Admission to day stay early parenting program is associated with improvements in mental health and infant behaviour: A prospective cohort study
© Rowe et al.; licensee BioMed Central Ltd. 2012
Received: 31 May 2012
Accepted: 31 July 2012
Published: 13 August 2012
Australia’s Early Parenting Services support families and intervene early in mental health problems in parents. The Victorian Early Parenting Strategy, a platform for government policy recommended a stronger evidence base for early parenting services. Tweddle Child and Family Health Service (TCFHS) is a not-for-profit public sector early parenting centre, which provides residential, day stay, home visiting and outreach programs. This study aimed i) to examine the health, social circumstances and presenting needs of clients attending the Tweddle Day Stay Program (DSP) with infants under 12 months old and ii) to assess the parent mental health and infant behaviour outcomes and the factors associated with program success.
A cohort of clients was recruited prior to admission and followed-up 8 weeks after discharge. Data were collected using standardised measures in a study specific questionnaire at baseline, participant’s Tweddle records and a follow-up telephone interview. Health, social circumstances and presenting needs of clients were described. Changes in parents’ symptoms of depression and infants’ sleep and settling between admission and follow-up were calculated. Multiple regression analyses were conducted to examine factors associated with changes in primary outcomes.
Of the total 162 clients who were eligible and invited to participate, 115 (72%) were recruited. Parents admitted to the DSP had worse general self-reported physical and mental health than community samples. Infants of DSP participants were no more likely to be premature or have low birth weight, but significantly more unsettled than other community samples. Participants’ mental health and their infants’ behaviours were significantly improved after DSP admission. In multivariate analysis, higher depression score at baseline and greater educational attainment were significantly associated with improvements in parents’ mental health. Worse unsettled infant behaviours and longer time between discharge and follow up were significantly associated with improvements in infant sleep and settling.
Tweddle DSPs appear to respond effectively to the needs of families presenting with substantial physical and emotional health morbidity and a range of vulnerabilities by treating parental mental health and infant behaviour problems together. DSPs offer important potential benefits for prevention of more serious family problems and consequent health care cost savings.
KeywordsParenting Infants Mental health Health services
Health policy context
The mental health of parents of infants in Australia is a growing clinical and public health priority. Australia’s National Perinatal Depression Initiative  has provided funding to each state and territory to improve care for women who are at risk of or experiencing depression in pregnancy and in the first year after birth. The initiative aims to enhance recognition of mental health problems in primary care services, foster better networks of support groups for new mothers and enhance care and support in community-based, as well as specialist psychological and acute inpatient services. In addition to implementing the national initiative, the Victorian State Government has identified early childhood is a priority. Recent policy and legislative changes are intended to promote earlier intervention and more timely and effective services for vulnerable children and families .
Victoria’s early parenting sector provides day stay, residential, group and home-based programs focussing on infant health and development, promotion of family wellbeing and parent-infant emotional attachment. This sector is well placed to respond to both the national perinatal mental health and Victorian early childhood agendas. The Victorian Early Parenting Strategy (VEPS)  provides the policy platform for Victorian early parenting services. The strategy is consistent with the public health model of family care, which is underpinned by universal services such as the Maternal and Child Health nursing service, available free to all families with infants under the age of five . The second tier of the model includes the early parenting services, which are designed as intensive secondary services and which parents attend on a voluntary basis when universal services are insufficient for their needs. These services are focussed on prevention and early intervention. They are intended to reduce the need for referral to tertiary services, which constitute the third tier of the model of service provision .
The VEPS is based on growing evidence of the importance of investing in the early years of life and on recognition of the central role of the early parenting sector in achieving this goal. The strategy identifies three key focus areas. First, to strengthen the integration of the early parenting services within the Victorian Child and Family service system; second, to enhance the range of service responses to changing community needs and third, to build service capacity to promote quality and innovation . A review of existing early parenting services in Victoria was conducted as part of the VEPS. The Strategy recommended that, in order to make clear decisions about future service directions, a stronger evidence base about the outcomes of early parenting services be developed .
