Controlling parenting and executive functioning in children born preterm

Executive functioning (EF) is frequently compromised in children born prematurely (^{Aarnoudse-Moens et al., 2009}; ^{Arpi et al., 2019}). Controlling parenting might be one factor accounting for EF problems in children born preterm, because mothers of preterm-born children tend to display greater controlling parenting (^{Toscano et al., 2020}), and studies with normative samples have shown that maternal controlling behaviors are associated with poorer children’s EF (^{Fay-Stammbach et al., 2014}). However, little is known about the potential role of controlling parenting in the development of preterm children’s EF, and the few studies available were limited to the mother-child relationship. The present study adopts a more inclusive approach by analyzing the associations of both mothers’ and fathers’ controlling behaviors with the executive functioning of Portuguese preschoolers born preterm.

EF refers to a set of high-order cognitive processes that allow goal-directed behavior and regulate cognition and behavior, such as inhibitory control, working memory, and cognitive flexibility (^{Carlson et al., 2013}). EF skills are crucial for the child’s behavioral, emotional and social functioning, as well as for their academic success, enabling the child to ignore automatic, or impulsive thoughts and responses (^{Griffin et al., 2016}). The development of EF has a neurobiological basis, depending heavily on the brain maturation of the frontal and prefrontal cortices (^{Anderson, 2001}). However, a growing body of research with normative samples has shown that the quality of parenting behaviors also plays an important role in endorsing the emergence of EF (^{Valcan et al., 2017}). Substantial evidence has shown that parenting behaviors that support the child’s autonomy are particularly important in facilitating the development of better EF (^{Matte-Gagné & Bernier, 2011}; Valcan et al., 2017). In contrast, controlling parenting behaviors, which are behaviors providing the child with excessive external control, directing and forcing the child to meet demands, restricting and intruding on the child’s ongoing activities, and thus undermining the child’s development of autonomy (^{Toscano et al., 2020}), have been associated with poorer children’s EF skills (^{Fay-Stammbach et al., 2014}; ^{Valcan et al., 2017}).

Preterm birth, defined by the World Health Organization as birth before 37 weeks of gestation (^{WHO, 2018}), has been appointed by the literature as a risk factor for children’s development with repercussions throughout life, including impairments in EF (^{Aarnoudse-Moens, et al., 2009}; ^{Arpi et al., 2019}). Compared with children born full-term, preterm-born children tend to perform worse on executive functioning tasks (Aarnoudse-Moens, et al., 2009; Arpi et al., 2019; ^{Brydges et al., 2018}). Although these difficulties may be explained, in part, by the incomplete prenatal maturation of the brain related to prematurity (^{Brydges et al., 2018}), few studies have examined the potential role of parenting. Premature birth is a challenging event for parents and can have a significant impact on parents’ psychological well-being and parenting behavior (^{Goldberg & DiVitto, 2002}). A meta-analysis of 34 studies, carried out mostly with mothers, revealed that parents of children born preterm exhibit more controlling behaviors compared with parents of full-term children (^{Toscano et al., 2020}), highlighting the importance of considering controlling parenting when trying to explain EF impairments in preterm-born children. In line with this, a limited number of studies found a negative relation between mothers’ controlling behavior and EF skills in children born-preterm (^{Clark & Woodward, 2015}).

To our knowledge, the few previous studies examining the role of controlling parenting in preterm children’s EF have been limited to mothers, representing a major gap in the literature. In fact, even when examining other domains of preterm children’s development, research has given less attention to the fathers’ influence. Some authors have suggested that fathers may be particularly important in fostering children’s autonomy, because their parental role may be more focused on stimulating exploration and risk-taking, while mothers’ role is typically more focused on providing care and protection (^{Bögels & Phares, 2008}). Therefore, fathers’ behaviors may be particularly important for the development of EF skills, as suggested by some studies with full-term samples (^{Baptista et al., 2018}; ^{Meuwissen & Carlson, 2015}). If we wish to better predict the development of EF in children born preterm, the consideration of fathers’ behaviors is crucial. In general, data on fathers of preterm children is scarce, but recent studies have suggested that preterm birth may also negatively impact fathers’ psychological well-being (^{Barkmann et al., 2018}), and parenting behaviors in terms of control (^{Feldman, 2007}).

Another gap in the literature on the EF of children born preterm is the almost exclusive focus on children born very preterm (VPT; < 32 weeks of gestation), although they only represent about 10% of the preterm population (^{Euro-Peristat Project, 2018}), because this group is exposed to more neonatal adversity and carries higher neurobiological immaturity. However, studies have shown that children born moderately-to-late preterm (MLPT; 32-37 weeks of gestation) are also at higher risk of behavioral maladjustment and academic problems in comparison to full-term children (^{Chyi et al., 2008}; ^{Talge et al., 2010}). Therefore, the current study proposes a more inclusive approach to the study of EF in relation to prematurity by covering both VPT and MLPT children.

