henderson Building
      University Park, 16802
      Email: mef11@psu.edu
      www.famfound.net

      Study 1

      Feinberg, M. E., Jones, D. E., Kan, M. L., & Goslin, M. C. (2010). Effects of Family Foundations on parents and children: 3.5 years after baseline. Journal of Family Psychology, 24(5), 532-542.

      Feinberg, M. E., Jones, D. E., Roettger, M., Solmeyer, A., & Hostetler, M. L. (2014). Long-term follow-up of a randomized trial of Family Foundations: Effects on children’s emotional, behavioral, and school adjustment. Journal of Family Psychology, 28(6), 821-831.

      Feinberg, M. E., & Kan, M. L. (2008). Establishing Family Foundations: Intervention effects on coparenting, parent/infant well-being, and parent-child relations. Journal of Family Psychology, 22(2), 253-263.

      Feinberg, M. E., Kan, M. L., & Goslin, M. (2009). Enhancing coparenting, parenting and child self-regulation: Effects of Family Foundations one year after birth. Prevention Science, 10, 276-285.

      Feinberg, M. E., Roettger, M. E., Jones, D. E., Paul, I. M., & Kan, M. L. (2014). Effects of a psychosocial couple-based prevention program on adverse birth outcomes. Maternal Child Health Journal, published online 27 June 2014.

      Kan, M. L., & Feinberg, M. E. (2013a). Links between pre-birth intimate partner violence and observed parenting among first-time parents? Unpublished manuscript.

      Kan, M. L., & Feinberg, M. E. (2013b). Can strong family foundations prevent parent and partner aggression among couples with young children. Unpublished manuscript.

      Solmeyer, A. R., Feinberg, M. E., Coffman, D. L., & Jones, D. E. (2014). The effects of the Family Foundations prevention program on coparenting and child adjustment: A mediation analysis. Prevention Science, 15, 213-223.

      Feinberg, M. E., Jones, D. E., Kan, M. L., & Goslin, M. C. (2010). Effects of Family Foundations on parents and children: 3.5 years after baseline. Journal of Family Psychology, 24 (5), 532-542.

      Feinberg, M. E., Jones, D. E., Roettger, M., Solmeyer, A., & Hostetler, M. L. (2014). Long-term follow-up of a randomized trial of Family Foundations: Effects on children’s emotional, behavioral, and school adjustment. Journal of Family Psychology, 28 (6), 821-831.

      Feinberg, M. E., & Kan, M. L. (2008). Establishing Family Foundations: Intervention effects on coparenting, parent/infant well-being, and parent-child relations. Journal of Family Psychology, 22 (2), 253-263.

      Feinberg, M. E., Kan, M. L., & Goslin, M. (2009). Enhancing coparenting, parenting and child self-regulation: Effects of Family Foundations one year after birth. Prevention Science, 10, 276-285.

      Feinberg, M. E., Roettger, M. E., Jones, D. E., Paul, I. M., & Kan, M. L. (2014). Effects of a psychosocial couple-based prevention program on adverse birth outcomes. Maternal Child Health Journal, published online 27 June 2014.

      Kan, M. L., & Feinberg, M. E. (2013a). Links between pre-birth intimate partner violence and observed parenting among first-time parents? Unpublished manuscript.

      Kan, M. L., & Feinberg, M. E. (2013b). Can strong family foundations prevent parent and partner aggression among couples with young children. Unpublished manuscript.

      Solmeyer, A. R., Feinberg, M. E., Coffman, D. L., & Jones, D. E. (2014). The effects of the Family Foundations prevention program on coparenting and child adjustment: A mediation analysis. Prevention Science, 15, 213-223.

      Evaluation Methodology

      Design: A randomized controlled design was used to evaluate Family Foundations. Couples were randomly assigned to intervention (n=89) or to no-treatment control conditions (n=80), with the control condition consisting of receiving mailed literature on selecting quality childcare and developmental stages. Data from 4-5 couples were not utilized in analyses because of developmental difficulties, death of one of the parents, or congenital medical problems for the baby, resulting in a sample size of 164-165. Participants were primarily (81%) recruited from childbirth education programs at two hospitals located in small cities. All other couples were recruited from doctors’ offices or health centers (8%), by newspaper ads or flyers (7%), by word of mouth (3%), or by unknown means (including radio advertisement, 1%). Presumably, all couples responding to recruitment were enrolled, though no further details on recruitment procedures were provided.