Residential programs offered by early parenting services are internationally-unique, structured admissions to assist parents of infants with unsettled behaviour and feeding problems . There is no doubt that these residential programs in Victoria and other Australian states constitute an important component of comprehensive mental health care for young families . Up to 25% of mothers admitted meet diagnostic criteria for major depression, 25-32% meet criteria for a current anxiety disorder [5, 6] and severe fatigue is universal . Admission is consistently associated with significant and sustained improvements in maternal mental health and infant behaviour [4, 8].
A similar structured program of one day duration, designed to assist parents of infants with sleep and feeding difficulties, is offered in the Day Stay Program. Compared with residential programs, less is known about the characteristics and presenting needs of families attending day stay programs or the outcomes of these services. The effectiveness of a Melbourne metropolitan Day Stay Program was tested in a randomised controlled trial. Mental health status, parental confidence and infant behaviours all improved significantly after admission . Another recent prospective investigation of women admitted to a day stay early parenting program in Western Australia showed that one month after attendance, compared to a comparison sample, women who attended the day stay program had significantly better confidence and competence, but not mental health as assessed by the Edinburgh Postnatal Depression Score (EPDS) . These inconsistent findings should be interpreted with caution and might be explained by methodological factors. For example, in the first study, allocation to groups was not concealed and attrition in the control group was higher than in the intervention group . In Hauck and colleagues’  study ,the comparison group was a convenience sample of volunteers and the outcome analyses were not adjusted for worse baseline mental health in the admitted group.
In order to contribute to the VEPS recommendation to enhance the evidence base and as part of its commitment to a regular review and priority-setting agenda, the Board of Tweddle Child and Family Health Service commissioned an independent investigation of its Day Stay Program in 2010.
Aims of the study
This study was conducted in order to assist the Tweddle Board with their organisational strategic planning and to contribute to the evidence base about current Victorian Early Parenting Centre (EPC) service provision. The aims of the study were: i) to examine the health, social circumstances and presenting needs of clients attending the Tweddle DSP and ii) to assess the parent mental health and infant behaviour outcomes of the program and the factors associated with program success.
Ethics approval was obtained from the University of Melbourne Human Research Ethics Committee (Date of approval: 13 July, 2010; Ethics ID: 1033203).
Tweddle child and family health service
Tweddle Child & Family Health Service (TCFHS) is a not-for-profit public sector early parenting centre, established in the 1920s and now funded through the Victorian Government Department of Human Services. Tweddle’s residential, day stay, home visiting, outreach programs aim to facilitate learning and parenting skill development in parents of babies and children up to 4 years old. TCFHS is part of the second tier of services, and programs are offered by experienced and highly skilled maternal and child health nurses, midwives, and early childhood professionals free-of-charge to parents from a wide range of socioeconomic and cultural backgrounds, living in metropolitan and rural areas. TCFHS prioritises provision of services to vulnerable or isolated families and to parents of infants and young children assessed as at risk.
Tweddle day stay program
The Day Stay Program (DSP) service was established in 1992. DSPs are managed by Tweddle or jointly with other organisations. These programs have good local recognition and are highly regarded and used . A goal of the program is to link families to supports within their community including mental health, maternal and child health, general practice and family support agencies.
The objectives of the DSP are that parents explore alternative ways of managing their parenting concerns, receive coaching in interpreting their child’s cues; explore factors that have contributed to their loss of confidence and be referred to services in their community .
Parents self-refer to the DSP by telephoning the service directly. Experienced nurses conduct an assessment interview and triage to the appropriate Tweddle service, based on severity of presenting needs, age of child and personal and socioeconomic circumstances.
Theoretical model of DSP
Groups of 2 to 4 families are admitted together to the 7-hour program. Parents are assisted individually to establish short-and long-term goals for their child and themselves. A health promotion model of practice is used in which one-to-one and group learning opportunities and supported practice are provided. Educational strategies include discussion, self-directed learning, counselling, coaching, demonstration and didactic presentations. Participants learn about infant behaviour management strategies to promote settling and sleep, optimal infant nutrition and feeding practices, infant development and behaviour, managing parental fatigue and promoting emotional well being, parent - infant relationships, safety and play .
