Individual variability in parenting profiles and predictors of change: Effects of an intervention...

Journal of Applied Developmental Psychology 27 (2006) 349–369

Individual variability in parenting profiles and predictors of change:Effects of an intervention with disadvantaged mothers

Cathy L. Guttentag a,⁎, Claudia Pedrosa-Josic a,1, Susan H. Landry a,Karen E. Smith b, Paul R. Swank a

a University of Texas Health Science Center at Houston, USAb University of Texas Medical Branch, Galveston, USA

Available online 12 May 2006

Abstract

Four components of a comprehensive, responsive parenting style (Responsiveness to Signals, Maintaining Attentional Focus,Rich Language, and Warmth) have been previously identified [Landry, S. H., Smith, K. E., & Swank, P. R. (in press). Responsiveparenting: Establishing early foundations for social, communication and independent problem solving. Developmental Psychology].In the current study, Latent Class Analysis revealed classes (profile groups) of mothers who demonstrated 4 distinct patterns ofskills across these parenting factors. Latent Transition Analysis revealed that mothers randomly assigned to a parenting interventionwere more likely than comparison mothers to transition from weaker to stronger profile groups; e.g., 60% of comparison groupmothers who were in the lowest profile group at pre-intervention remained in the lowest profile group at post-intervention, versus17% of intervention group. Mental health symptoms, social support, and parenting beliefs individually predicted profile groupmembership prior to treatment, but only parenting beliefs predicted pre-intervention profile group membership using a multivariablemodel. Social support predicted positive change among intervention mothers. Implications include the potential importance ofassessing parents' initial behavioral profiles and parenting beliefs to tailor interventions to individual strengths and weaknesses.© 2006 Elsevier Inc. All rights reserved.

Keywords: Parenting; Intervention; Parent training; Parent–child interaction; Infant development; Early childhood; Beliefs; Social support

1. Introduction

It is well recognized that when parents provide higher quality stimulation of language and cognitive development andprovide warm emotional nurturance, children develop greater emotional competence, acquire larger vocabularies,perform better on a variety of cognitive measures, and achieve greater success academically (e.g., Bornstein & Tamis-LeMonda, 1989; Hart & Risley, 1995; Landry, Smith, Swank, Assel, & Vellet, 2001; Tomasello, 1988; Weizman &Snow, 2001). In light of this established body of knowledge, numerous interventions have been developed to assistparents in developing the skills necessary to provide optimal support for their children's development (e.g., Bakermans-

⁎ Corresponding author. Developmental Pediatrics, University of Texas Health Science Center, 7000 Fannin, Suite 2300, Houston, TX 77030,USA. Tel.: +1 713 500 3719; fax: +1 713 500 3705.

E-mail address: cathy.guttentag@uth.tmc.edu (C.L. Guttentag).1 Claudia Pedrosa-Josic is now at the School of Public Health, University of Texas Health Science Center at Houston. This study was supported by

NIH grant HD36099.

350 C.L. Guttentag et al. / Journal of Applied Developmental Psychology 27 (2006) 349–369

Kranenburg, van IJzendoorn, & Juffer, 2003; Beckwith & Rodning, 1992; Olds & Kitzman, 1993). Such interventionsoften target children at risk for less optimal outcomes due to biological (i.e., premature birth) or environmental (i.e.,poverty, low maternal education) risk factors. A number of these studies have documented that improving maternalresponsiveness skills results in improvements in young children's socioemotional development, attachment status, andcognitive skills (e.g., Anisfeld, Casper, Nozyce, & Cunningham, 1990; Gross et al., 2003).

In determining the success of these interventions, the focus of analyses has traditionally been on establishing groupdifferences in outcomes between an intervention group and a control or comparison group. Results of such analyses candemonstrate whether parents and/or their children showed, on average, positive changes as a result of the intervention.However, there is typically little information available about how a given intervention may have differentially impacteddifferent types of participants.Within an intervention group, there may be subgroups of parents who show specific patternsof responsiveness to the intervention that would not be revealed by examining group means. For example, some mothersmay show improvement in stimulating their infant's language development but not in providing emotional support, or viceversa. It is also possible that mothers who showed a particular profile of characteristics or skills prior to intervention mayrespond to the intervention in a different manner than mothers with a different pre-intervention profile. Previous studieshave examined moderating variables, and to a lesser extent, mediating variables, that may impact intervention outcomes.For example, it has been found that variables such as ethnic/racial group of participants, infant birth weight, maternaleducation, degree of poverty, andmaternalmental health can serve asmoderators of intervention effectiveness (e.g., Berlin,Brooks-Gunn, McCarton, & McCormick, 1998; Barrera, Cunningham, & Rosenbaum, 1986; Heinicke et al., 2000).

These types of studies do provide some insight into predictors of change. However, the moderators identified tend tobe used as distal markers serving as proxies for the behaviors targeted by the interventions. One of the major limitationsof focusing only on such distal markers is the absence of qualitative information about individual mothers' existingparenting skills at the start of an intervention. Knowing more about mothers' strengths and weaknesses ahead of timecan serve not only as a baseline for assessing changes in specific areas, but may also allow interventionists to identify amother's specific needs, tailor the administration of the treatment protocol accordingly, and predict the likelihood of herresponsiveness to the intervention. Such analyses are rare in the parenting intervention literature. One study that didexamine psychosocial characteristics in mothers that might be considered more proximal is a study by Booth, Mitchell,Barnard, and Spieker (1989), which assessed mothers' pretreatment social skills, perceived social support, anddepression. Although these factors predicted mothers' responsiveness to the intervention, they did not provideinformation about mothers' quality of parenting prior to the intervention, which might have guided interventionimplementation.

1.1. Major objectives

The present paper addressed the need for more information about individual differences in mothers' pre-existingbehaviors by examining variability within a group of mothers who were randomly assigned to either a parentingintervention (target) condition or to a comparison condition in which infants' development was screened across multipleareas and reported to mothers. The goals of the current study were distinctly different from those of previous reports ofthese samemothers, which focused on establishing the general effectiveness of the intervention (Landry, Smith, & Swank,in press), and the added benefit of community mentors (Dieterich, Landry, Smith, Swank, & Hebert, 2006). Those twopapers reported findings of significant differences between the target intervention and comparison group mothers andinfants as a result of the intervention. The intervention program was found to be successful, on average, in changing targetmothers' emotional responsiveness and stimulation of their at-risk infants across 5 to 12 months of age, and in enhancingtheir infants' cognitive, language, and social development (Landry et al., in press).

There were three major objectives for the current study. The first was to use Latent Class Analysis to classifymothers into distinct classes (profile groups) based on their parenting styles prior to receiving the intervention. Creatingthese profile groups allowed us to investigate how mothers who began the intervention with different profiles of skillsresponded to the intervention. This approach is unique in the parenting intervention literature. The second objectivewas to determine whether mothers were likely to remain within the same profile group over the course of theintervention or to shift into different profile groups as a result of the parenting intervention or lack of such intervention.The third objective was to determine whether certain maternal characteristics (specifically mental health symptoms,childrearing beliefs, and social support) predicted pre-intervention profile group membership and change in profilegroup membership over time.

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1.2. Theoretical frameworks for the intervention curriculum

The intervention curriculum, Play and Learning Strategies (PALS), was designed to facilitate change in mothers'behaviors across both the cognitive stimulation and emotional support domains, and was drawn from two broadtheoretical frameworks. The first was Vygotsky's (1978) sociocultural theory of child development, which emphasizesthe critical role that caregiving adults play in stimulating and supporting children's learning through behaviors such asscaffolding and maintaining the child's focus of interest (e.g., Bakeman & Adamson, 1984; Bruner, 1972; Wertsch,1979). Scaffolding involves assisting children to raise their performance to the next level beyond what they canaccomplish independently (Wertsch, 1979). Examples of such parent behaviors include demonstrating a new way touse a toy or using a hand-over-hand technique to help an infant hold an object. Maintaining focus of interest refers tokeeping the child's attention and interest focused on a toy or activity, rather than redirecting the child to a differentobject or activity, and has been shown to facilitate children's learning (Landry, Garner, Swank, & Baldwin, 1996;Tomasello & Farrar, 1986).

The second theoretical framework was attachment theory, in which the development of a secure attachment to acaregiver constitutes the primary source of the young child's feelings of safety confidence. These feelings thenenable the child to explore the environment and to use the parent as a source of emotional and instrumental supportduring times of distress (Ainsworth, Blehar, Waters, & Wall, 1978; Sroufe, 1988). Based on this framework, thePALS intervention emphasized helping parents respond to their infants in ways that would result in a positive,secure attachment relationship between parent and child. Target behaviors included attending to infants'communicative signals, responding to these signals promptly and contingently (i.e., in a manner that is linked towhat the child signaled), and responding in an affectively supportive manner that is not harsh or overly restrictive.The intervention also targeted behaviors consistent with sociocultural theory (i.e., use of cognitive and languagestimulation techniques such as labeling, scaffolding, and maintaining attentional focus). This approach included asynthesis of didactic and experiential/practice components to teach and coach mothers, one-on-one, to use theseskills under the guidance of a facilitator during a series of home visits (see Landry et al., in press). The interventionemphasized the development of mothers' competence in all of these skills and integrating them into a cohesive,responsive style.