      Data were collected on participants five times. The study gathered pretest data (Wave 1) on all 164-165 couples when mothers were pregnant. Posttest data collection (Wave 2) occurred after the intervention couples had completed the postnatal classes, when babies were about 6 months old. Of the eligible enrolled couples, 92% of mothers and 90% of fathers completed wave 2. The study administered a six-month follow-up (Wave 3), when babies were about one year old. For this wave, 93% of mothers and 88% of fathers participated. A two and a half year follow-up (Wave 4) was conducted when children were about three years old and included 137 families. Wave 5 took place when children were ages 6 to 7.5, or six to seven years after program conclusion. Ninety-eight families provided parent and/or teacher data on child development.

      Additional analysis was conducted on a subsample (N=123) of mothers consenting to baseline cortisol measurement and completing posttest data collection (Feinberg, Roettger et al., 2014).

      The investigators provided Blueprints with exact numbers of valid data for each outcome by each wave. Overall, they report sample sizes of 123 at the birth outcome assessment, 152 at wave 2, 156 at wave 3, 142 at wave 4, and 98 at wave 5. Among these samples of completers, the measures generally had little missing data. In a few instances, however, missing data among completers reached higher levels: 9.2% (138/152) in wave 2 for father’s Infant Behavior Questionnaire Duration of Orienting, 22.4% (121/156) in wave 3 for mother and father’s Dyadic Couple Communication, 24.6% (107/142) in wave 4 for Child Social Competence, and 27.6% (71/98) in wave 5 for teacher reports of Child Emotional Problems. The analytical sample for adverse birth outcomes (Feinberg et al., 2014) was 147.

      Sample: Participants were 169 heterosexual couples who, at the time of recruitment, were expecting their first child and were living together. All participants were at least 18 years of age. The couples resided in rural areas, towns, and small cities. The majority of couples were married (82%) and the sample consisted mostly of non-Hispanic whites (90-91%), with the remaining participants of African American, Asian, Hispanic, or other ethnic descent. For the most part, participants were well-educated and middle class. The median annual family income was $65,000 and mothers attained an average of 15.06 years of education and fathers attained an average of 14.51 years. Mothers averaged 28 years old, and fathers averaged 30 years.

      The subsample used to examine program effects on pregnancy-related outcomes was demographically similar to the overall sample. The subsample was 92.7% white and 85% married, and had a mean educational level of 15.1 years.

      Measures: The study used the following mother, father, and relationship outcomes:

      • Parental depression, taken from a subset of the Center for Epidemiological Studies Depression Scale, developed and validated by others. Cronbach’s alphas were .84 for mothers and .66 for fathers across waves 1 and 2, and .86 for mothers and .83 for fathers at wave 4. This survey was administered to mothers and fathers at waves 1, 2, 3, and 4.
      • Parental anxiety, taken from the Taylor Manifest Anxiety Scale, developed and validated by others. At baseline, alphas were .85 for mothers and .78 for fathers. This survey was administered to mothers and fathers at baseline and wave 2.
      • Parent-reported efficacy, taken from the Parenting Sense of Competence scale, developed and validated by others. This survey was administered at waves 2, 3, and 4, with alpha coefficients of .84 for mothers and .83 for fathers.
      • Parent-reported stress, taken from the Parenting Stress Index, developed and validated by others. This survey was administered at waves 2, 3, and 4, with alpha coefficients of .90 for mothers and .87 for fathers.
      • Observed couple behaviors, taken from coded videotaped interactions between mother and father. Undergraduate and graduate students used coding systems created for the study or adapted from prior work. Subscales included negative communication and warmth to partner, with inter-rater intraclass correlations ranging from .63 to .88. Couple behaviors were observed at waves 1 and 3.
      • Parent-reported relationship satisfaction, taken from the Quality of Marriage Index, developed and validated by others. This survey was administered at wave 4 and had alpha coefficients of .97 for mothers and .95 for fathers.