The study was a prospective longitudinal cohort, or single group pre-and post-test design. Participants were assessed twice: once prior to admission to the DSP and once 4 – 8 weeks after discharge from the program.
Clients were identified by the TCFHS intake team as being eligible for the study if they were 18 years old or over, with English proficiency sufficient to give informed consent to participate and complete a written questionnaire and a telephone interview, and had accepted a place in the DSP with an infant under 12 months old.
Based on the normal distribution, a sample size of 97 at outcome, provides 95% confidence that the true population prevalence of study parameters will lie between ± 5% of the prevalence estimates observed in the study .
Tweddle Client Record
Follow-up computer assisted telephone interview (CATI)
The interview assessed general and mental health, infant behavior, health service use, assessment of child’s behavior and parenting enjoyment since attending the DSP.
- 2.Mental health
The EPDS is a widely-used 10-item self-rating scale for screening for probable depression, using 4 response options (0–3) and yielding a total score of 0–30 . It has been validated in Australia against diagnostic interviews. A score of greater than 12 yields a sensitivity of 100%, a specificity of 95.7% and a positive predictive value of 69.2% for depression .
The Kessler 6 is a six-item self-rating scale  used to detect serious mental illness. Five response options for each question (scored 1 – 5) generate a total score between 6 and 30. A higher score indicates more distress and a score of 19 and over signifies a high risk of mental disorder .
The Baby Behaviour Scale (BBS)  is a parent self-report measure of average duration of infant crying, frequency of night time waking, ease of soothing and settling and number and length of day time sleeps in a 24-hour period during the last two weeks. Maternal confidence is assessed with a single question. These eight items yield good internal consistency (Cronbach Alpha = 0.7 ). Scores on 8 individual items are summed, total scores range between 0 and 21, higher scores indicate more unsettled infant behaviour.
Comparison population data
2009 Victorian Child Health and Wellbeing Survey
Birth in Victoria 2007 and 2008
Tweddle Residential Service in 2004
- 4.Two community samples
A survey assessing the mental health of 12,361 women recruited from 43 health services across Australia at 6–8 months postpartum .
Mental health and infant behaviour reported by 800 women attending local government immunisation clinics in the Tweddle catchment area with their four month old infants .
All eligible women who were offered and accepted a place at a Tweddle DSP were posted a letter of invitation to participate, a plain language statement, a consent form, a contact detail form and a brief study specific questionnaire with their standard pre-admission pack.
Participation and follow-up
Those agreeing to participate signed a standard consent form, provided contact details and completed the study specific questionnaire. Clients placed their sealed envelope (whether materials had been completed or not) in a box provided during attendance at the DSP. Trained telephone interviewers contacted participants within 4–8 weeks of attendance of the DSP to assess their continued willingness to participate and arrange a suitable time to conduct the interview. Where necessary, at least three repeated attempts were made to reach participants by telephone.
To compensate for participants’ time and inconvenience, a shopping voucher to the value of AUD 25 was posted to those who completed all stages of the study.
Data extraction from client record
Data were extracted from participants’ client record and entered into a study-specific standardised data extraction tool by a member of Tweddle staff and the research team working together.
Data management and analysis
The sources of data, measures used and response options for sociodemographic characteristics, heath and circumstances, reproductive history, maternal mental health, partner relationship, social support, infant characteristics, health service use, parenting and infant behaviours are presented in Additional file 1.
Data were analysed in SPSS v 19 . Total scores and proportions above relevant cut-off scores on standardised scales were computed for the EPDS  and Kessler 6  measures.. Clinically significant symptoms, defined as EPDS scores over 12 (for clinical samples) and over 9 (for community samples)  and Kessler 6 scores over 19  were computed and entered as categorical variables. Items on the BBS  were recorded on individual 3 or 4-point scales. Individual item scores were summed and a total score computed as a continuous variable. Individual items were reported as frequencies (n; %) and total score as a continuous variable.