Taking into account all the evidence and gaps in the literature, this study aimed to analyze the relations of both mothers’ and fathers’ controlling behaviors with the executive functioning of preterm-born children at preschool age, which is considered the period of greatest EF development (^{Carlson et al., 2013}). Children’s EF abilities are intrinsically related to their cognitive ability (^{Bayless & Stevenson, 2007}), so children’s IQ was controlled for.

Method

Participants

The sample of the current study included 68 preterm-born children at 31/2 years old and their parents. Table 1 provides detailed demographics and medical information of the study sample.

The sample was drawn from a larger longitudinal study about the cognitive and socio-emotional development of children born preterm during the first 31/2 years post-partum, which recruited 172 preterm children from two hospitals in northern Portugal. Children were born between 2013 and 2015. Exclusion criteria included congenital or current neurological problems, chromosomal disorders, and/or fetal drug/alcohol exposure. From the initial recruited sample, 110 families participated in the last assessment point (i.e., when children were 31/2 years old). However, 40 out of these 110 children refused to complete the EF assessment task; and two families were not able to provide parenting behavior assessment, and thus were not included in the sample of the current study. There were no differences between participants included in the sample of the current study and those from the original sample who were not (i.e., those who either dropped out or refused EF/parenting assessment) regarding child gender, gestational age, birth weight, family income, parental education, and father’s age. However, mothers included in our sample were older, t(169) = -2.79, p = .006. Furthermore, children included in our study sample had a higher IQ than those who refused to complete the EF assessment task, t(105) = -4.10, p < .001.

Both parents were invited, but not required, to take part, with the possibility of just the mother or just the father participating. Therefore, data on controlling parenting behavior of both parents was not available for all participating children. For 45 out of the 68 children, both mother’s and father’s data was available. For 19 children, however, only the mother’s data was available; and for 4 children, only the father’s.

Table 1 Study Sample Demographics and Medical Information 

Results

Preliminary Analyses

Descriptive statistics and bivariate correlations for the study variables are presented in Table 2. As shown in the Table, children’s EF performance was positively related to their cognitive ability, and negatively related to both mothers’ and fathers’ controlling parenting behaviors. Examination of potential demographic covariates revealed that child EF was positively related to mother’s years of education, r = .29, p = .02, and father’s years of education, r = .27, p = .03. There were no child gender effects on EF performance, t(66) = 0.51, p = .62. Child EF was not significantly related to gestational age, r = -.03, p = .79, or birth weight, r = .14, p = .26. Furthermore, there were no significant differences between children born VPT and children born MLPT regarding EF, t(66) = 0.68, p = .05.

Table 2 Descriptive and Bivariate Correlations for Study Variables 

Table 3 presents the results of the two hierarchical regression models predicting child EF from controlling parenting, after controlling for child cognitive ability. The first presented model examines the predictive role of father’s controlling parenting, and the second examines the predictive role of mother’s. Visual inspection of scatterplots and normal P-P plots indicate the fulfillment of assumptions of linearity, normality, and homoscedasticity. VIF values indicate no multicollinearity concerns and examination of standardized residuals, and Mahalanobis and Cook’s Distances revealed no outliers.

Table 3 Hierarchical Regression Models Predicting Child Executive Functioning From Controlling Parenting, Controlling for Child Cognitive Ability 

As shown in Table 3, for the model with fathers, in the first stepchild cognitive ability was significantly associated with child EF, p = .03, accounting for 9% of its variance. After controlling for child cognitive ability, fathers’ controlling parenting was significantly associated with child EF, p = .04, accounting for an additional 8% of the variance in child EF, and the association between child cognitive ability and EF became marginal, p = .08. Similarly, for the model with mothers, in the first stepchild cognitive ability was significantly associated with child EF, p = .01, and accounted for 10% of its variance. After controlling for child cognitive ability, mothers’ controlling parenting was significantly associated with child EF, p = .04, accounting for an additional 6% of its variance, and child cognitive ability became a marginal predictor, p = .09.

Given the significant correlation between child EF and parents’ years of education identified in the preliminary analyses, hierarchical regression models were re-run in order to examine the association of mothers’ and fathers’ controlling parenting with child EF, after accounting for parents’ education. For the model with fathers, after controlling for father’s years of education, controlling parenting was marginally associated with child EF, 𝛽 = -.28, p = .05. For the model with mothers, after controlling for mother’s years of education, controlling parenting was significantly associated with child EF, 𝛽 = -.30, p = .02.