      The study used the following parenting and coparenting indicators as outcomes:

      • Parent-reported coparenting, taken from a measure developed for the study based in part on adaptation of prior measures. Subscales from this measure included coparental support, parenting-based closeness, and coparental undermining. Cronbach’s alphas ranged from .72 to .83 for mothers and from .65 to .80 for fathers. This measure was collected at waves 2, 3, and 4.
      • Parent-reported parent-child dysfunctional interaction, taken from a scale in the Parental Stress Index, developed and validated by others. Alphas were .79 for mothers and .77 for fathers. This measure was collected at wave 2.
      • Observed coparenting, taken from coded videotaped interactions at wave 3 among mother, father, and child. Undergraduate and graduate students used coding systems created for the study or adapted from prior work. Subscales for coparenting included competition, triangulation, warmth, and inclusion, with inter-rater intraclass correlations ranging from .44 to .87.
      • Observed parenting behaviors, taken from coded videotaped interactions at wave 3 among mother, father, and child. Undergraduate and graduate students used coding systems created for the study or adapted from prior work. Subscales for parenting behaviors included positivity, negativity, intrusiveness, and reactivity with inter-rater intraclass correlations ranging from .69 to .73.
      • Parenting practices, taken from the Parenting Scale, developed and validated by others. This scale assesses discipline practices in parents of children from 18-48 months. The measure produced three outcomes: laxness, overreactivity, and physical punishment. Alpha coefficients for laxness and overreactivity ranged from .76 to .85. Physical punishment included a single item. The scale was administered at wave 4.
      • Parent-reported partner psychological aggression, assessed at waves 1 and 4 with subsets of items from the Revised Conflict Tactics Scales. Behaviors reported by mother and father were combined and summed to create a frequency measure. The mothers' alpha was .65 and the fathers' was .68.
      • Parent-reported parent-child physical aggression, assessed at wave 4 with the corporal punishment subscale of the Parent-Child Conflict Tactics Scales. Items in the subscale were summed to create a frequency score. Cronbach’s alphas were .55 and .57 for mothers and fathers, respectively.

      The following child behavioral and academic outcomes were used:

      • Parent-reported infant regulation, taken from the Infant Behavior Questionnaire, developed and validated by others. This measure produced two outcomes for mothers and fathers, duration of orienting and infant soothability, and one outcome reported by mothers, child sleep habits. Alphas ranged from .75 to .86 for these indicators measured at wave 2.
      • Observed child behaviors, taken from coded videotaped interactions at wave 3 of the mother, father, and child. Undergraduate and graduate students used coding systems created for the study or adapted from prior work. Subscales for child behaviors included self-soothing and sustained attention, with inter-rater correlations ranging from .67 to .87. The measure of child adjustment problems (alpha=.69) aggregated subscales of anger, activity, resistance to control, and sustained attention.
      • Mother-reported child behavior problems, taken from the Child Behavior Checklist and the Head Start Competence Scale, administered at wave 4. The Checklist produced five outcomes, including three overall scores (total problems, externalizing problems, and internalizing problems) and two specific subscales (aggression and attention/hyperactivity). Two subscale outcomes were taken from the Competence Scale: social competence and emotional competence. Alpha coefficients for these indicators ranged from .78 to .90.
      • Teacher-rated classroom participation, taken from the Total Classroom Participation, developed and validated by others. This outcome was collected at wave 5 (alpha=.95).
      • Teacher-rated academic motivation, taken from the Academic Competence Evaluation Scales, developed and validated by others. This outcome was collected at wave 5 (alpha=.96).
      • Teacher- and parent-reported conduct problems and emotional problems. These outcomes were collected at wave 5 from the Strengths and Difficulties Questionnaire, developed and validated by others. Teachers showed alpha coefficients of .72 (conduct) and .62 (emotional), and parents had alphas of .60 (conduct) and .59 (emotional).
      • Teacher-reported child behavioral problems, taken from the Child Behavioral Checklist, developed and validated by others. The checklist provided five outcomes at wave 5, composed of three specific scales (anxious/depressed, attention problems, and aggressive behavior) and two broad-band indices (internalizing behavior and externalizing behavior). Alpha coefficients ranged from .55 to .92.