1.3. Variability in pre-intervention profiles

To address the study objectives, first it was necessary to determine whether there were distinct profile groups ofmothers in both the target and comparison groups who varied on the four responsive parenting components prior tointervention. Based on prior longitudinal descriptive research (Landry et al., 2001), we expected to find a group ofmothers who were able to use high levels of warm responsiveness and cognitive and language stimulation (i.e.,strongest profile) and another group in which members were low across all of the parenting components (i.e., weakestprofile). We also expected to find groups of mothers who would show a discrepancy in the strength of their parentingskills across these two frameworks, i.e., mothers who were high in some parenting components and low in othercomponents.

1.4. Variability in intervention impact

Next, it was important to determine whether or not the intervention was equally effective for mothers across alltypes of initial profiles. For example, if the intervention was equally and highly effective for all mothers, the mothersfrom each of the pre-intervention profiles who had received the PALS intervention would form a large profile groupin which all mothers used all the targeted behaviors at a relatively high level. In contrast, mothers receiving onlydevelopmental information and assessment feedback (comparison group) would be expected to remain stable in theirprofiles or show decreases on the four factors. Decreases in the four factor optimal parenting behaviors might occurfor mothers who did not receive the intervention because the latter half of the child's first year is a time whenchildren's increasing mobility and autonomy-seeking behaviors present increasing challenges for parents (e.g.,Campos, Kermoian, & Zumbahlen, 1992). We also wished to investigate whether mothers who initially did notcombine behaviors across the two frameworks improved in this aspect of parenting by the end of the intervention, orwhether gains in one domain might be offset by losses in another. To answer these questions, it was necessary to

determine the likelihood of mothers transitioning from one profile group to another over the intervention period andwhether their participation in the PALS intervention versus the comparison program predicted change from weaker tostronger parenting profiles.

1.5. Predictors of initial profiles and changes in profiles

A third question was whether maternal personal/social characteristics that were present prior to the interventionpredicted the pre-intervention parenting profile as well as changes in mothers' profiles over time. Belsky's model ofdeterminants of parenting (Belsky, Hertzog, & Rovine, 1986) was used as an organizing framework to select maternalinternal and interpersonal characteristics that were expected to predict mothers' initial parenting profiles as well aschange in profiles. In this model, mother's internal (i.e., parenting beliefs; mental health status) and external (i.e., socialsupport) resources are theoretically linked to parenting strengths and weaknesses and have been shown to relate tomore responsive parenting (e.g., Assel et al., 2002; Landry et al., 2001). Parenting beliefs that are more child-centeredhave been found to predict parents' ability to interact with their children in responsive ways (e.g., Landry et al., 2001).Thus, this type of internal resource is likely to be important in understanding parenting profiles. However, such parentalknowledge may not be sufficient to ensure behaviors such as responsiveness to child signals, maintaining attentionalfocus, using rich language, and warmth, when other resources are limited. If a mother is preoccupied or distressed withmental health symptoms related to anxiety, depression, or hostility, she is less likely to have the cognitive andemotional resources to devote to meeting the needs of her child. Similarly, a mother who feels socially isolated orperceives herself as having limited social support may not have the positive relationships needed to feel valued as anindividual or have the social networks available to discuss and problem-solve around childrearing issues. We thereforesought to identify the internal and external maternal characteristics that predicted pre-intervention profiles and thenthose that predicted change in these profiles for those mothers receiving the PALS intervention. We expected thatmothers with more child-centered parenting beliefs, fewer mental health symptoms, and higher levels of perceivedsocial support, would have stronger initial parenting profiles and would be more likely to move from weaker to strongerparenting profiles in response to the PALS intervention.

Addressing the above sets of questions was expected to provide clinically relevant information that would deepenour understanding of which mothers are most likely to benefit from which aspects of the intervention, which types ofbehaviors are easier versus more difficult to change, and how the intervention (versus the comparison program) impactsmothers with particular types of pre-intervention characteristics.

2. Method

2.1. Participants

Descriptive information regarding the participants is presented in Table 1 separately for mothers in the PALSintervention group and mothers in the comparison group. Families were recruited during 1997 through 2000 from threehospitals in the Houston–Galveston area, and included (sample remaining after attrition) high-risk (n = 63) and low-risk (n = 91) infants born at very low birth weight (VLBW), as well as full-term infants (n = 87). The medical criteria forrecruitment and exclusion of infants born VLBW have been described in other studies (e.g., Landry et al., 2001).Mothers were excluded if they were under 18 years old or had a documented mental health or substance abuse disorder,as the intervention was not designed to meet the more comprehensive needs of these maternal populations. Very LowBirth Weight was defined as b 1500 g. Infants were classified as low-risk based on the presence of acute respiratorydisorders and/or mild (grade I or II) intraventricular hemorrhage (IVH). High-risk infants had experienced chronicrespiratory disorders and/or more severe grades of IVH without hydrocephalus (e.g., Landry et al., 2001). Full-terminfants were recruited to match the demographics (e.g., SES, maternal education, maternal age, ethnicity) of those bornVLBW but had to meet the medical inclusionary criteria of normal pregnancy histories, deliveries, birth weights, andphysical exams at birth. Families who spoke either English or Spanish were recruited as the study could beimplemented in either language.

The cohort initially included 264 mother–infant pairs from predominately lower-middle to low socioeconomicstatus (SES; Hollingshead, 1975) but was reduced to 241 families who completed the 10-session programs andassessments through the follow-up assessment. Study attrition, defined as not completing all 10 sessions and the pre-,

Table 1Comparison of infant, maternal, and program characteristics by intervention condition

PALSa n = 121 DASb n = 120

InfantBirth weight: (M g) High/Low/Term 833/1256/3385 918/1412/3332Gestational age: (M week) High/Low/Term 27/30/40 27/31/40Risk status: % High/Low/Term 28/38/34 25/37/38Gender: % M/F 45/55⁎ 52/48⁎

MaternalAge (years) 27.8 (5.7) 27.0 (6.2)Education (years) 12.6 (2.6) 12.6 (2.4)SESc 31.0 (12.3) 32.7 (12.3)% One/two parent 62/38 55/45Ethnicity: % Afr. Amer./Cauc./Hisp./Other 37/34/27/2 29/36/31/4

ProgramTime to complete—week 14.5 (3.5)⁎ 13.4 (3.2)⁎

Note. Data are M (SD) unless otherwise indicated as percentages (%).⁎p b .05 for PALS vs. DAS condition.a Play and Learning Strategies (intervention group).b Developmental Assessment of Skills (comparison group).c Based on Hollingshead 4-factor scale.

interim, post-, and follow-up assessments, was 9% (n = 23) and was primarily due to scheduling problems or movingoutside the study area. The only difference found between families who completed the program versus those lost to thestudy was ethnicity, χ2(3; N = 264) = 13.49, p b .004. An omnibus test was conducted with the four ethnic groups,results of which were significant. Post-hoc analyses revealed that African American and “Other” ethnicities wererepresented at higher numbers in the attrition group compared to Hispanic and Caucasian ethnic groups, χ2(1; N = 264)= 12.22, p = .0005. This was the only significant difference among the groups.

When examining for differences between families in the two study conditions (see Table 1), VLBW infants in theintervention group had lower birth weights than those in the comparison group, F(1, 247) = 4.15, p b .04. With respectto demographics, only sex of the infant differed across study conditions, χ2(1) = 5.01, p b .03. In the PALS group, therewere 10% more female infants than male infants, whereas in the comparison group there were 4% more males thanfemales. The Hollingshead four-factor scale (1975) was used to determine family socioeconomic level. This scaleaverages level of education and occupational rankings for the maternal caregiver and, if present, another adult in thehome who is providing financial support of the study infant. The scale ranges from 6 to 66 and thus, the average of 31.9(SD = 12.4) for this sample is representative of families across the lower-middle to middle socioeconomic range.

2.2. Measures

2.2.1. MothersT child-centered beliefsThe 20-item Concepts of Development Questionnaire (CODQ; Sameroff & Feil, 1985) examined the extent to

which mothers held child-centered parenting beliefs. This measure has been used extensively in parent–child research.Parents were asked to indicate the extent of their agreement with statements such as “Parents must keep to theirstandards and rules no matter what the child is like”, “There is no one right way to raise children”, and “Boy babies hugand kiss less than girl babies”. Response choices are on a 4-point Likert-type scale ranging from 0 (“StronglyDisagree”) to 3 (“Strongly Agree”). A weighted average score is computed by summing the scores for the odd-numbered items (representing a “Perspectivistic” or child-centered approach) and summing the scores for the reverse-scored even-numbered items (representing a “Categorical” or less child-centered approach). In the present study,weighted average scores ranged from 1.3 to 8.5,M = 1.90, SD = .49, with higher scores reflecting more child-centeredattitudes. Comparable maternal scores, M = 1.80, SD = .25, were found during infancy in a longitudinal, descriptivestudy of parent–child interactions (Smith, Landry, & Swank, 2000). The predictive validity of this instrument has beenpreviously demonstrated as higher CODQ scores predict better cognitive and social development for children (Landry

et al., 1996; Sameroff & Feil, 1985). Internal consistency for this measure with families from a broad range ofsocioeconomic backgrounds has been shown to be .82 (Sameroff & Feil, 1985), and with a low SES sample, .67(Landry et al., 1996).