Normality tests were conducted on continuous data. Internal consistencies of numerical measures were established and reported as Cronbach’s alpha statistic. Descriptive statistics were computed using mean (SD) for continuous variables and frequency distributions for categorical data. Non-parametric one-sample binomial and chi-square tests were used to establish all significant differences in baseline variables from population-based comparison data. Baseline characteristics of participants retained in the study were compared with those lost to follow-up using Pearson chi-square and Fisher’s exact test for multinomial and binomial categorical variables respectively; Mann–Whitney tests for non-normally distributed and t-tests for normally distributed continuous variables.
The primary outcomes were defined as changes in mean EPDS and BBS scores between baseline and follow-up (Time 2 – Time 1) and reported as mean differences (95% confidence interval for the difference). Employment status was re-coded into a binary variable as employed versus not in paid employment; mode of birth as caesarean or assisted versus spontaneous vaginal; birth weight as low (<2500grams) versus normal (>2500grams) in regression analyses. Multiple regression analyses were conducted in order to examine the factors associated with the primary outcomes. First, factors potentially associated with outcomes as hypothesised were checked in bi-variable analyses. Variables with p-values < 0.2 were included in the models. Model statistics including regression coefficients, 95% CIs, and p-values are presented. Negative coefficients indicate greater improvements in the outcomes and positive coefficients indicate deteriorations in outcomes.
Health, social circumstances and presenting needs of clients attending the Tweddle DSP
Number of valid responses
Mean (SD) age (years)
30.82 32.2 (4.9)3
Aboriginal/ Torres Strait Islander n (%)
Born in Australia n (%)
Language spoken at home n (%)
Other than English
Marital status n (%)
Education attainment n (%)
Current employment status n(%)
No (study part time)
Yes (maternity leave)
Pension/ Health care card
Participant (n (%))
Partner (n (%))
Socioeconomic Positiond (IRSAD) (n (%))
General and reproductive history
Health and reproductive history
Number of valid responses
General health question n(%)
How would you describe your sleep pattern? n(%)
Experienced distressing life events in the last 12 months
Number of pregnancies n(%)
Three or more
Total children n(%)
Three or more
Adverse pregnancy events n(%)
Mode of birth n(%)
Continuing concerns n(%)
Postnatal complications n(%)
Mental health and social support
The mental health of the sample was assessed using self-report measures. The study sample mean EPDS score and the proportions scoring more than 9 and more than 12 (clinically significant symptoms of depression in community and clinical samples respectively) were both significantly higher, indicating worse mental health, than two community comparison samples [20, 24]. However the degree of psychological distress in this sample was not as severe as in the sample admitted to Tweddle residential programs .
Participant mental health
Number of valid responses
EPDS * score
n (%) >9
n (%) >12
Mean Kessler 6 *score
n (%) at risk of mental disorder (>18)
Current feelings of depression or anxietyn (%)
Previously feelings of depression or anxiety n (%)
The availability of social support is known to act protectively or to increase risk of mental health problems in the life stage when caring for an infant . More than half (n = 64, 55%) of the study participants rated the support that they were receiving from their partner in the work of infant care and household management as low or very low. Few participants (n = 14, 12.1%) were receiving substantial support from friends or family and even fewer still (n = 10, 8.6%) endorsed their community as a source of support. These findings are consistent with those in the sample admitted to the residential service . It appears that attendance at the DSP is a means of addressing substantial need for additional parenting support and countering feelings of social isolation (Table 3).
Infant characteristics at admission
Number of valid responses
Mean (SD) infant age (weeks)
Gestational age n(%)
Pre-term (<37 weeks)
Birth weight n(%)
Illnesses or medical conditions since birth n(%)
Health development concerns n(%)
Prior health service
Participants reported contact with a variety of health services prior to attending Tweddle DSP. Of the 7 listed services, participants endorsed a mean (SD) = 2.2 (0.98) (range 0 – 5) services which they had attended since the birth of the baby. Contact with a MCH nurse was near universal (n = 101, 90%) and a smaller proportion (n = 91, 81%) had consulted a general practitioner.
