STEP: Final Report

Supporting the Transition to and Engagement in Parenthood in Adults who are Survivors of Child Maltreatment

Introduction

Objectives

The primary objective of Project STEP: Supporting the transition to and engagement in parenthood in adults who are survivors of child maltreatment, was to design, deliver and evaluate an innovative group intervention for pregnant women who experienced maltreatment as children. The ultimate goal of this intervention was to:

- Support the adjustment and perinatal mental health of pregnant women who experienced maltreatment as children;

- Support their children’s development and the establishment of a secure mother-child relationship;

- Help interrupt intergenerational cycles of abuse.

In response to the COVID-19 pandemic, a second objective was to design and evaluate a brief, online adaptation of the STEP program to support the mental health and resilience of pregnant women during the pandemic.

Acknowledgements

This project was made possible by $1,151,601 in funding from the Public Health Agency of Canada between September 28, 2016, and March 31, 2022, as part of the investment for the Supporting the Health of Survivors of Family Violence initiative. The research program also received financial support from the Fonds de recherche du Québec - Santé (2020-2021 Scholarship Program), the Canada Research Chair in Developmental Trauma (2021-2022) and the New Frontiers in Research Fund - Exploration (Social Sciences and Humanities Research Council of Canada 2019-2022).

The Project STEP team would like to thank all of the families and the many partners who have contributed to the development of the STEP program and the research project:

• Université du Québec à Trois-Rivières
• Centre d’études interdisciplinaires sur le développement de l’enfant et la famille
• Centre de recherche interdisciplinaire sur les problèmes conjugaux et les agressions sexuelles (Interdisciplinary research centre on intimate relationship problems and sexual abuse)
• Groupe de recherche et d’intervention auprès des enfants vulnérables et négligés (Research and intervention group for vulnerable and neglected children)
• Centre intégré universitaire de santé et de services sociaux de la Mauricie-et-du-Centre-du-Québec (Integrated university health and social services centre of Mauricie and central Quebec)
• Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale (Integrated university health and social services centre of the Capitale-Nationale region)

• Centres d’aide aux victimes d’actes criminels de la Mauricie (Crime victims’ assistance centres of Mauricie)
• Centre d’aide et de lutte contre les agressions à caractère sexuel de Trois-Rivières (Sexual assault crisis centre of Trois-Rivières)
• ESPACE Mauricie social service organization
• Maternaide
• Regroupement pour la valorisation de la paternité (Group for valuing of fatherhood)
• EMPHASE Mauricie
• Centre de pédiatrie sociale de Lévis (Social pediatrics centre of Lévis)
• Oxygen Homes Network
• Institut national de santé publique du Québec

Background

More than one-third of pregnant women report having experienced some form of abuse or neglect during their childhood.1 This represents more than 120,000 mothers across the country each year. Being a survivor of maltreatment may increase the vulnerability inherent in the perinatal period and interfere with psychological well-being, the course of pregnancy, and the experience and practice of motherhood.2-6 In addition, child maltreatment may have intergenerational implications. This can be observed in two ways. First, children born to a parent who is a survivor of maltreatment may be three times more likely to be exposed to some form of maltreatment than those whose parents were not maltreated as children. Second, even in the absence of exposure to maltreatment, children of mothers with a history of maltreatment may be at greater risk than children of mothers without a traumatic history of maltreatment for problems in various areas of functioning, such as biological abnormalities interfering with stress regulation, internalizing problems, externalizing behaviours, and disorganized attachment patterns.2-6 The prenatal period may represent a critical period for the intergenerational transmission of risks associated with abuse and neglect. In this sense, pregnancy could also be a window of opportunity for preventive intervention. However, very few prenatal interventions have been specifically developed to address the unique challenges of pregnant women who have experienced childhood maltreatment.2

The COVID-19 pandemic also had a significant negative impact on the mental health of pregnant women,7 which in turn may have had an impact on the social-emotional development of their children.8 However, although studies evaluating the effectiveness of online prenatal interventions have been considered a priority since the beginning of the pandemic, such studies remain rare or non-existent.9

Key activities and outcomes

STEP program development and evaluation process

The project was carried out in the province of Quebec, more specifically in the administrative region of Mauricie and central Quebec and the National Capital region, between September 2016 and March 2022. The process of developing and evaluating the STEP program was divided into eight stages as illustrated in Figure 1.10 First, those responsible for developing the program conducted a review of the scientific, theoretical and clinical literature on parenting after abuse and on existing interventions.2-6 Next, a consultation process was carried out with fifteen practitioners, managers and researchers from nine organizations in the health and social services, community, and academic sectors in order to clarify the actions to be implemented within the framework of the STEP program.