      The study used the pregnancy related-outcomes listed below. The data were collected at wave 2, but reflect mid-program assessments when four of the eight classes had been offered. Few details were provided on these outcomes.

      • Birth weight, in pounds
      • Number of weeks born prior to due date
      • Premature status, defined as born three or more weeks early
      • Caesarian section
      • Pregnancy complications rated from parent reports by research team pediatrician
      • Number of days child in hospital after birth
      • Number of days mother in hospital after birth

      The study used the following measures as moderators:

      • Parental education measured by total years of education at baseline.
      • Parent-reported attachment insecurity in close relationships, measured at baseline with a 20-item subscale of the Relationships Scale Questionnaire, developed by others. Alphas were .80 for mothers and .79 for fathers.
      • Parent gender and marital status indicating married and unmarried mothers or fathers at waves 2, 3, and 4.
      • Child gender.
      • Maternal cortisol levels at baseline. Trained research assistants collected saliva samples during home visits. The measure reflects residualized cortisol levels from regression models using time of day and gestation weeks to predict sample results.
      • Observed parental negative communication level at baseline. Trained coders rated maternal and paternal behaviors in videotaped interactions and averaged scores across the two parents. Cronbach’s alpha was .84 for this measure.
      • Intimate partner violence at baseline. The overall violence scores multiplied frequency by severity, with frequency of violence created from summing mothers’ and fathers’ item frequency scores, and severity of violence produced from summing item severity scores. Cronbach’s alphas were .77 and .81 for prevalence and .92 and .76 for frequency of mothers’ and fathers’ behaviors, respectively.
      • Parent-reported partner psychological aggression at baseline, as described in the above measure of parent-reported psychological aggression.
      • Parent-reported severity of parental physical aggression. This mutually exclusive categorical measure defined couples as perpetrating any severe aggression, perpetrating minor aggression only, or not perpetrating any aggression.

      The study used the following mediating measure:

      • Observed coparenting subscales of competition and positivity measured at wave 3, as described in the above outcome measure of observed coparenting.

      Analysis: Multilevel, general linear model, ordinary least squares, logistic, and negative binomial regression models analyzed program effects. For outcomes available separately for mothers and fathers, multilevel models controlled for within-family dependency. For analyses looking at multiple waves of data, multilevel models nested waves of data within family, aggregated at the parent level (Feinberg et al., 2010). Some analyses used full-information maximum-likelihood techniques to accommodate missing data and allow for inclusion of the full eligible sample (Solmeyer et al., 2013; Kan and Feinberg, 2013a; Kan and Feinberg, 2013b). Condition status was assigned at the couple level. Analyses looking at maternal or paternal outcomes appropriately adjusted for clustering within couples, while other analyses were appropriately conducted at the couple level.

      Additional analyses explored moderating effects with interaction terms for intervention by parent education and attachment insecurity (Feinberg and Kan, 2008), child gender (Feinberg et al., 2010; Feinberg, Jones et al., 2014), parent gender and marital status (Feinberg et al., 2010), baseline negative communication levels (Feinberg, Jones et al., 2014), and baseline cortisol level (Feinberg, Roettger et al., 2014). Mediation analyses used path analysis, a bias-corrected bootstrap test and the proportion-mediated measure to determine size and significance of mediators (Solmeyer et al., 2013).

      The study used different covariates in analyses including parent age, education, and social desirability (Feinberg and Kan, 2008; Feinberg et al., 2009), respondent age, marital status, family income, respondent educational level, social desirability score, financial strain score, and maternal relationship attachment insecurity (Feinberg et al., 2010), child gender, child age, marital status, and baseline characteristics of parental education, family income, and negative communication (Feinberg, Jones et al., 2014), child gender, baseline maternal education, and marital status (Feinberg, Roettger et al., 2014), wave 1 maternal education and parent reports of social desirability (Solmeyer et al., 2013), mother’s education (Kan and Feinberg, 2013a), and parent mean education (Kan and Feinberg, 2013b).

