Do supports during pregnancy or in the two years after birth improve parenting capacity or wellbeing for parents experiencing trauma-related symptoms, or who experienced maltreatment in their childhood?
Key messages
Most evidence either suggested that parenting and psychological interventions made little or no difference in parental psychological wellbeing and parenting capacity, or it was of low quality so that confidence in the results was very uncertain.
Parenting interventions may slightly improve relationships between mothers and their child compared to usual care.
One psychological intervention could possibly help a slightly greater number of mothers quit smoking when pregnant compared to enhanced usual treatment. Another psychological intervention potentially benefits parents' relationships slightly and another may slightly improve parenting skills.
Interventions for parents with complex PTSD (post-traumatic stress disorder) or who experienced childhood maltreatment
Childhood maltreatment can lead to complex post-traumatic stress disorder (CPTSD) in adulthood and problems with relationships. People who experienced childhood maltreatment are also more likely to experience other life adversities and health inequity. These problems can affect parenting and lead to ‘intergenerational cycles’ of trauma.
Types of support for parents who experience childhood maltreatment include psychological therapies, parenting interventions, mind-body and biomedical approaches, pharmacological therapies and service system approaches.
What did we want to find out?
We wanted to find out which of these supports helped improve parenting capacity and wellbeing in parents who had experienced childhood maltreatment or CPTSD.
What did we do?
We searched for studies that looked at how well these interventions worked compared to usual perinatal supports, for improving parents' parenting skills and their wellbeing. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sample sizes.
What did we find?
We found 15 studies that involved 1925 parents who had experienced childhood maltreatment and/or who had CPTSD or PTSD symptoms. About half of the studies included people who had experienced moderate-severe childhood maltreatment, while the others experienced lower levels of childhood maltreatment.
Most studies looked at how well parenting or psychological interventions worked, and these were mostly compared to usual prenatal or postnatal care. We found no studies that looked at mind-body, biomedical or pharmacological approaches to improving parenting capacity or parent wellbeing. Most studies reported changes in wellbeing or parenting outcomes immediately after finishing the intervention. The interventions ranged from a single session to 12 months of weekly sessions. All but one study took place in the USA, and almost all people who took part were mothers. Most studies were funded by major research councils, government departments and philanthropic/charitable organisations.
Main results
We found that most of the studies did not use rigorous methods (to account for dropout) and therefore the results were uncertain.
Parenting interventions
Evidence was very uncertain from a study of a parenting intervention compared to a control on trauma-related symptoms, and psychological wellbeing symptoms (postnatal depression), in mothers who had experienced childhood maltreatment and were experiencing current parenting risk factors. Two studies found that parenting interventions may slightly improve the relationship between mothers and their child compared to usual care. Four studies found little to no difference between a parenting intervention and usual care in parenting skills. No studies assessed the effects of parenting interventions on parent's substance use, relationship quality or self-harm.
Psychological interventions
Four studies found little or no difference in trauma-related symptoms from a psychological intervention compared to usual care. Eight studies found little or no difference between a psychological intervention and usual care in parents psychological wellbeing (depression). Another study showed that the addition of a psychological intervention may help slightly more women quit smoking in pregnancy than usual prenatal care and smoking cessation counselling. Another found that a psychological intervention may help parents' relationship quality slightly. The evidence from one study was very uncertain about whether a psychological intervention made any difference to parent-child relationships compared to usual care. Another study found that there may be small improvements in parenting skills when parents received a psychological intervention compared to usual care. No studies assessed the effects of psychological interventions on parents' self-harm.
Service system approaches
One financial education programme for parents with low incomes and childhood maltreatment histories increased depression symptoms slightly compared to usual care. No studies assessed the effects of service system interventions on parents' trauma-related symptoms, substance use, relationship quality, self-harm, parent-child relationships or parenting skills.
What are the limitations of the evidence?
We are not confident in the results from a lot of the studies because many people dropped out during the study, so there was a lot of missing data and there were not enough large, well-designed studies to be certain about the results. There is limited evidence of important benefits available so far in this emerging field.
How up-to-date is this evidence?
The evidence is up-to-date to October 2021.