No comparison data are available for these questions, but almost all participants described themselves as happy with the job of being a parent (n = 110, 94.8%) and their relationship with their child (n = 106, 91.4%). However, a smaller proportion (n = 88,76%) reported being happy with their child’s behaviour and less than half (n = 49, 48%) were enjoying parenting.
Infant sleep and settling
Infants admitted to DSPs (n = 106) were reported as exhibiting significantly more unsettled behaviour (mean; SD = 10.9; 2.96) than those in the community (mean = 6.1; mean difference = 4.8 (95%CI: 4.26; 5.40); p < .001) . Infants were reported as having shorter daytime sleeps, crying inconsolably for longer periods, more difficult to soothe, waking more often at night and more difficult to settle back to sleep, having fewer daytime sleeps, and more difficult to look after than infants in the community (p < 0.001 for all items). Only 81% of the parents (n = 94) attending the DSP reported feeling confident about looking after their babies compared to 97% of the community sample . The BBS at admission yielded a Cronbach alpha of 0.62.
Parent mental health and infant behaviour outcomes of the program and factors associated with program success
The median time to follow-up was 7 (range 2 – 25) weeks. There was a need, for staffing reasons, to interview a small group (n = 5) before 4 weeks after discharge and another group (n = 27) were unable to be interviewed until after 8 weeks.
Mental health at admission and at follow up (n = 103 + )
Kessler 6 score**
Factors associated with difference (T2-T1) in EPDS scores between baseline (T1) and follow-up (T2)
95 % CI
Education (1:Tertiary; 0:Year 12 and less)
−3.64 ; -0.1
EPDS score at baseline
−0.77 ; -0.41
Work(1: Employed; 0: not in paid employment)
−2.25 ; 0.64
English at home (1: Yes; 0: No)
−3.95 ; 0.88
Distressing event (1: Yes; 0: No)
−3.91 ; 0.44
Baby Behaviour score at baseline
−0.35 ; 0.2
Birthweight (1: Low; 0: Normal)
−1.48 ; 3.51
Time to follow-up (month)
−1.76 ; 0.41
−2.96 ; 3.91
−0.46 ; 0.08
Infant behaviour had also improved significantly. The mean (95% CI) reduction in BBS score was 2.4 (1.8; 3.0), but the mean (95% CI) score at follow-up (8.4 (7.7; 8.9)) remained significantly higher than in 4 month old infants in the community (6.1; p < 0.001) . The BBS at follow up yielded a Cronbach alpha of 0.67. Responses to individual BBS items at baseline and follow-up were compared. There had been significant improvements on all items, except the number of daytime sleeps. Most infants were still having two or three sleeps during the day, which is appropriate in this age group. Importantly, parental confidence had increased significantly (data not shown).
Factors associated with difference (T2-T1) in Baby Behaviour scores between admission (T1) and follow-up (T2)
95 % CI
Baby Behaviour score at baseline
−0.61 ; -0.18
Time to follow-up (month)
−1.87 ; -0.21
Breastfeeding (1: Fully; 0: Partly/ none)
−2.73 ; 0.39
Working (1: Employed; 0: not in paid employment)
−0.28 ; 1.96
EPDS score at baseline
−0.2 ; 0.07
Birth (1: c/s/assisted; 0: spontaneous vaginal)
−1.95 ; 0.48
Birthweight (1: Low; 0: Normal)
−1.28 ; 3.16
Baby medical condition (1: Illness; 0: None)
−1.89 ; 0.41
Baby age (month)
−0.3 ; 0.22
Health service use
A stated aim of the DSP at Tweddle is to link families into other health and social services in their local communities. Almost one quarter (n = 22, 21%) of participants had been referred by staff during their DSP admission to another service, including MCH nurse, GP, paediatrician, social worker, counsellor or psychologist and the Tweddle residential program. Some participants had been given beyondblue pamphlets for their partners to use. However, only half of these participants had taken up their referral. Reported reasons for not attending their MCH nurse included dissatisfaction with their nurse, too long a gap between visits, the inability to get a date for an appointment and improvements their infant‘s night-time sleep and settling. A partner did not take up a referral to a psychologist because of his reluctance to talk about his feelings with someone unknown to him. Reasons for not attending the Tweddle residential program as suggested related to the perception that this service is for more problematic cases.