      Baseline controls were not collected for coparenting, parenting, or child outcomes, as they would not have been appropriate before birth. Thus, most analyses did not control for baseline outcome levels. Analyses for parental depression and anxiety (wave 2) and couple behaviors (wave 3) controlled for baseline levels through the use of group-by-time interactions (Feinberg and Kan, 2008; Feinberg et al., 2009)

      Analyses were run as intent-to-treat and included all parents completing data collection, regardless of level of program participation.

      Outcomes

      Implementation Fidelity: Though couples did not appear to participate fully in the program, the study showed high fidelity to program content. An observer from the project team attended and rated over 90% of intervention sessions for implementation fidelity, finding that an average of 95% of the curriculum content was delivered. Average attendance was 5.50 classes for mothers and 5.38 classes for fathers, with only 3% of mothers and 5% of fathers attending no sessions. Most couples (66% of mothers and 63% of fathers) attended five or more sessions.

      Baseline Equivalence: As child outcomes could not have been collected at pre-birth baseline assessment, equivalence could not be tested for all measures. However, the study reported that “analyses indicated no significant differences between intervention couples and control group couples on a wide range of pretest variables, including age, income, education, marital status, weeks of gestation, mental health, and relationship quality” (Feinberg and Kan, 2008). In addition, the investigators provided Blueprints with comparisons of the intervention and control group on 35 parent variables at the time of birth and at waves 2-5. The results demonstrate group equivalence. Only 4 of 175 comparisons (5 times 35) showed a significance difference, and only one variable – father’s insecure attachment – showed consistent significant differences across waves.

      Differential Attrition: Attrition differed according to the wave of data collection, with participation declining across the study period. The studies reported partial information on differential attrition for individual waves (described below). However, the investigators provided Blueprints with a more detailed analysis of differential attrition that summarizes the pattern across five waves for 39 variables. The 195 tests (5 times 39) for differences between completers and dropouts showed no significant results at the time of birth and wave 2, one significant result at wave 3, five significant results at wave 4, and two significant results at wave 5. The wave 4 pattern of higher attrition among high risk subjects was found in additional analyses to occur primarily in the control group, which may serve to attenuate differences across conditions.

      Participation in posttest data collection was high, with 92% of mothers and 90% of fathers completing wave 2. The rates of participation were similar across control (91%) and intervention (89%) couples, and the study noted that “there were no differences in the association of pretest variables with continued participation across conditions” (Feinberg and Kan, 2008).

      For wave 3, 88% of mothers and 93% of fathers of the original 165 couples completed data collection. At both baseline and wave 3, married couples were more likely to have videotaped interactions (Feinberg et al., 2009).

      The study reported that 84.6% (N=137) of families provided data at wave 4. Regressions testing whether study participation between intervention and control groups was associated to background characteristics indicated that attriters in the control condition had lower maternal education levels than intervention attriters, though no other significant differences emerged. The study reported that wave 4 analyses using imputation techniques to estimate missing values for attriters supported the reported results for models only including wave 4 participants (Feinberg et al., 2010).

      Wave 5 showed substantial attrition, due to the long follow-up period. The study predicted participation in wave 5 using several demographic and key study variables, finding only that family income was a significant predictor (Feinberg, Jones et al., 2014).

      Analyses looking at moderation of program effects on mid-program pregnancy-related outcomes by cortisol levels used a subsample of mothers who consented to have cortisol measurements at baseline and completed data at wave 2. Of the 137 mothers who provided cortisol levels, 90% (N=123) completed posttest data. No analyses comparing participation rates were provided (Feinberg, Roettger et al., 2014).

      Mid-Program Assessment: Pregnancy-related outcomes assessed mid-program (4 of 8 classes) indicated 1 main effect of the intervention (reduced levels of Caesarian birth), out of 6 outcomes. Birth weight, number of weeks born premature, premature status, the number of days the child was in the hospital, pregnancy complications, and the number of days the mother was in the hospital showed no direct program effects.

      Posttest: At wave 2 (posttest when children were six months old), two of four child outcomes and 6 of 12 parent outcomes showed significant improvement. Mothers and fathers’ coparental support, fathers’ parent-child dysfunctional interaction and parenting-based closeness, mothers’ depressive symptoms and anxiety, father-reported infant soothability, and child duration of orienting all showed significant differences. Mothers’ and fathers’ coparental undermining, mothers’ parent-child dysfunctional interaction and parenting-based closeness, fathers’ depressive symptoms and anxiety, mother-reported infant soothability, and child sleep habits did not show any significant program effect.