Discussion

The current study investigated the relations between mothers’ and fathers’ controlling behaviors and the EF of Portuguese preschoolers born preterm. Results showed that more controlling behaviors of both mothers and fathers were associated with worse EF performance of preterm-born children, even after controlling for children’s cognitive ability. Furthermore, parents’ level of education was also significantly related to children’s EF performance. Several studies have shown that children born preterm are at risk of EF impairments due to their neurobiological vulnerability (^{Aarnoudse-Moens, et al., 2009}; ^{Arpi et al., 2019}; ^{Brydges et al., 2018}). Our results bring evidence to the additional important role of environmental factors in the EF development of this population, suggesting that parental socialization - in particular, controlling parenting behavior - may also play a role in such impairments. This highlights the importance of providing psychosocial support to parents of children born preterm in order to help them develop adaptive parenting strategies and benefit the children’s (already at risk) EF development.

Despite the already documented relation between mothers’ controlling behaviors and EF skills in children born preterm (^{Clark & Woodward, 2015}), to our knowledge, this is the first study assessing the association between fathers’ control and EF skills in preterm-born children, revealing the important role of fathers in these children’s development. Our results are in line with studies with normative samples, in which the implication of fathers’ behaviors on EF development has already been analyzed. Meuwessin and Carlson (2015), for example, found that fathers’ controlling behaviors have a negative influence on preschoolers’ EF development. According to these authors, controlling behaviors, such as criticism and interference, take away the power of children to control their environment, activities, and behavior. Therefore, this may be reflected in fewer self-regulation abilities in children at preschool age, which includes EF skills (^{Karreman et al., 2006}). The significant association between fathers’ behaviors and children’s EF highlights the importance for health professionals to include and engage fathers in the monitoring, support, and intervention provided to children born preterm during their first years of life. Furthermore, results also reinforce the importance of including fathers in the study of parenting and child outcomes of prematurity.

One strength of this study was the inclusion of a large gestational-age range given that, to date, most studies examining EF in children born preterm were exclusive to children born VPT, and little attention has been given to children born MLPT (e.g., ^{Aarnoudse-Moens, 2009}). Our results showed no differences in the EF between children born VPT and children born MLPT, highlighting the importance of monitoring both groups, providing also attention to MLPT children when studying the outcomes of prematurity. Although these children might be exposed to less neurobiological risk, they are, nevertheless, at risk for less optimal developmental outcomes, as suggested by previous studies (^{Chyi et al., 2008}; ^{Talge et al., 2010}).

Other strengths of the study included the observational nature of the assessment, the inclusion of both mothers and fathers, and the unique nature of the Portuguese sample. Limitations should also be discussed, however. Firstly, a significant number of children rejected EF assessment, and these were children with lower cognitive abilities, representing a major limitation for the generalization of the results. Secondly, the attrition rates of the longitudinal sample from which participants were drawn were high and selective on maternal age. Thirdly, there were a different number of participating mothers and fathers, thus the inclusion of both parents in the same regression model was not possible. Fourthly, participants were assessed in different settings (i.e., hospital, university laboratory, or participant’s home), which could have had different effects on behavior (^{Gardner, 2000}). Finally, the cross-sectional nature of the data did not allow the examination of causality and direction of the relations between executive functioning and controlling parenting behaviors. Future research would benefit from the longitudinal analysis of these relations, and should examine the associations between controlling parenting and preterm-born children’s EF in other age groups. Furthermore, it would be relevant to explore the impact of other domains of fathers’ parenting on preterm-born children’s EF development, given that the father’s role in the development of these children remains under-investigated.

In conclusion, this study suggests that, besides the well-known effect of mothers’ behavior on preterm children’s EF development, which is crucial for the child’s socio-emotional and behavioral development (^{Griffin et al., 2016}), fathers’ parenting behavior also plays an important role in the EF outcomes of these children. Findings highlight the importance for healthcare professionals to support and guide both mothers and fathers of preterm infants in developing adaptive parenting strategies, in order to prevent their engagement in excessive controlling behavioral patterns and associated EF problems in the child. Mother- and father-child relationships and, in particular, parents’ ability to support children’s autonomy, should be considered as important targets for interventions aimed at improving preterm-born children's EF, and, consequently, their behavioral, emotional, social, and academic functioning.

CRediT authorship contribution statement

Carolina Toscano: Conceptualization; Methodology; Software; Formal analysis; Investigation; Data curation; Writing - original draft; Visualization; Funding acquisition; Cindy Sá: Conceptualization; Investigation; Data curation; Writing - original draft; Visualization; Joana Baptista: Conceptualization; Methodology; Resources; Supervision; Data curation; Project administration; Writing - review & editing; Vanessa Moutinho: Methodology; Investigation; Data curation; Isabel Soares: Conceptualization; Methodology; Resources; Supervision; Project administration.

Acknowledgments

This study was supported by the Portuguese Foundation for Science and Technology (SFRH/BD/118495/2016).