This study examined the mental health of parents attending a short-admission early parenting service in Victoria Australia and gives important insights into the nature and severity of their presenting problems and the value of the service. However, the study was limited by the need to collect some data from client record, rather than with study specific questions. This was necessary to maximise client participation and minimise the burden on participants and staff. The “single group pre- and post-test” design limits the conclusions that can be drawn about the effect of the DSP program on the outcomes of interest. This is because improvements in indicators of parent and infant wellbeing might be expected to occur spontaneously with the passage of time, growing infant developmental capacities and recovery from the birth. However, the longitudinal design, high participation and retention, the collection of data using relevant standardised measures with which comparisons with population-based data could be made, from a sample which is large enough to provide statistically precise estimates of sample characteristics. However, the findings should be generalised to all parents who use the DSP with caution, because not all women who attended the DSP were offered the opportunity to participate in the study.
The results provide the service with important opportunities for review. The most striking finding is the level of need that is being addressed by the DSP. Many participants reported current health problems and coincidental adverse life events. On average their physical and mental health status and their infants’ unsettled behaviour were significantly worse than community norms. The significantly elevated symptoms of anxiety and depression prior to admission had, by follow up, declined to community norms and the infants were on average significantly more settled. Greater improvements were experienced by clients who were more symptomatic at admission. Together, the findings confirm the value of integrating assistance for infant sleep and settling into mental health services for parents of infants .
The program also appears to be more beneficial for people with more experience in formal learning settings, who gained an almost two fold greater benefit from participation than those with fewer years of formal education. As well as the generally protective effect on mental health of socioeconomic status and better education, it is possible that better educated participants were able to make more effective and sustained use of the psycho-education during admission than those with less education. The service is currently reviewing the model of care, including simplifying written materials and providing more supported practice of new skills and opportunities for individual explanation during the admission. Longer elapsed time to follow up was also associated with greater improvements in infant behaviour. This might be explained by growing infant maturity with the passage of time or resulted from the time taken for parents to establish new patterns of infant care before the benefits became apparent.
The finding that DSP clients were better educated, in higher status occupations and less likely to be born overseas than in the general population could be explained by possible, unfamiliarity with community services of overseas-born Australians, and the preferential triage of the more disadvantaged to the residential program at the service. However, it emphasizes that more advantaged groups can also be vulnerable at this phase of life.
Changes to the service model, which include increasing visibility and access for vulnerable and culturally and diverse families and modifying the educational components to meet the needs of clients with less formal education are recommended. The low uptake of referral to other services after discharge is of potential concern given that a key objective of the DSP is to improve links to other community resources. Participants expressed dissatisfaction with other available services but their reasons for lack of engagement with these services warrant exploration.
The potential prevention of more serious of mental health-related problems associated with the DSP early intervention is an important finding. This would be likely to reduce the costs associated with treatment, productivity losses, and to reduce impaired quality of life of families, which sometimes may be immeasurable . The cost effectiveness of the DSP service remains to be investigated.
The findings of this study suggest, notwithstanding sub-optimal integration with other services, that the Tweddle DSPs form an important part of the spectrum of services for parents of infants in Victoria. DSPs appear to respond effectively to needs that are more complex than can be met in universal MCH services but generally do not require residential admission. The DSPs are responding to high level of physical and emotional health need and a range of vulnerabilities. DSPs offer important potential benefits for prevention of more serious family problems and consequent health care cost savings.
The Tweddle Child and Family Health Service Board funded the study and CEO Ms Vivienne Amery ensured that staff time was made available. Dr Renzo Vittorino oversaw implementation of the study and Ms Karen Clarke; Ms Ann Hindell; Ms Rae McKay; Ms Cammy Naidoo, Ms Milinda Steve; Ms Le Ann Williams and the Tweddle Intake Team assisted with recruitment of participants. Mr Thach Tran provided statistical assistance. Professor Jane Fisher assisted with interpretation of the findings.
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