This consultation identified actions to prioritize to ensure that the program would be relevant, complementary to existing services and sensitive to interpersonal trauma.11,12
In addition to this consultation with expert practitioners, there was a consultation process with the target clients. A total of ten mothers and fathers who were survivors of child maltreatment participated in a semi-structured interview exploring their experiences of parenting, the fit between the perinatal services offered and their needs, and their perceptions of the fundamental characteristics to be considered in the development of the STEP program. This qualitative approach was complemented by an online quantitative study of 965 pregnant women in the community in order to clarify the particular challenges faced by pregnant women with a history of maltreatment.1

Based on these consultations with experts and the target clients, the three psychologists in charge of developing the STEP program designed the intervention and wrote its two intervention manuals: a guide for the facilitation team and a guide for the participants.13,14 The STEP program consists of a group intervention of eight to nine 2-hour meetings offered during pregnancy to women who experienced abuse or other forms of interpersonal trauma during their childhood. The program was originally designed to be offered in a classroom setting. In the context of the COVID pandemic, it has been adapted so that it can also be offered online in synchronous mode. It is a psychological support and education program that includes structured activities based on theory and scientific research. The program is consistent with the broad principles of mentalization-based interventions and meets all of the guidelines for trauma-sensitive interventions.

Objectives of the STEP program

• Promote a better understanding of emotions and acquire new skills to better deal with stress and unpleasant emotions;
• Develop a realistic vision of motherhood and the unborn child and support reflection on the changes that occur when becoming a mother;
• Promote engagement in motherhood and a positive investment in the mother-child relationship;
• Support the identification of the person’s strengths, resources, and areas of vulnerability;
• Provide information about the impact of abuse;
• Promote a better understanding of the impact of abuse on current functioning and the experience of motherhood;
• Reduce isolation;
• Stimulate an openness to the helping relationship and to health care, both in the health network and in the community, and establish links with available resources.

A second round of consultations was then undertaken to assess the acceptability of the program according to a panel of experts and the target clients. First, six independent experts with complementary expertise participated in a meeting in which they were asked to comment on each of the STEP activities and to assess whether they were relevant and sensitive to interpersonal trauma (i.e., low risk of re-traumatizing participants and causing distress). Subsequently, parents assessed the acceptability of the intervention. They were asked to review the two intervention manuals, provide feedback, and evaluate the relevance, clarity, and interest of the meetings and activities.10

To complete the evaluation of the acceptability of the STEP program, the program was offered to 41 pregnant women who had experienced abuse or other forms of interpersonal trauma. They completed a series of questionnaires and participated in semi-structured interviews before and after the program and six months after the birth of their child. Participants also completed a brief questionnaire after each program meeting.10 Given the significant needs expressed by pregnant women in the community during the COVID-19 pandemic, we also adapted the STEP program to extend the program offer to all women in the community in a shorter format (six meetings rather than eight to nine meetings).15,16 A total of 21 pregnant women from various regions of Quebec participated in this adaptation of the intervention, entitled STEP-COVID (Supporting the Transition to and Engagement in Parenthood during the COVID-19 pandemic).9,17 A total of 62 participants were thus invited to participate in one or the other version of the STEP program.

Knowledge dissemination and exchange activities

Summary of dissemination activities

  • Two illustrated facilitation guides, in French and English;
  • A website, in French and English (31,225 hits at the end of the project) projetstep.ca;
  • A Facebook page with over 1,000 followers https://www.facebook.com/projetstep.uqtr/
  • 66 presentations at scientific conferences;
  • 18 knowledge mobilization activities with health and social service professionals or community groups;
  • 44 articles or interviews in the mainstream media (see Press Review at projetstep.ca);
  • 19 video vignettes on the experience of parenting after abuse and the resources available in the community (see Videos under the Parents tab at projetstep.ca) (in French only);
  • 8 practitioners trained in the STEP program;
  • 8 infographics.

 

Project results

Results of the STEP evaluative research

The results of the evaluative process support the acceptability of the STEP program. Participants report that they have a high level of motivation throughout the program, learn new things, make important insights, and find each meeting useful. Participants report improvements from baseline to post-program in areas associated with resilience, such as their psychological well-being, their sense of being able to cope with the obstacles they face, and their ability to ask for help or support when they need it.10 A decrease in psychological distress and unpleasant emotions is observed among women who participated in either version of the STEP program,9,10 but not among participants in the no-intervention control group.