2.2.2. Maternal emotional well-beingThe Symptom Checklist 90-Revised questionnaire (SCL-90-R; Derogatis, 1994) is a 90-item measure used to

examine psychological symptoms. Respondents are asked to reflect on how distressed they were over the precedingweek by symptoms such as: “Trouble remembering things”, “Feeling easily annoyed or irritated”, “Thoughts of endingyour life”, “Crying easily”, and “Spells or terror or panic”. Response choices are on a 5-point scale from 0 (Not at all) to4 (Extremely). In the present study, all nine subscales were analyzed but only three [depression (13 items), anxiety (10items), and psychoticism symptoms (10 items)] were found to be related to the latent category profiles. Reliability ofthese subscales as measured by coefficient alphas reported by Derogatis (1994) for a study of symptomatic outpatientswere as follows: Depression = .90; Anxiety = .85; Psychotocism = .77. Factor analyses have established constructvalidity, convergent-discriminant validity, and factorial invariance (Derogatis, 1994). Scores for each subscale arecomputed by summing the scores for all items in the subscale and dividing by the number of items in the subscale, thusyielding an average score (possible range = 0 to 4). For all subscale scores, higher scores reflect greater psychologicalsymptomology. In our study, the scores ranged as follows: Depression, 0 to 3.54,M = .65, SD = .67; Anxiety, 0 to 2.38,M = .25, SD = .38; Psychoticism, 0 to 2.08, M = .20, SD = .32. These correspond to approximate T-scores (M = 50,SD = 10) of 58 for Depression, 51 for Anxiety, and 58 for Psychoticism. Mean (and SD) comparison scores fromDerogatis's (1994) female non-patient/female outpatient normative sample are as follows: Depression = .46 (.52)/1.94(.93); Anxiety = .37 (.43)/1.59 (.90); Psychoticism = .15 (.25)/.98 (.47).

2.2.3. Maternal perceived social supportThe 20-item Personal Relationships Inventory was developed for a longitudinal descriptive study with disadvantaged

mothers (Landry et al., 2001). In an interview format, mothers listed and then ranked persons who provided her withsupport and then responded to 20 items, some positively worded and some negatively worded, regarding the six highestranked individuals. Each statement required a “true” or “not true” response from the participant. Items includestatements such as: “This person is willing to help me with my problems”, “I can count on this person in an emergency”,“Sometimes this person makes things difficult for me”, and “This person does not understandmy problems”. An averagesocial support satisfaction score for each listed person was calculated by giving one point for each positive statementendorsed and one point for each negative statement not endorsed (possible range = 0–20 for each of six persons, totalpossible score = 120) and dividing by the number of individuals listed. In this study, average support scores ranged from8.8 to 20, M = 16.4, SD = 2.7, with higher scores indicating greater perceived social support. Comparable maternalscores (M = 16.0, SD = 2.7) were found in a longitudinal, descriptive study of parent–child interactions that includedfamilies of similar economic backgrounds (Smith et al., 2000). Internal consistency for this measure with a similarpopulation from a previous study was found to be .88 (Landry et al., 2001).

2.2.4. Maternal observed behaviorsMother–infant interactions were videotaped for 15 min during four assessment visits. These observations were

conducted in the laboratory in a naturalistic living room situation. Books, toys,magazines, and other items found in a livingroom were provided during this time. Mothers were asked to do what they would typically do in their home. A 5-minsegment from each of the 15-min interactionswas randomly selected for coding ofmaternal behaviors. Table 2 summarizesthe definitions for the behaviors targeted in the intervention. All targeted maternal behaviors have been included in a largebody of previous descriptive research and shown to predict various aspects of infant and child development includingexploratory goal-directed play, language, and following requests (e.g., Landry et al., 1996; Landry, Miller-Loncar, Smith,& Swank, 2002). A historical review by Darling and Steinberg (1993) provides a theoretical model that emphasizes theimportance of capturing both specific parenting behaviors and more global parenting characteristics. Thus, behaviors thatare more discrete, such as labeling, verbal scaffolding, and restrictiveness were coded using frequency counts, whereasbehaviors that reflect a disposition that permeates all of a mother's interactive behaviors, such as those involved incontingent responsiveness, voice tone, and warm sensitivity (Bakeman & Brown, 1980), were coded using global ratings.Using both methods has proven to be successful in previous research in capturing highly reliable and valid measures ofmother and child behaviors (e.g., Landry et al., 2001).

Table 2Definitions of the maternal interactive behavior measures grouped by factors

Responsiveness to SignalsContingent

responsiveness aDegree of responsiveness to infant cues including promptness and appropriateness of maternal reactions, appropriate pacethat fits the infant's abilities and patience.

Lack of negativebehaviors:Restrictiveness b Maternal physical or verbal attempts to interrupt an activity in which the infant is engaged, often involving statements

such as, “get that toy out of your mouth”, or taking an object from the infant.Physicalintrusiveness a

Abruptness when moving infant or taking objects away, physical expressions of impatience, and repositioning thatinterferes with infant activity.

H a r s h v o i c etone a

Abrupt, impatient, and/or harsh verbal intonation.

Maintaining Attentional FocusMaintaining b Maintaining is coded when maternal requests were related to the activity or object the infant is currently visually and

physically engaged with (e.g., while an infant is holding rattle, mother says, “yeah, that's a rattle”), or in direct responseto the infant's attempts to attract mother's attention to an object or activity (e.g., “Do you want me to take that block?”while infant was handing a block to mother).

Verbalencouragement b

Statements that involve praising infants' efforts (e.g., “way to go”) or serve to encourage their activity involvingobjects or toys or infant's vocalizations (“yeah”, “that's it”).

Rich Language InputVerbal

scaffolding bVerbal hints/prompts offered that provide conceptual links between objects, persons, activities, or functions thatmay occur in relation to objects, activities, and topics of conversation.

Labeling b Specific names of objects (e.g., “ball”) and actions (e.g., “Can you roll it?”) provided during the interaction with the infant.

WarmthPositive affect a Degree to which mother displays smiling, laughing, and facial animation.Warm sensitivity a Degree of sensitivity to infant cues including acceptance of interests and needs, amount of physical affection, enthusiasm

in activities, positive tone of voice, and avoidance of negative comments.

a Global rating scores.

2.2.4.1. Global ratings of maternal behaviors. After viewing the randomly selected 5min segment, coders completeda set of five separate global ratings (contingent responsiveness, physical intrusiveness, harsh voice tone, positive affect,and warm sensitivity). Each of the five point scales was based on the proportion of time the mother was engaged in thebehaviors of interest. Multiple criteria were relied upon for each scale and coders based ratings on the strength of theconstellation of criteria displayed by the mother. For example, mothers rated high (5) on contingent responsiveness wererequired to consistently respond to child initiates, expand on their child's interests, and pace their involvement to fit theirbaby's needs. When rating physical intrusiveness, coders considered behaviors such as abruptness in movements andrepositioning as well as the unnecessary removal of toys or other objects. Mothers' behaviors rated as 5 on this scaledisplayed 0–1 instances of intrusiveness, whereas those at the bottom of the scale were classified as almost alwaysintrusive. Ratings of harsh tone included behaviors such as abrupt, impatient tone, or raising one's voice and rangedfrom 5 (0–1 instances of mild negative tone) to 1 (frequent use of harsh tone). Positive affect scores were based on thenumber of smiles directed toward the child during the 5 min segment. Finally, warm sensitivity ratings were based on arange of criteria including mother's level of engagement, the presence of positive talking, physical affection, and thefrequency of encouragement and praise. A warm sensitivity rating of 5 represents mothers who were almost alwayswarm, whereas a 1 refers to mothers who displayed no warmth. Although global ratings of contingent responsivenessand warm sensitivity were based primarily on the consistent presence of a constellation of criterion behaviors, raterswere also instructed to assign lower ratings to those mothers who displayed 1 or 2 very negative behaviors in areasrelated to these scales, even if they also displayed some positive behavior. By taking these negative behaviors intoaccount in the global ratings the upper range of these two scales was better able to represent those mothers who bothconsistently displayed positive behavior and lacked negative behaviors. Mid range ratings then represent mothers whowere inconsistent but displayed some positive behaviors, whereas those at the lowest point of the scale lacked anypositive behavior.