      Follow-up: Of the 20 parenting, couple, coparenting, and child outcomes tested at wave 3, 13 showed significant improvements for the intervention participants. Mothers and fathers in the treatment group showed reduced competition and triangulation in coparenting, increased warmth to partner, and increased parenting positivity. Mothers, but not fathers, improved on coparenting inclusion and negative communication to partner, while fathers significantly increased coparenting warmth and reduced parenting negativity. Neither maternal nor paternal active coparenting cooperation showed a significant difference. For child outcomes, self-soothing improved significantly, but sustained attention did not.

      Wave 4 analyses indicated a significant program effect on 10 of the 17 parent, interparental relationship, parenting, and child outcomes. Intervention participants improved parental stress, parental efficacy, coparenting quality, parenting overreactivity, parenting laxness, physical punishment, total behavior problems, child externalizing problems, child aggression, and child social competence. No significant effect emerged for parental depression, relationship satisfaction, child internalizing problems, child attention/hyperactivity, or child emotional competence (Feinberg et al., 2010), or for partner psychological aggression or parent-child physical aggression (Kan and Feinberg, 2013b). Additional analyses showed that among families with boys, the program had an effect on internalizing, attention/hyperactivity, and parent relationship satisfaction, and showed a stronger effect on total behavior problems, externalizing, and aggression for boys. For models assessing outcomes available at multiple waves (parental stress, efficacy, depression, and coparenting quality), there was no evidence that intervention and control conditions differed in rates of change across postintervention assessments.

      Main effects analyses indicate that of the two parent-reported and nine teacher-reported child academic and behavioral outcomes measured at wave 5, two showed significant improvements for the intervention group: teacher-reported anxious/depressed and internalizing problems. In looking at program effects by child gender, boys but not girls showed significant improvement for attention problems, aggressive behavior, and externalizing. Parent- and teacher-reported conduct problems and emotional problems and teacher-reported classroom participation and academic participation showed no direct or gender moderated program effects.

      Moderation: The study reported parental education, maternal and paternal attachment insecurity, the interaction of parent gender and marital status, baseline negative communication levels, baseline cortisol levels, baseline psychological partner aggression, baseline physical partner aggression, and baseline intimate partner violence as significant moderators of relationships between intervention status and different outcomes.

      Results of moderation analyses on wave 2 parental and child outcomes indicated that intervention effects were greater for those with less education or higher levels of attachment insecurity. Parental education significantly moderated the intervention effect on maternal depression, mother report of coparental support, and child sleep habits, but did not moderate the other 13 outcomes. Of 16 moderation models determining whether the effects of the intervention depended on maternal or paternal attachment insecurity, seven showed significant results, though one effect was not interpreted as it showed a direction opposite to the other six. Father’s insecurity moderated the effect of the intervention on maternal depression, mother’s coparental support, coparental undermining, maternal dysfunctional interaction, and paternal dysfunctional interaction. Mother’s insecurity moderated maternal depression.

      Wave 3 models showed moderation of the treatment by baseline intimate partner violence perpetration for 6 of 12 comparisons. For mothers and fathers, parenting positivity, negativity toward daughters, and reactivity to distress indicated stronger program effects for couples with higher baseline levels of intimate partner violence. Parenting positivity, negativity toward sons, and parenting intrusiveness showed no moderation effects for mothers or fathers.

      Models also tested for moderating effects of parent gender and marital status on parent and child outcomes collected at wave 4. One significant result indicated that among nonmarried mothers, intervention participants showed lower levels of depression. No other significant moderating effects of child gender or parent gender and marital status emerged. Additional results looking at moderation effects for wave 4 outcomes showed that the intervention had stronger effects on fathers’ psychological partner aggression for couples with higher baseline levels of psychological partner aggression or physical partner aggression and on mothers’ aggression toward the child for couples with higher baseline levels of psychological partner aggression. Parents’ baseline negative communication moderated program effects on most parent- or teacher-reported child outcomes at wave 5. Parent-reported emotional problems and teacher-reported classroom participation, academic motivation, conduct problems, emotional problems, anxious/depressed, aggressive behavior, internalizing, and externalizing all indicated that the intervention worked best for children whose parents had negative communication at baseline.