Key findings from the STEP program evaluation process

• The STEP program is separate from and complementary to other existing programs;
• The program’s activities are judged by an independent panel of experts and parents to be highly likely to reach their target and to be safe;
• Pregnant women rate the program as appealing: 51% of the women in the community who were briefly introduced to the program would like to be invited to take part;
• The program connects participants with other resources in the community and with front-line services when needed;
• The program does not cause harm: no adverse effects have been reported;
• Participants reported a high level of appreciation for the program and activities;
• Three dimensions were identified by participants as central to their positive experience of the program: (1) the content is perceived as sensitive, balanced, concrete and progressive, (2) the collective of mothers favours the socialization of motherhood, taking a step back, exchanges and self-validation, and (3) the facilitation framework is seen as reassuring thanks to the benevolence, competence, cohesion and reciprocity between the members of the facilitation team and the participants;18
• Both versions of the program (STEP and STEP-COVID) contribute to decreased distress and positive changes in areas associated with resilience.9,10

Quotes from participants

“The STEP program has changed my life as a parent. It was huge for me to be able to discuss and work through these experiences.”

“I was looking forward to meeting other moms-to-be, learning more about motherhood and dealing with emotions related to difficult experiences. It made me feel good, feel heard and helped me stop putting unnecessary pressure on myself. It was liberating for me.”

“The meetings were significant in my personal process. I needed to go through certain stages and reflections to welcome my baby in a better psychological state.”

“I really enjoyed the group, as it allowed me to take time out to reflect on my motherhood, a kind of obligation to be in the moment that was good for me. I made connections between my past and my current reactions/emotions and it made a lot of sense to me. This allows me to be more forgiving of myself since I am aware that there is a reason my reactions are sometimes excessive.”

Next steps

This project developed one of the first prenatal group interventions for women who experienced abuse or other forms of interpersonal trauma in childhood. The results of the evaluation process are promising. The team is already actively engaged in the subsequent stages of the STEP program development and evaluation process:

Subsequent stages in the STEP program development and evaluation process

• Evaluate the effectiveness of the STEP program using a randomized controlled design;
• Evaluate the implementation of the STEP program in the health and social services network;
• Develop an adaptation of the STEP program for fathers;
• Co-develop an adaptation of the STEP program for pregnant women with significant psychosocial vulnerability factors;
• Co-develop an adaptation of the STEP program for pregnant women who have experienced trauma in the context of their migration trajectory;
• Co-develop an adaptation of the STEP program with First Nations partners that addresses intergenerational and systemic trauma, is culturally safe, incorporates Indigenous cultural knowledge, builds on community strengths and needs, and uses Indigenous research methods.

Publications produced by the project

  1. Garon-Bissonnette, , Grisé Bolduc, M.-È., Lemieux, R., & Berthelot, N. (2022). Cumulative childhood trauma and complex psychiatric symptoms in pregnant women and expecting men.

BMC Pregnancy and Chilbirth, 22(10), https://doi.org/10.1186/s12884-021-04327-x.