2.2.4.2. Maternal behavior frequencies. In addition to completing global ratings on the 5 min segment selected,coders recorded more detailed frequency-based information on a subset of behaviors including restrictions, maintainingattention, verbal encouragement, verbal scaffolding, and labeling. To code each of these behaviors, the mother–infantinteraction was divided into attention-directing events. An attention-directing event was defined as any maternal verbal(questions, comments, or directives) or nonverbal behavior (orienting gestures, demonstrations, giving of objects)directed toward the child. Three criteria were used to determine the length of attention-directing events. Separate eventswere coded when more than 3 s elapsed between each related maternal behavior (i.e., an event was considered completewhen the mother stopped all nonverbal and verbal behavior toward the child for a period of three or more seconds).New attention-directing events were also coded when the mother switched from one toy or activity to anotherregardless of the 3 s guideline. Finally, the presence of both verbal (e.g., “Stop that”, “No”) and nonverbal (e.g., taking atoy away) restrictions were considered to break an attention-directing event. With the exception of labeling, each of thetargeted behaviors was scored dichotomously as either present or not present within in each attention-directing event.Because the number of attention-directing events varied from mother to mother, participant differences were evaluatedbased on each mother's proportion of events in which the behaviors of interest either occurred or did not occur. Oncethe boundaries of the maternal attention-directing events were designated using the above criteria, the coder watchedthe event again to see if the mother's initial behavior aimed to maintain the child's focus of attention. Verbalencouragement included any statement that praised the baby's efforts or served to further encourage their activities(e.g., “Good job!”; “You can do it.”). Rich language input was based on the combination of scaffolding and labelingcontent in mother's verbalizations. Scaffolding consisted of 16 categories that capture the various ways mothers canprovide conceptual links between objects, persons, activities or functions. For instance, mothers received scaffoldingcredit for any attention-directing event in which they talked about cause and effect relationships, contrasting concepts(big/little), or an object's function (e.g., “Can you shake the rattle?”). Coders also recorded up to two action and twotangible object labels per attention-directing event. Labels within a single event were not double coded.

2.2.4.3. Training procedures and inter-rater reliability. Two procedures were used to assure reliability in coding theobservational measures. For the first of these, a team of research staff from both university sites (n = 4, Houston; n = 2,Galveston) were trained to code mother and infant observed behaviors by an expert, senior coder under the direction ofthe Principal Investigator. Initial training involved each coder achieving inter-rater agreements N80% per variable. Toguard against observer drift, monthly cross site meetings were conducted where videotapes were coded as a team andinter-rater agreements were checked to assure that they continued to meet the criterion of N80% per variable.Inconsistencies from previous reliability checks were discussed and consensus reached. Mother–infant data wererandomly selected for measurement of interrater reliability (15%). To ensure that coders were blind to treatmentcondition and biological risk level, data collected at one site were coded at the other site and vice versa.

The second procedure determined reliability of the variables used in data analyses, with generalizability coefficientsused to evaluate both relative and absolute error across raters.

A second rater coded 15% of the videotapes and generalizability coefficients using repeated measures ANOVAswere calculated, with coefficients N .50 indicative of adequate reliability (Mitchell, 1979). This method isrecommended for studies using continuous behavioral observational data, and has the advantage of evaluating boththe consistency across a variable for each rater and the variance across participants (Frick & Semmel, 1978).Generalizability coefficients for the individual maternal behaviors that made up the four factors were as follows:Contingent responsiveness, r = .74; restrictiveness, r = .75; physical intrusiveness, r = .45; harsh voice tone, r = .70;maintaining attention, r = .81; verbal encouragement, r = .78; verbal scaffolding, r = .64; labeling, r = .75; positiveaffect, r = .74; warm sensitivity, r = .74. Generalizability coefficients all were within adequate ranges with theexception of physical intrusiveness, which may have been less reliable due to its low incidence.

2.2.4.4. Maternal behavior factors. A principal axes factor analysis (Landry et al., in press) reported in a previousstudy (Landry et al., in press) showed that the interaction style taught to mothers in the PALS curriculum included fourdistinct, but related, factors: Responsiveness to Signals, Maintaining Attentional Focus, Rich Language Input, andWarmth. Moderate relations among the four factors provided further support for these distinct components as parts ofan overarching responsiveness construct. Infants' skills were facilitated most optimally when mothers used behaviorsacross the four components rather than just in one area. These four factors were selected based on their relation withpositive infant outcomes in descriptive studies and for the type of support they provided (Landry et al., 2001; Landry et

al., in press). The Responsiveness to Signals factor included observations of contingent responsiveness and a lack ofnegative behaviors such as restrictions, physical intrusiveness, and harsh voice tone. The Maintaining AttentionalFocus factor included maintaining the child's focus of attention, and verbal encouragement. The Rich Language Inputfactor included verbal scaffolding, and labeling objects and actions. The Warmth factor included positive affect andwarm sensitivity.

2.3. Procedure

Telephone recruiters explained that families would need to agree to: (1) Be randomly assigned to one of two studyconditions, (2) allow home visitation with a facilitator for 10 weekly sessions, and (3) participate in four parent–infantassessment sessions. Once recruited, families were randomly assigned to either the “PALS” (Play and LearningStrategies) parenting intervention or to the “DAS” (Developmental Assessment of Skills) comparison condition.Assessments of maternal interactive behaviors were conducted by trained research staff blind to the study condition atthe pre-assessment that was conducted 2 weeks prior to Session 1 [N = 264, infant age M (SD) = 6.2 (.66) months]; atthe interim point after session 5 [n = 253, infant age M (SD) = 8.4 (.1.1)]; post-assessment 2 weeks after Session 10[n = 258, M (SD) = 10.7 (1.5) months, and follow-up about 3 months after Session 10 [n = 241, M (SD) = 13.1 (1.5)months]. In order to be assessed at the last two evaluations, all 10 sessions had to be completed. This report focuses onchanges in profile group membership from pre- to post-intervention (i.e., the first and third time points). Measures ofmaternal parenting beliefs, emotional well-being, beliefs, and social support were obtained from all mothers in bothgroups at the pre-assessment.

2.4. Description and rationale of the intervention and comparison conditions

2.4.1. The intervention curriculum, Play and Learning Strategies (“PALS”)The intervention sessions were guided by a detailed curriculum called Play and Learning Strategies (PALS) that

included scripted sessions, probing questions, video segments to illustrate each concept, and points for discussion, toensure systematic implementation across families. However, facilitators, whose education ranged from bachelor's tomaster's degrees, were trained to use the curriculum in a flexible manner to meet the individual mother's learning needs.An adult learning approach was used to guide the session format and sequence. This approach was learner-centered,knowledge-based, and provided information and guided practice so that mothers could build on previously learnedexperiences (Bransford, Brown, & Cocking, 2000). The targeted behaviors were chosen based on extensive researchevidence showing how they support infants' immature abilities in signaling interest, shifting attention, and organizingbehaviors (Landry et al., 2001).

A comprehensive description of the intervention and control protocols can be found in Landry et al. (in press). Thetarget skills taught in 10 weekly, 1-h PALS sessions included reading infant signals, responding with warm, sensitivebehaviors, maintaining versus redirecting infants' focus of attention, watching for opportunities to introduce an object orsocial game, stimulating language development by naming objects and actions in combination with physicaldemonstrations, and incorporating the use of the constellation of behaviors during daily tasks such as dressing andfeeding. There were also two review sessions (sessions 4 and 8) that enabled mothers to consolidate their learning anddemonstrate their new skills to another adult (known as the “Alternate Caregiver”) who participated in the baby's life(typically a familymember or friend). In addition to serving as a review opportunity for themother, these two sessionsweremeant to provide support for themother's practice of new skills by familiarizing another adult close to themother and childwith PALS concepts and skills. Facilitators also encouraged the Alternate Caregiver to begin using at least some of thePALS skills with the infant, thereby providing the infant with additional experiences of responsive caregiving. The generalsession format included a discussion of the mother's practice during the preceding week; introduction of the new topic;viewing of videotaped segments demonstrating the skill; guided, videotaped practice using the new skill with her owninfant; review of the videotaped practice; and planning for practice during the upcoming week.

2.4.2. Description of the comparison condition (“DAS”)In the comparison condition, known as Developmental Assessment of Skills (DAS), mothers received the same

number of home visits as those in the PALS condition. During the DAS visits, the infants' development was screenedacross multiple areas and reported to mothers. If mothers posed questions regarding how to help their infants'

development, they were referred to their infants' health care providers. Mothers in both groups were given handoutscontaining suggestions for management of typical infant development issues such as challenges with sleep or feeding.

2.4.3. Intervention fidelityFidelity of implementation occurred through multiple procedures: (1) Use of a detailed curriculum manual with

accompanying educational videotapes, (2) extensive facilitator initial training, and (3) ongoing supervision of facilitatorsboth within a site (weekly) and within combined research teams (monthly), which have been detailed in previous reports(Landry et al., in press; Smith, Landry, & Swank, 2005).

3. Results

3.1. Statistical analyses plan

For the present study, factor scores were constructed for each participant for both the pre- and post-interventionassessment data based on the four latent constructs of Responsiveness to Signals,Maintaining Attentional Focus, RichLanguage Input, and Warmth. Latent transition analysis (LTA) that included the four factor scores at two time pointswas used to classify participants into unique, underlying classes (groups of mothers) at pre- and post-intervention.These two time points were used because they are the most critical for assessing intervention impact. In addition, thecategorical nature of our data analyses would have increased the number of cross-classifications to an unwieldy numberwith too few cases per cell had we used all four time points. LTA (Collins & Wugalter, 1992; Langeheine, 1994) is anextension of latent class analysis (LCA) (Bartholomew, 1987; Clogg, 1995) that is useful in examining longitudinaldata. As with LTA, in LCA a set of observed variables, or indicators, is used to group similar individuals into classes(profile groups) with individuals in one class being different from individuals in the other classes. The latent classmodel gives estimates of class probabilities for each individual. For longitudinal data, LTA can examine for latentclasses at each time point and then estimate the probability of an individual transitioning from one class at one stage(i.e., pre-intervention) to another class at a subsequent stage (i.e., post-intervention).