There is currently a lack of high-quality evidence regarding the effectiveness of interventions to improve parenting capacity or parental psychological or socio-emotional wellbeing in parents experiencing CPTSD symptoms or who have experienced childhood maltreatment (or both). This lack of methodological rigour and high risk of bias made it difficult to interpret the findings of this review. Overall, results suggest that parenting interventions may slightly improve parent-child relationships but have a small, unimportant effect on parenting skills. Psychological interventions may help some women stop smoking in pregnancy, and may have small benefits on parents' relationships and parenting skills. A financial empowerment programme may slightly worsen depression symptoms. While potential beneficial effects were small, the importance of a positive effect in a small number of parents must be considered when making treatment and care decisions. There is a need for further high-quality research into effective strategies for this population.
Acceptable, effective and feasible support strategies (interventions) for parents experiencing complex post-traumatic stress disorder (CPTSD) symptoms or with a history of childhood maltreatment may offer an opportunity to support parental recovery, reduce the risk of intergenerational transmission of trauma and improve life-course trajectories for children and future generations. However, evidence relating to the effect of interventions has not been synthesised to provide a comprehensive review of available support strategies. This evidence synthesis is critical to inform further research, practice and policy approaches in this emerging area.
To assess the effects of interventions provided to support parents who were experiencing CPTSD symptoms or who had experienced childhood maltreatment (or both), on parenting capacity and parental psychological or socio-emotional wellbeing.
In October 2021 we searched CENTRAL, MEDLINE, Embase, six other databases and two trials registers, together with checking references and contacting experts to identify additional studies.
All variants of randomised controlled trials (RCTs) comparing any intervention delivered in the perinatal period designed to support parents experiencing CPTSD symptoms or with a history of childhood maltreatment (or both), to any active or inactive control. Primary outcomes were parental psychological or socio-emotional wellbeing and parenting capacity between pregnancy and up to two years postpartum.
Two review authors independently assessed the eligibility of trials for inclusion, extracted data using a pre-designed data extraction form, and assessed risk of bias and certainty of evidence. We contacted study authors for additional information as required. We analysed continuous data using mean difference (MD) for outcomes using a single measure, and standardised mean difference (SMD) for outcomes using multiple measures, and risk ratios (RR) for dichotomous data. All data are presented with 95% confidence intervals (CIs). We undertook meta‐analyses using random‐effects models.
We included evidence from 1925 participants in 15 RCTs that investigated the effect of 17 interventions. All included studies were published after 2005. Interventions included seven parenting interventions, eight psychological interventions and two service system approaches. The studies were funded by major research councils, government departments and philanthropic/charitable organisations. All evidence was of low or very low certainty.
Parenting interventions
Evidence was very uncertain from a study (33 participants) assessing the effects of a parenting intervention compared to attention control on trauma-related symptoms, and psychological wellbeing symptoms (postpartum depression), in mothers who had experienced childhood maltreatment and were experiencing current parenting risk factors. Evidence suggested that parenting interventions may improve parent-child relationships slightly compared to usual service provision (SMD 0.45, 95% CI -0.06 to 0.96; I2 = 60%; 2 studies, 153 participants; low-certainty evidence). There may be little or no difference between parenting interventions and usual perinatal service in parenting skills including nurturance, supportive presence and reciprocity (SMD 0.25, 95% CI -0.07 to 0.58; I2 = 0%; 4 studies, 149 participants; low-certainty evidence). No studies assessed the effects of parenting interventions on parents' substance use, relationship quality or self-harm.
Psychological interventions
Psychological interventions may result in little or no difference in trauma-related symptoms compared to usual care (SMD -0.05, 95% CI -0.40 to 0.31; I2 = 39%; 4 studies, 247 participants; low-certainty evidence). Psychological interventions may make little or no difference compared to usual care to depression symptom severity (8 studies, 507 participants, low-certainty evidence, SMD -0.34, 95% CI -0.66 to -0.03; I2 = 63%). An interpersonally focused cognitive behavioural analysis system of psychotherapy may slightly increase the number of pregnant women who quit smoking compared to usual smoking cessation therapy and prenatal care (189 participants, low-certainty evidence). A psychological intervention may slightly improve parents' relationship quality compared to usual care (1 study, 67 participants, low-certainty evidence). Benefits for parent-child relationships were very uncertain (26 participants, very low-certainty evidence), while there may be a slight improvement in parenting skills compared to usual care (66 participants, low-certainty evidence). No studies assessed the effects of psychological interventions on parents' self-harm.
Service system approaches
One service system approach assessed the effect of a financial empowerment education programme, with and without trauma-informed peer support, compared to usual care for parents with low incomes. The interventions increased depression slightly (52 participants, low-certainty evidence). No studies assessed the effects of service system interventions on parents' trauma-related symptoms, substance use, relationship quality, self-harm, parent-child relationships or parenting skills.