      Four of the 6 pregnancy-related outcomes indicated moderation, showing that the intervention improved outcomes only for women with high cortisol levels. This effect was observed for birth weight, number of weeks born premature, the number of days the child was in the hospital, and the number of days the mother was in the hospital. Caesarian birth and pregnancy complications showed no moderation effects from cortisol levels.

      Mediation: In Solmeyer et al. (2014), coparenting competition mediated the effect of the intervention on wave 4 child adjustment problems for mother-son and father-child relationships, but not mother-daughter relationships. The proportion of total effects mediated by coparenting competition was 39% for mothers and sons and 55% for fathers. Coparenting positivity did not mediate program effects for mothers or fathers.

      Feinberg, M. E., Jones, D. E., Roettger, M. E., Hostetler, M. L., Sakuma, K.-L., Paul, I. M., & Ehrenthal, D. B. (2015). Preventive effects on birth outcomes: Buffering impact of maternal stress, depression, and anxiety. Maternal Child Health Journal, published online 21 July 2015.

      The results from this article come from the same larger project as Study 1 but differ enough in sample, measures, and analysis to present separately.

      Evaluation Methodology

      Design:

      Recruitment: Couples were primarily recruited through childbirth education programs and Ob/Gyn clinics, but also through media advertisements and fliers. The study reported identifying 743 eligible couples, of which 399 agreed to participate.

      Assignment: The study randomly assigned the 399 couples to the treatment or control condition in a randomized block design, based on pretest data. The intervention sample included 221 couples and the control sample included 178 couples.

      Attrition: Of the randomized sample, 259 (64.9%) were included in the analytical sample. Eighty-seven couples were lost to follow-up, and additional exclusions included those with birth complications, low class attendance, missing data, or extreme propensity scores.

      Sample: The average education level in the sample was 15.79 years and the average age among mothers at pretest was 29.3. No information on the race/ethnicity of the sample was given, but the study referred to the sample as low-risk.

      Measures: The study measured birth weight in kg, maternal length of stay in hospital after birth (days), and newborn length of stay in hospital after birth (days) as outcome measures. These measures were obtained from parents up to 10 months after the birth of the child and depended on accurate recall.

      Analysis: The study used separate regression models for each outcome to examine main and moderated effects of the intervention. Moderation was analyzed using two- and three-way linear and quadratic interactions.

      Intent-to-Treat: The study violated intent-to-treat by excluding subjects who attended fewer than three of the five prenatal classes, which was deemed insufficient participation. However, it also used propensity score matching to attempt to correct for selection bias created by dropping non-participants.

      Outcomes

      Implementation Fidelity: The average attendance rate at the five prenatal classes was 87.9% among participants, with an average of 4.3 classes. The authors estimated that attending three of the five prenatal classes would represent minimally adequate dosage. Of the intervention mothers, 91.8% achieved that minimum attendance.

      Baseline Equivalence: Because all outcomes related to subsequent birth of the child, the study did not examine baseline equivalence in outcome measures. Although it did not provide significance tests for differences in demographic and other measures at baseline, the percentages appear similar (Table 1).

      Differential Attrition: The study stated that it found no significant condition differences in attrition by demographic measures.

      Posttest: Feinberg et al. (2015) found no main effects of the program on parent-reported birth outcomes.

      However, they found significant moderation effects on birth outcomes in 7 of 36 interaction terms (p < .05). The significant moderation indicated that the intervention reduced the harm of high economic strain, depression, and anxiety. For birth weight, the study reported significant moderation of the intervention effect by economic strain and maternal depression but only for those with preterm births (at 36 weeks or earlier). For newborn length of stay, moderation by economic strain and prenatal maternal depression was linear, while a significant curvilinear pattern was reported for prenatal maternal anxiety. For maternal length of hospital stay, the intervention reduced the positive association between economic strain and anxiety found in the control condition.

      Long-Term: The study did not conduct long-term follow-up.