3.2. Evidence of parenting profiles at pre- and post-intervention

Latent transition analysis was conducted on the factor scores for all mothers irrespective of interventionassignment condition at pre- and post-intervention assessments using a latent transition model in Mplus Version 3(Muthén & Muthén, 1998–2004). Mothers assigned to both of the two intervention conditions were combined forboth the pre- and post-analyses in order to determine whether the class structure obtained for the pre-assessmenttime point remained stable across time points, independent of intervention effects. This was important to establish,because the class structure represents a conceptual framework for patterns of parenting. Similar to the rationale forconfirming an obtained factor structure, documenting the stability of these latent classes adds credence to theexistence of these distinct profiles of parenting skills. Various models that included two to five latent classes werefitted to the data and the extent to which the model fit the data assessed by examining the residuals using Akaike's(1974) information criterion (AIC) and the approach proposed by Muthén (2003). This procedure tests the fit of themodel to the data by testing whether the multivariate skewness and kurtosis estimated by the model fits thecorresponding sample quantities. Based on these procedures, the best fitting model consisted of four classes at bothtime points.

Table 3 provides profile definitions (Lower, Moderate, Higher, Mixed) for the first time point and summarizes theestimated means and standard errors for the four factors comprising the four latent classes at pre- and post-intervention.Profile means are interpreted like z-scores, whereM = 0, and scores above and below zero represent relatively greater orlesser use of each of the four types of maternal responsive behaviors, respectively. A comparison of these classes(profile groups) with those obtained at the post-intervention revealed that the structure of the classes for the most partremained consistent. At post-intervention, a Lower and a Higher profile group were identified that were quite consistentthose observed at pre-intervention. The means for all four parent behavior factors are low (negative) at both the pre- andpost-intervention time points for the Lower profile group and are high (positive) at both time points for the Higherprofile group. The means for language and warmth behaviors are especially similar in the pre- and post-phases fortheses two profile groups. A Moderate profile group was identified in both the pre- and post-intervention analyses. In

Table 3Estimated latent class mean (SD) maternal behaviors at pre- and post-intervention combining target intervention and comparison conditions

Maternal behavior factor Time point and latent class (profile group)

Pre-intervention Post-intervention

Lower profile groupResponsiveness to Signals −0.42 (0.11) −0.89 (0.24)Rich Language Input −0.68 (0.1) −0.79 (0.13)Maintaining Attentional Focus −1.05 (0.11) −0.55 (0.12)Warmth −1.10 (0.1) −1.09 (0.17)n 48 52

Moderate profile groupResponsiveness to Signals −0.00 (0.14) 0.19 (0.13)Rich Language Input −0.21 (0.08) −0.23 (0.24)Maintaining Attentional Focus −0.13 (0.07) −0.23 (0.09)Warmth −0.04 (0.11) −0.19 (0.19)n 94 91

Higher profile groupResponsiveness to Signals 0.65 (0.07) 0.88 (0.06)Rich Language Input 0.48 (0.13) 0.62 (0.10)Maintaining Attentional Focus 0.74 (0.11) 0.34 (0.12)Warmth 0.83 (0.06) 0.81 (0.12)n 84 65

Mixed profile groupResponsiveness to Signals −2.33 (0.39) −0.38 (0.17)Rich Language Input 1.07 (0.43) 0.79 (0.17)Maintaining Attentional Focus 0.29 (0.20) 0.81 (0.18)Warmth −0.71 (0.14) 0.82 (0.15)n 15 33

Note. Class means are interpreted as z scores with M = 0, SD = +1; Class definitions are as follows: Lower = ≤ .50 for most factors;Moderate = ≥− .50≤+.50 for most factors; Higher = N .50 for most factors; Mixed = inconsistency across factors.

both phases, the LTA revealed moderately low scores on Maintaining Attentional Focus, Rich Language Input, andWarmth. However, mothers in this profile group at post-intervention tended to have higher Responsiveness to Signalsscores than mothers in the Moderate profile group at pre-intervention. Thus, the mothers' behaviors in the post-intervention Moderate profile group were characterized by moderately low scores overall but a slight strength inResponsiveness to Signals. The Mixed profile group of mothers identified at both time points was notable for lowerscores on Responsiveness to Signals than on the other factors. The pattern of behaviors was relatively consistent acrossthe pre- and post-intervention assessments, although the mothers in the Mixed profile group at post-intervention hadhigher scores for Responsiveness to Signals andWarmth than did mothers in theMixed profile group at pre-intervention.

3.3. Transition probabilities (full sample)

Table 4 shows the transition probabilities across the total sample for moving from a pre-intervention latent class(profile group) to a post-intervention class and thus provides descriptive information about movement to differentprofile groups for all the mothers. The diagonal entries show the probability of remaining in the pre-intervention profilegroup at post-intervention. These probabilities range from 36% to 41% across all four pre-intervention profile groups,leaving considerable possibility for transition in each of the four pre-intervention profile groups.

As a whole (PALS and DAS groups combined), mothers in the pre-intervention Lower profile group (top row ofTable 4) had a reasonably good probability of transitioning into the Moderate profile group during the course of thestudy but quite a low probability of moving into the Higher or Mixed profile group. Note that the probability ofremaining in the Lower profile group at post-intervention was relatively high, with 41% of the mothers remainingclassified in the Lower group, though it was slightly more likely that mothers in the Lower profile group would moveinto the Moderate profile group than remain classified in the Lower group.

Table 4Estimated transition probabilities from LTA collapsed across intervention (PALS/DAS) conditions

Pre-intervention profile Post-intervention profile group

Lower Moderate Higher Mixed

Lower 0.41 0.50 0.09 0.00Moderate 0.30 0.38 0.23 0.09Higher 0.08 0.22 0.41 0.29Mixed 0.12 0.53 0.00 0.36

In contrast, mothers in the Moderate profile group at pre-intervention were somewhat more likely to remainclassified in the corresponding Moderate post-intervention profile group than to move to other profile groups (thoughrecall that the post-intervention Moderate profile group showed stronger Responsiveness to Signals skills than the pre-intervention Moderate profile group; see Table 3). However, a sizable percentage of mothers in the Moderate profilegroup at pre-intervention moved downward to the Lower profile group, and a nearly a quarter of the mothers in theModerate profile group transitioned into the Higher profile group at post-intervention.

The mothers who comprised the Higher profile group at pre-intervention (third row) were most likely to remain inthis profile group at post-intervention, though a sizable number of these mothers (29%) transitioned to the Mixedprofile group and to the Moderate profile group. About half of the mothers initially in the Higher profile group weresubsequently classified in the Moderate or in the Mixed profile group. Mothers who were initially classified in theHigher profile group were quite unlikely to transition to the Lower profile group.

Finally, the mothers in the Mixed profile group (bottom row of Table 4), i.e., those who showed discrepant strengthsin favor of stronger Maintaining Attentional Focus and Rich Language Input skill at pre-intervention, showed a highprobability of transitioning to the Moderate profile group at post-intervention. Indeed, the likelihood of mothersclassified as Mixed at pre-intervention remaining in the Mixed profile group was somewhat lower than the probabilityof transitioning to the Moderate profile group. In addition, none of the mothers initially in the Mixed profile groupmoved into the Higher profile group over time and few moved into the Lower profile group.

There was evidence that transitions of Lower profile group mothers upward and Higher profile group mothersdownward was unlikely to be due to regression to the mean, because these transitions occurred differentially, andprimarily in the expected directions, based on intervention group membership, as described below.

3.4. Does PALS participation predict profile group transitions?

Table 5 presents the Latent Class Probabilities (number and proportion of families in each profile group) for PALSand DAS groups separately at pre- and post-intervention. As the frequency of the distribution of mothers randomlyassigned to either the PALS intervention or the DAS comparison group presented in Table 5 shows, mothers were mostoften initially classified into the Moderate or the Higher profile group based on their parenting behaviors; few motherswere classified as Mixed at pre-intervention. A chi square test of independence was used to compare profile groupmembership of the mothers assigned to the PALS versus the DAS group prior to the intervention implementation.

Table 5Latent class probabilities (and n) at pre- and post-intervention by profile group and intervention group

Intervention groupand time point

Profile group

PALSPre 14.88 (18) 43.80 (53) 35.54 (43) 5.79 (7)Post 12.40 (15) 33.06 (40) 34.71 (42) 19.83 (24)

DASPre 25.00 (30) 34.17 (41) 34.17 (41) 6.67 (8)Post 30.83 (37) 42.50 (51) 19.7 (23) 7.5 (9)

Results revealed no significant differences, indicating that mothers in the PALS and DAS intervention groups did notdiffer from one another in membership in the four latent classes (profile groups) at the outset of the study.