  1. Berthelot, N., & Garon-Bissonnette, J. (Sous Presse). Répercussions périnatales des traumas complexes et implications pratiques. Dans J. Poissant, G. Tarabulsy et T. Saïas. Prévention en période périnatale : Principaux facteurs de risque et interventions reconnues. Presses de l’Université du Québec. Chap.8. Québec,
  2. Berthelot, N., & Garon-Bissonnette, J. (2022). Modèle développemental des cycles intergénérationnels de maltraitance. Dans D. St-Laurent, K. Dubois-Comtois et C. Cyr (Éds.). La maltrai- tance - Perspective développementale et écologique-transactionnelle. Presses de l’Université du Québec. 3, 99-124. Québec, Qc.
  3. Berthelot, N. & Garon-Bissonnette, J. (2019). Soutenir les parents ayant vécu de mauvais traitements ou des traumatismes développementaux afin d’interrompre les trajectoires de risque intergénérationnelles. Mémoire déposé à la Commission spéciale sur les droits des enfants et la protection de la 12 décembre 2019. Québec, Qc. https:// www.csdepj.gouv.qc.ca/fileadmin/Fichiers_clients/Documents_deposes_a_la_Commission/P-207_Memoire_Nicolas_Berthelot.pdf
  4. Lemieux, R., Berthelot, N., & Drouin-Maziade, C. (2021). Réactions traumatiques de parents victimes de mauvais traitements durant leur enfance susceptibles d’interférer avec leur rôle Dans G. Piché, A. Vilatte, & S. Bourque (Eds.), Trouble mental chez le parent : Enjeux familiaux et implications cliniques. Québec, Canada: Presses de l’Université du Québec. Chap. 10. pp.187-208. https://doi.org/10.2307/j.ctv1v7zd09.15
  5. Berthelot, N., Garon-Bissonnette, J., Lemieux, R., & Drouin-Maziade, C. (2021). Soutenir les parents en attente d’un enfant ayant vécu des traumas développementaux: état des connais- sances, obstacles à l’innovation, et récents développements. Dans C. Lacharité et T. Milot (Éds), Les Cahiers du CEIDEF: Vol .8, Vulnérabilité et familles. Les Éditions du CEIDEF. Chap. 14. 270-297. Trois-Rivières, Qc. ISBN 978-2-924451-28-1. 
  6. Berthelot, N., Lemieux, R., Garon-Bissonnette, J., Drouin-Maziade, C., Martel, E., & Maziade, M. (2020). Uptrend in distress and psychiatric symptomatology in pregnant women during the COVID-19 pandemic. Acta Obstetricia et Gynecologica Scandinavica, 99(7), 848-855. https://doi:10.1111/AOGS.13925
  7. Duguay, G., Garon-Bissonnette, J., Lemieux, R., Dubois-Comtois, K., Mayrand, K., & Berthelot, N. (2022). Socioemotional development in infants of women that were pregnant during the COVID-19 pandemic: the role of prenatal and postnatal maternal Child and Adolescent Psychiatry and Mental Health. First published online. https://doi.org/10.1186/s13034-022

-00458-x

  1. Berthelot, , Garon-Bissonnette, J., Drouin-Maziade, C., Bergeron, V., & Sériès, T., (Soumis). STEP-COVID : A pilot study of a prenatal intervention for pregnant women during the COVID-

19 pandemic.

  1. Berthelot, N., Drouin-Maziade, C., Garon-Bissonnette, J., Lemieux, R., Sériès, T., & Lacharité, C. (2021). Evaluation of the acceptability of a prenatal program for women with histories of childhood trauma: STEP (Supporting the Transition to and Engagement in Parenthood). Frontiers in Psychiatry, 12, article #772206, 1-8. https://doi.org/10.3389/fpsyt.2021.772706
  2. Berthelot, N., Lemieux. R., & Lacharité, C. (2018). Development of a prenatal program for adults exposed to childhood abuse or neglect: A Delphi consensus consultation study. Health Promotion and Chronic Disease Prevention in Canada, 38(11), 393-403. https://doi.org/10.24095/hpcdp.38.11.01
  3. Berthelot, N., Lemieux. R., & Lacharité, C. (2018). Développement d’un programme d’accompagnement prénatal pour les adultes ayant été victimes d’abus ou de négligence au cours de leur enfance: étude de consensus par la méthode Delphi. Promotion de la santé et prévention des maladies chroniques au Canada, 38(11), 343-453. https://doi.org/10.24095/ 38.11.01f
  4. Drouin-Maziade, , Lemieux, R. & Berthelot, N., (2020). Programme STEP : Guide à l’intention de l’équipe d’animation, version 1.0. Manuscrit inédit. Trois-Rivières, Qc.
  5. Drouin-Maziade, , Lemieux, R. & Berthelot, N., (2019). Programme STEP : Guide des participantes, version 1.0. Trois-Rivières, Qc. ISBN : 978-298 18743-0-6
  6. Drouin-Maziade, , Berthelot, N. & Lemieux, R. (2021). Programme STEP-COVID: Guide des participantes. Trois-Rivières, Qc.
  7. Drouin-Maziade, , Berthelot, N. & Lemieux, R. (2021). Programme STEP-COVID : Guide à l’intention de l’équipe d’animation. Trois-Rivières, Qc.
  8. Berthelot, N., Drouin-Maziade, C., Bergeron, V., Garon-Bissonnette, J. & Sériès, T., (En révision). Une intervention brève pour favoriser le bien-être des femmes enceintes pendant la pandémie de COVID-19 et soutenir la résilience des Revue internationale de la résilience des enfants et des adolescents.
  9. Berthelot, N., Goupil, É., Drouin-Maziade, C., Lacharité, , Lemieux, R & Garon-Bissonnette, J. (Accepté). L’expérience des participantes au programme STEP : une intervention prénatale pour les femmes ayant subi de mauvais traitements durant leur enfance. Revue de Psychoéducation.