The likelihood of transitioning from one profile group at pre-intervention to each of the four profile groups at post-intervention was compared for the PALS versus DAS conditions. The transition probabilities are provided in Table 6 forPALS intervention condition (upper portion) and for the DAS comparison condition (lower portion). The entries indicatethe percentage of mothers who comprised each of the four profile groups by their initial, pre-intervention profile groups(represented by rows) and by their post-intervention classification (represented by columns). As shown in the upperportion of Table 6, mothers who received the PALS intervention program had a higher likelihood of transitioning to aprofile group that represented improved parenting behavior scores or staying in a relatively better group, as opposed tomoving to a weaker group or staying in a weaker group at the end of the intervention. In comparison, mothers in the DAScomparison group (see lower portion of Table 6) had a higher likelihood of transitioning downward to the Lower orModerate profile groups at post-intervention, and a lower likelihood of transitioning to or staying in the Higher profilegroup or the Mixed profile group. For example, more than half of the PALSmothers in the pre-intervention Higher profilegroup remained in the Higher profile group at post-intervention and none of them transitioned to the Lower profile group.However, in theDAS group, only 34% of themothers whowere in theHigher profile group at pre-intervention remained inthe Higher profile group at post-intervention, and nearly 10% transitioned to the Lower profile group. Of those in theLower profile group at pre-intervention, nearly a quarter of the PALS mothers transitioned to the Higher profile group,whereas none of the DAS mothers made such a transition.

3.5. Demographic predictors of pre-intervention profile group membership

We were first interested in whether there were demographic and child-related predictors of initial profile group mem-bership. As shown in Table 7, there were no infant characteristics and only three significant maternal/family demographicpredictors of pre-intervention profile group membership. The only significant demographic predictors were maternaleducation (more educatedmothers weremore likely to start out the interventionwith stronger profiles thanwere less educatedmothers), maternal SES (mothers in the Higher profile group tended to be of a higher SES level than those in the other threeprofile groups), and maternal ethnicity (approximately half of mothers in the Higher profile group were Caucasian and morethan half of mothers in theMixed profile group were Hispanic). It should also be noted that maternal education and maternalSES were moderately correlated (r = .57), so the significance of both variables in these analyses may be due to sharedvariance.

3.6. Interpersonal and intrapersonal predictors of pre-intervention profile group membership

Because demographic variables such as SES often serve as markers for more specific characteristics impactingparenting behaviors, for the next set of analyses we sought to examine the unique relation of more proximal, interpersonaland intrapersonal factors to mothers' parenting styles. We were particularly interested in whether mothers' childrearing

Table 6Estimated likelihood percentages of transitioning among profile groups for each intervention group

Intervention group andpre-interventionprofile group

Post-intervention profile group

PALS groupLower 16.7 61.1 22.2 0.0Moderate 22.6 37.7 28.3 11.3Higher 0.0 14.0 53.5 32.6Mixed 0.0 42.9 0.0 57.1

DAS groupLower 60.0 40.0 0.0 0.0Moderate 34.2 43.9 22.0 0.0Higher 9.8 36.6 34.2 19.5Mixed 12.5 75.0 0.0 12.5

Table 7Relations between demographic characteristics and pre-intervention profile group membership

Pre-intervention profile group F orχ2

Infant characteristicsRisk status (High/Low/Full-Term) % 31/25/44 49/24/27 43/23/35 27/33/40 4.67 (6, 241) nsGender (M/F) % 49/51 48/52 40/60 46/54 .40 (3, 240) ns

Maternal/family characteristicsEthnicity (Afr.Am./Hisp./Cauc./Asian) % 45/38/15/2 36/34/28/2 19/25/52/4 40/53/7/0 30.40 (9, 238) .0004Marital status (Married/Divorced/Never Married) % 48/11/41 55/4/41 70/6/23 50/0/50 12.16 (6, 226) nsEducation: M (SD) years 11.3 (2.9) 12.5 (2.2) 13.7 (2.3) 12.7 (1.6) 10.4 (3, 238) b .0001SES: M (SD) 28.3 (10.7) 30.0 (11.6) 37.4 (13.2) 28.5 (9.0) 8.51 (3, 234) b .0001Number of siblings: M (SD) 1.3 (1.3) 1.1 (1.1) 1.2 (1.3) 1.2 (2.0) 1.55 (3, 235) ns

beliefs, social supports, and/or mental health symptoms were potential predictors of latent profile group membership atpre-intervention. A multinomial logit model was fitted using the profile group membership for all mothers at pre-intervention from the LTA as the dependent variable and using the following variables as predictors: The threepsychological symptom scores (SCL-90-R Depression, Anxiety, and Psychoticism scores), the child-centered parentingbeliefs scores from the CODQ, and the total perceived social support score from the Personal Relationships Inventory.Separate univariate logit models were fitted for each predictor followed by a multivariable model with all significantunivariate predictors. This strategy was used in order to analyze the unique contribution of each predictor over and abovethe contribution of the other predictors. For the univariate models, all of these variables, depression, χ2(3) = 7.7, p = .05,anxiety, χ2(3) = 10.14, p = .02, and psychoticism, χ2(3) = 9.47, p = .02, childrearing beliefs, χ2(3) = 13.0, p b .01, andsocial support, χ2(3) = 7.98, p b .05, scores were significant predictors of pre-intervention profile group membership.However, when these were examined simultaneously in the multivariable logit model with backward elimination used toselect the significant predictors, only childrearing beliefs significantly predicted profile group membership at pre-intervention, χ2(3) =13.0, p b .01. For example, a parent with a CODQ score one standard deviation above the mean (i.e.,more child-centered parenting beliefs) had 3.5 times greater odds of being in the Higher profile group than the Lowerprofile group, and 12.5 times greater odds of being in the Higher profile group than in the Mixed profile group.

3.7. Predictors of change in profile group membership for PALS mothers

A multinomial logit analysis was performed to test whether these same maternal characteristics predicted change inprofile group membership from pre- to post-intervention for mothers in the PALS condition. For this analysis, we firstformed four categories of mothers that reflected their profile group membership across pre- and post-intervention.These categories were then used in the analyses as grouping variables: (1) “Negative Stayers” (no change in Lower andModerate profile groups over time), (2) “Positive Stayers” (mothers in the Higher profile group at both time points), (3)“Positive Changers” (mothers who transitioned from a less optimal to more optimal profile group), and (4) “NegativeChangers” (mothers who transitioned from a more optimal to less optimal profile group). Separate univariate logitmodels were fitted for each of the predictors and then a multivariable logit model with all of the univariate significantpredictors was fitted. For the univariate models, maternal anxiety scores, χ2(3) = 7.8, p b .05, and perceived socialsupport scores, χ2(3) = 7.98, p b .05) were significant predictors of membership in the above four categories. However,only social support remained a significant predictor of the change categories in the multivariable analysis, χ2(3) = 7.98,p b .05. With every unit increase in social support, the odds of being in the “Positive Stayer” category were 1.5 timesthe odds of being in the “Negative Changer” category, and the odds of being in the “Positive Changer” category were1.1 times the odds of being in the “Negative Changer” category. The odds of being in the “Negative Stayer” and the“Negative Changer” category were not significantly different.

4. Discussion

This study sought to demonstrate that discrete profile groups of mothers who varied in their pre-interventionparenting profiles responded differentially to a parenting intervention. We also wished to identify predictors of pre-

intervention profile group membership and predictors of change in profile group among those who received theresponsive parenting intervention program. Findings were obtained in four key areas: (1) We identified four distinctgroups of mothers who showed differing profiles across four major parenting behavior factors: Responsiveness toSignals, Rich Language Input, Maintaining Infant's Attentional Focus, and Warmth. (2) As expected, mothers whoreceived the intervention program, regardless of initial profile group status, were more likely to transition upwards intheir parenting behavioral profiles than mothers in the comparison group. In other words, the PALS interventionpromoted positive change and prevented decline in parenting skills that have been shown to have a positive impact onchildren's development. (3) In terms of predictors of initial profile group membership, mothers who had more childcentered childrearing beliefs at pre-intervention were more likely to show stronger parenting profiles prior to receivingany intervention than those with less child-centered beliefs. (4) Within the group of mothers who received the PALSintervention, those with higher levels of social support were more likely to maintain pre-existing optimal parentingbehaviors and to show positive change (i.e., transition to a stronger profile group) following the PALS intervention thanmothers with lower levels of social support.

4.1. Variability in initial parenting profiles

In contrast to most reports of parenting interventions, which focus on average group effects across participants, animportant contribution of the present study was to identify pre-existing differences in mothers' interaction styles with theirinfants. In addition to three profile groups of mothers reflecting lower, moderate, and higher levels of skill on each of thefour factors, we obtained a fourth profile group ofmothers who demonstrated a “mixed” pattern ofmaternal responsiveness.These mothers were relatively strong in rich language input and at least average in their ability to maintain their infants'focus of attention. However, they showed less warmth during interactions with their infants and were poor at responding totheir signals in a contingent manner. Though perhaps less common, this Mixed profile group may be the most interestingone, as its emergence provides support for proposals that a responsive parenting style is comprised of distinct componentsthat parents may possess to a greater or lesser degree, rather than only as a whole on a continuum. This profile group alsoprovided the opportunity to examine the impact of the intervention on these mothers' skills in each of the four areas.

4.2. Effectiveness of the PALS program

Examination of changes in mothers' responsive parenting profiles from pre- to post-intervention showed thatmothers who received the PALS program were indeed more likely than those in the comparison condition to transitioninto profile groups reflecting higher levels of competence in their use of responsive parenting behaviors. Thesebehaviors included those emphasized by sociocultural theorists (i.e., maintaining attention and rich languagestimulation), as well as those emphasized by attachment theorists (i.e., warmth and contingent responsiveness). Someof the most dramatic improvements were seen among mothers with the lowest pre-intervention profiles. For example,only 16% of PALS mothers who started in the lowest profile group remained there after receiving intervention, incontrast to 60% of mothers initially in the lowest profile group who received a developmental information approach.Most encouraging, 22% of those who started in the lowest profile group and received the PALS intervention shifted tothe highest profile group by the end of the intervention. These results cannot be accounted for by phenomena such asregression to the mean, because we do not see such movement toward the mean in the Lower profile group ofcomparison (DAS) mothers. Additionally, these outcomes were achieved in spite of the fact that mothers in thecomparison group received the attention of a facilitator during weekly home visits, informational materials aboutchildrearing, and assessment feedback about their infants. This combined with the random assignment experimentaldesign supports the conclusion that the positive gains seen in the target group can reasonably be attributed to thespecific components of the PALS intervention rather than to other factors. Although the focus of the present study wasnot on infant outcomes, our previous report of this sample demonstrated the influence of increases in responsivenessbehaviors on infant social and cognitive skills. Similar to the behavioral profiles in the present study, changes inmothers' warm responsiveness, maintaining of infant's attentional focus, and language stimulation mediated the effectof the intervention on infant skill domains. (Landry et al., in press). Thus, the positive shifts in these same mothersfound in the present study also can be inferred to reflect corresponding improvements in infants' skills.

The finding that parenting profiles of many mothers who were initially in the more positive profile groups but didnot receive PALS intervention transitioned to weaker profile groups supports the notion that mothers may have

difficulty sustaining responsive interactive behaviors as their infants become more mobile (e.g., crawling) and start toexhibit their own desires and interests. This might be especially true for mothers in poverty, who (at least in Westernculture) may tend to react more harshly to children's autonomy-seeking behaviors and be less familiar or comfortablewith more positive ways to respond (e.g., Kelly, Sanchez-Hucles, & Walker, 1993; McLoyd, 1998). Over time, as theexcitement of having a new baby fades, these issues are likely to impact a mother's ability to remain focused on theneeds of her infant. However, with the support of a targeted intervention program, mothers can be assisted to continueto use and improve upon a supportive and stimulating parenting style.

There are several critical aspects of the PALS program that we believe contributed to its success in helping mothersachieve skills across a range of behaviors. First, the program used an adult learning model that combined didacticpresentation of information, guided discussion of how the concepts and skills related to the individual mother and herinfant, guided practice implementing the skills with her baby, and mothers' self-critique based on watchingvideotapes of themselves interacting with their babies. This use of a variety of instructional formats gave mothersample opportunities to become familiar with the concepts and skills and develop competence in implementing themwith their own infants. Second, the curriculum specifically taught mothers ways to use the new skills within thecontext of everyday caregiving activities such as feeding, dressing, and bathing. Thus, even if mothers had difficultyfinding time for frequent child-centered play times, they were assisted to attend to their babies' signals and useresponsive and stimulating behaviors during the course of caregiving activities that naturally occur multiple times perday. Third, facilitators worked hard to establish and maintain warm, trusting relationships with each mother to supporther continued participation and help her feel comfortable enough to risk trying new parenting behaviors that often didnot feel natural or familiar to them. In particular, facilitators structured their relationship to model the kinds ofbehaviors they were trying to teach parents: Warmth, respect, praise for accomplishments, responsiveness toquestions and concerns, etc. Our impressive low rate of attrition was largely due to the intensive efforts of facilitatorsto maintain these relationships and proceed with visits in spite of the challenges inherent in working with thispopulation, such as disconnected phone numbers, no-shows for appointments, and chaotic household conditionsduring home visits.

4.3. Predictors of initial parenting profiles

As expected, we found that among mothers receiving the PALS intervention, maternal mental health, parentingbeliefs, and perceived quality of social support, when examined individually, showed relations with mothers' initialprofiles. However, only the mother's child-centered belief system predicted initial profile membership when all ofthese variables were considered together. The child-centered parenting belief system represents a mother's ability to seeher child as a unique individual who has personal needs and interests. She is thus more likely to attend to her infant'ssignals and respond contingently (Miller-Loncar, Landry, Smith, & Swank, 2000). One implication of this finding isthat when disadvantaged mothers have a child-centered belief system, even if they may struggle with mental healthsymptoms or perceive themselves as having minimal social support, this belief system enables them to provide morenurturing and stimulating care for their children than mothers without this perception. Future research should considerincorporating parents' beliefs about children as a potential target of intervention. This would include discussion withparents about their child-related belief systems (e.g., recognizing that the infant has its own individual needs andpersonality, that infants are not capable of being manipulative, that babies' desire for cuddling or attention does notmean they are spoiled, etc.), as well as reflection by mothers on their own experiences of being parented and themessages they received from their parents or other caregivers regarding how children learn and develop. Addressingsuch issues early in the intervention could potentially help mothers shift the way they think about their infants andthereby be more open to incorporating responsive behaviors into their interactive style.

4.4. Predicting changes in parenting profiles

Among mothers in the PALS group, mental health, parenting beliefs, and social support were important whenexamining their ability to predict class membership individually, but only mothers who perceived that they had a higherquality of social support had a greater likelihood of maintaining a more optimal profile of responsive parenting orshifting toward more positive profiles by the end of the intervention. This result suggests that when a mother is able toget her own needs met, she is better able to focus on those of her infant. What is particularly interesting about our

findings is the apparently unique role of perceived social support in predicting positive changes in mothers' parenting,as opposed to the internal resources examined (i.e., mental health and parenting beliefs). In considering why this mightbe the case, several explanations might be considered. For example, it is possible that when mothers perceivethemselves as having adequate social support, they feel less isolated in coping with whatever other issues or internalsymptoms they may be experiencing, and are thereby able to be more emotionally available to their children. Somesupport for this hypothesis is provided by data regarding the inclusion of a neighborhood mentor condition in areplication of the PALS intervention (Dieterich et al., 2006). Mothers who received the additional support of a one-on-one community mentor showed greater gains in responsive behaviors than those without this social support. Mentorshelped them with life challenges such as housing needs, job resources, and transportation, which presumably allowedthe mothers to have more positive time with their infants.

Mothers in the present study with more perceived social support might also have been able to use their supportrelationships in instrumental ways. For example, they may have been able to elicit help with childcare, housekeepingtasks, or transportation from family members and friends, to enable them to devote more attention to the goals of theintervention. In addition, these mothers may have found it easier to find an alternate caregiver to participate in the PALSsessions where this was required, and thus were able to share the skills they were learning with another supportiveadult. Recall that for these Alternate Caregiver review sessions, the mother was asked to invite another caregiving adultto the session to introduce the PALS concepts to that adult. Typically mothers invited the infant's father, grandparent,aunt, or other relative for these sessions, but there were times when a research assistant needed to play the role of analternate caregiver when a mother was truly unable to find another adult in her life to attend these sessions.

It is important to note that there were some PALS mothers who started in the Higher profile group but dropped intoweaker profile groups (“Negative Changer” mothers). As social support was found to be the only significantindependent predictor of transitions among profile groups, it would appear that these mothers were not able to sustaintheir positive responsiveness skills over time when social support was at low levels. This finding is consistent with thefindings of the Dieterich et al. (2006) PALS replication study, in which the addition of neighborhood mentors resultedin more favorable outcomes for participating mothers when compared to mothers who did not have a mentor. It isencouraging that social support (potentially a more malleable characteristic) can be so critically related to mothers'ability to benefit from the intervention. In future studies it would be interesting to address the question of how muchsocial support is needed to make that critical difference in outcomes for mothers and explore what happens long-termfor mothers who have social support during the intervention via a mentor but then lose it at the conclusion of theprogram.

In terms of current implications for applied practice, the findings suggest that it is important for interventionists tolearn as much as possible about participating mothers' bases of support outside of the intervention program, and toconsider how they might include this area as a target for intervention. Mothers may need sources of support that areboth instrumental (i.e., practical help with childcare, transportation, home repair, etc.) and emotional (i.e., affection,intimacy, validation of self-worth, etc.). Problem-solving with mothers directly about how to get these needs met mayenable them to preserve more physical and emotional energy to focus on learning new parenting skills, and therebyimprove outcomes.

4.5. Additional implications for parenting programs

One of the major strengths of this study was its applicability to real-world implementation and diverse populationsof mothers. This short-term, focused and structured parenting curriculum was effective with mothers from diverseethnic backgrounds, speaking Spanish or English, with infants who were both pre-term and full-term. The results of thepresent study demonstrated that mothers vary in their patterns of strengths and weaknesses on components ofresponsive parenting previously identified as important for children's development, and that all mothers do not benefitequally from a even well-planned, theoretically sound, and carefully implemented parent program.

An important clinical implication of these findings is that mothers' individual parenting profiles, assessed prior tointervention, could profitably be used to inform the manner in which parenting programs are implemented. Even a briefperiod of time spent systematically observing a mother interacting with her child (less than 15 min) can yield valuableinformation regarding the mother's ability to provide rich language input, maintain her child's focus of interest,respond promptly and appropriately to her child's communicative signals, use her voice tone in a warm vs. harshmanner, etc. Such information could then be used to select the components of intervention that are most critically

needed for that mother, in contrast to those behaviors that can be supported and reinforced but do not need to be taughtfrom baseline. For example, if a mother is found to be initially strong in stimulating her infant's language developmentbut weak in reading the infant's signals and responding contingently, her intervention program could be tailored toinclude more intensive attention to these emotional support behaviors, and less time could be spent introducing skillsthat she has already mastered. Alternatively, if a mother begins the program with relatively strong skills in all areas, theemphasis could be shifted towards articulating for this mother exactly what she is doing that is so effective and how it ishelping her infant's development in various domains (language, cognitive, social, behavioral, etc.). She could also behelped to anticipate the kinds of challenges she will face in parenting as her infant becomes more mobile, more vocal,more assertive, etc. Heightening this skillful mother's conscious awareness of her own behaviors, praising her observedskills, and articulating how they relate to her baby's future successful outcomes can potentially help her to maintain andbuild on these skills over time, to the benefit of her child.

Another applied implication is the importance of assessing mothers' parenting beliefs. Gathering such data prior tointervention can be used to anticipate the ease with which a mother is likely to embrace and integrate the new skills sheis learning with her own child. If a mother is lacking in this area prior to intervention, it may be important to increaseemphasis on strengthening her ability to understand the needs and abilities of young children, and to discuss with herthe origins and implications of her specific beliefs. Previous research has shown that mothers' knowledge about childdevelopment and attitudes about discipline mediates the relationship between maternal social support and morepositive psychological well-being and responsive parenting behaviors (O'Callaghan et al., 1999).

Finally, interventionists who wish to intervene with mothers who are impoverished need to be prepared for thevarious challenges inherent in working with this population. They need to be aware of the level of effort involved inkeeping regular appointments with mothers (even when providing home visits, for which mothers did not needtransportation). They must work actively to keep mothers focused and engaged during sessions where multiple familymembers may be in and out of the house, older children may be distracting the mother's attention, insects and/or verminmay be present, and amenities such as air-conditioning, adequate heating and lighting, and/or furniture may be lacking.Related to the above issues, interventionists need to be able to strike a balance between empathizing with the very realand urgent issues facing these mothers on a daily basis (e.g., financial, logistical, family-related), while still conveyingto them the importance of taking the time to focus on their infants' emotional and cognitive needs. When working withmothers with infants born at very low birth weight, interventions have the additional task of educating mothersregarding the impact of their infants' fragile, immature nervous systems on their ability to take in stimulation andproduce an appropriate coordinated behavioral response. These babies may become more easily overwhelmed duringinteractions or activities, making it more difficult for a mother to elicit a rewarding positive response to her overtures.Helping mothers to gently engage with these infants and anticipate situations that are too over-stimulating can set thestage for a successful parent–child relationship and optimize opportunities for their infants' learning.

4.6. Limitations and future directions

There are several areas in which more information would have helped to further elucidate our findings and answersome additional questions raised by our results. For example, social support was important in helping mothers tobenefit optimally from intervention, but we did not gather data that focused on the ways that mothers actually used theirsocial support networks or how these may have changed over the course of the intervention. In future studies it wouldbe useful to have specific information about the roles mothers' social support networks were actually playing, and whatimpact these forms of assistance had on mothers' parenting attitudes, feelings toward their infants, time spent with theirinfants, etc. Such information may guide interventionists toward helping mothers to strengthen their support networks,and helping each mother identify potential sources of support in the areas most needed (i.e., childcare assistance,transportation, emotional support, spiritual nurture, etc.).

Another area in which additional data would have been helpful concerns the impact on mothers and infants of theAlternate Caregivers' participation in at least two of the intervention sessions. For example, we could not investigatewhether these individuals' brief participation in the program did result in increasing their knowledge and/or use of thePALS concepts with the target infants, or whether the act of sharing their learning with another supportive adult wasbeneficial to the mothers. Gathering such data in the future would enable a better assessment of the value of havingthese sessions included the curriculum, and determining whether the alternate caregivers' participation in more vs.fewer sessions would change outcomes for the mother or her infant.

It is important to note that our sample consisted of mothers exclusively, and no information was provided regardingthe role of fathers and other significant adults in the child's or the mother's life. Although we did document thatmothers' marital status was not significantly related to initial profile group membership, this does not address the issueof potential benefits of fathers' participation in the intervention program. Although mothers were the primarycaregivers for their infants, gathering data regarding the role of the infant's father (or the primary male figure in themother's life), as well as documenting these men's level of participation in the intervention, may yield valuableinformation. For example, fathers did at times serve as the “Alternate Caregivers” for the PALS sessions in which analternate caregiver was requested to participate. Having two parents implementing the PALS techniques, rather thanmother only, may enhance the results of intervention, both in terms of reinforcing the mother's use of the behaviors andin terms of creating a stronger impact for the infant due to receiving additional responsive parenting experiences. Wemay discover that fathers respond in similar or different ways from mothers when learning how to engage responsivelywith their infants, and the profile groups obtained through latent class analysis with mothers may or may not also applyto fathers.

The present study targeted lower income families with pre-term and full-term infants from African-American,Caucasian, and Hispanic ethnic backgrounds. Our findings are thus relevant to a variety of types of families. However,families from a higher SES sample were not included, nor was there significant representation from families of otherbackgrounds such as Asian or Middle Eastern ethnicities. Important information may be obtained if future studiesexamine whether the content and format of the PALS program works equally well with members of these and othergroups or would need to be modified in any ways to be culturally sensitive or to be applicable to more educated/affluentfamilies. For example, our curriculum videotapes intentionally featured mothers from ethnic backgrounds that matchedour target sample in an effort to help target mothers feel comfortable and identify most readily with the mothersdemonstrating the behaviors. Implementing the program with a very different population might require creating someadditional demonstration segments to depict mothers (and fathers) who were more representative of the population tobe targeted. As another example, mothers from some cultural backgrounds may be uncomfortable with the idea ofgetting down on the floor with an infant, may feel particularly self-conscious about being videotaped during thecoached practice, or may have religious beliefs that influence their approach to parenting their infants. Modificationsmay need to be made to the manner of presentation of concepts or to expectations about how the practice coaching willoccur, based on knowledge about the cultural background of the target mothers.

In considering the effectiveness of the current PALS intervention, another issue that is important to address is whetherany other factors might have been responsible for the impressive results achieved by mothers in the PALS condition ascompared to the developmental information comparison condition mothers. For example, perhaps mothers in the DAScondition felt less supported by facilitators who referred them back to their pediatrician for most developmental advicequestions, or perhaps they did not feel that they were getting a “real” intervention despite our efforts to create a parallelexperience for these families, minus the actual PALS curriculum. Although we cannot absolutely rule out this possibility,satisfaction surveys conducted as part of an exit interview during the last session of both programs showed that motherswho received the educational and assessment information (DASgroup) reported just asmuch satisfactionwith the programas those receiving the PALS curriculum. There was also no differential attrition between the PALS andDAS groups. Thesetwo indicators would suggest that these mothers did not feel slighted or put off by their facilitators' protocol for handlingquestions that were outside the boundaries of the intervention condition. Another issue that could have impacted the resultswas whether coders of the mother–child observations were truly naive regarding group status and the purpose of the study.The collaborative cross-site study design enabled an exchange of videotape coding across the two university sites, whichwas designed in part to minimize coders' familiarity with specific families and preserve blindness to the group assignmentof the mothers they were coding.

Future directions in researching the effectiveness of the PALS curriculum would profitably include dismantlingstudies to identify which aspects of the PALS curriculum are in fact the most critical. We have already established,through the provision of a carefully constructed comparison group design, that the mere provision of regular homevisits and attention provided to mother and child did not account for the intervention's effectiveness, because the DASgroup mothers in general did not make gains or sustain pre-existing skills at the level of the PALS group mothers.However, it would be useful to know whether the same findings would be achieved if only certain parts of theintervention were provided, especially in situations where the cost of the intervention might be an issue. For example,what would be the impact of providing mothers with responsive coaching practice but without watching curriculumvideos? Alternatively, perhaps watching curriculum videos would be sufficient without the individual coaching, which

is the most expensive and labor-intensive component. It would also be helpful to know whether providing theintervention in a group format would work equally well, because this would allow greater time efficiency and cost-effectiveness compared to meeting with each mother individually in her home.

4.7. Conclusions

Although there are many possible areas for future research on the PALS curriculum itself and on the variability inparticipants' responses to it, it is encouraging that the intervention was successful with mothers in spite of all of thechallenges of working with this target population: Mothers with limited financial resources and education, and (for asizable percentage of our sample) infants born at risk due to low birth weight. The findings demonstrate that a time-limited, focused intervention can help mothers who start out strong in responsive parenting skills maintain their skillseven as infants move into new developmental stages and pose new challenges. The same parenting intervention canboost the skills of those who start out weak in specific domains, and can prevent a relative decline in responsive andstimulating behaviors as infants grow and change. Including the enhancement of social support as a target forintervention, examining mothers' parenting beliefs prior to beginning intervention, and using pre-interventionobservations to assess mothers' pre-existing skills are major applied implications for practitioners. Examiningindividual patterns of change within a generally successful intervention is thus a fruitful area for further study, withpromising possibilities for tailoring intervention programs to meet the individual needs of parents.

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