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. Author manuscript; available in PMC: 2023 Mar 14.
Published in final edited form as: J Infant Child Adolesc Psychother. 2022 Mar 14;21(1):6–18. doi: 10.1080/15289168.2022.2045464

Harnessing Virtual Mom Power: Process and Outcomes of a Pilot Telehealth Adaptation of a Multifamily, Attachment-Based Intervention

Sarah A O Gray a,b,c, Stephanie A Moberg a, Elsia A Obus a, Victoria Parker a, Katherine L Rosenblum d, Maria Muzik d, Charles H Zeanah b, Stacy S Drury b,c
PMCID: PMC9853992  NIHMSID: NIHMS1862198  PMID: 36686598

Abstract

Objective:

The COVID-19 pandemic and mitigation strategies amplified racial and income-based health disparities, profoundly shifted family life, and altered delivery systems for support services. We report pilot data from a telehealth adaptation of Mom Power, an evidence-based, attachment-informed multifamily preventive intervention (clinicaltrials.gov: de-identified).

Method:

Virtual Mom Power (VMP), adapted for economically marginalized, predominantly Black mothers and their young children (n = 9) was implemented in New Orleans, an early COVID-19 hotspot with an entrenched history of structural racism and trauma. We outline our approach to adaptation of curriculum and service delivery, using a trauma-informed lens.

Results:

Maternal reports of maternal and child functioning from pre to post were consistent with improvements in maternal depressive and posttraumatic stress symptoms and child competence, comparable to outcomes from in-person trials. Feasibility and acceptability data were strong.

Discussion:

Preliminary results and reflections on process suggest that telehealth service delivery of a multifamily preventive intervention, with attention to decreasing barriers to online access and consideration of culture and context, facilitated engagement while maintaining fidelity and effects on intervention targets. Future research using larger samples, randomized controlled design, and multi-method assessment should continue to guide dissemination of reflective, group-based telehealth parenting programs.

Keywords: COVID-19, parenting, prevention, attachment, telehealth

The COVID-19 pandemic and subsequent mitigation strategies upended patterns of life for families worldwide, with some calling for it to be considered a collective trauma (Horesh & Brown, 2020). Disruptions to daily life and pandemic-related stress had major implications for family well-being, particularly for families with young children. One U.S. national survey showed 31% of parents of children aged 0-5 reported worsening mental health in themselves and in 18% of their children - exceeding decrements reported in older age ranges (Patrick et al., 2020). Copious research on collective and individual traumas suggests that parent-child relationships are critical buffers for children’s distress during adversity (Masten et al., 1990). Caregiver distress is also a key risk factor for child mental health outcomes in the context of mass stressors (Lai et al., 2015; Spell et al., 2008), including COVID-19 (Russell et al, 2020). However, as the COVID-19 pandemic unfolded, parents themselves faced mounting stressors, including employment and financial stress, online schooling demands, childcare instability, family health concern, and social isolation (Prime, Wade, & Brown, 2020), with subsequent decrements in maternal mental health observed in longitudinal samples (Racine et al., 2021).

The pandemic and mitigation strategies also exacerbated existing disparities in health and service access, with disease burden and mitigation-related disruptions in economic, social, and psychological stability disproportionately affecting Black, Indigenous, and other People of Color (BIPOC) and economically marginalized persons (Raifman & Raifman, 2020). In the U.S., the pandemic coincided with racial justice uprisings, highlighting health consequences of structural racism. Maternal-child health scholars and practitioners called for trauma-informed service delivery for young families, attending to social support and attachment (Choi et al., 2020). Despite amplified need for trauma-informed, culturally- and contextually-relevant services (Horesh & Brown, 2020), pandemic mitigation strategies forced massive shifts in service availability and format (APA, 2020). Thus, the twin pandemics of COVID-19 and structural racism presented a marked, immediate, need for accessible, trauma-informed telehealth services, particularly for BIPOC and economically marginalized children and families.

The current paper describes telehealth adaptation and piloting of Virtual Mom Power (VMP), a trauma-informed, attachment-based, multifamily intervention for mothers of young children. We first outline our approach to adapting curriculum and service delivery, guided by principles of trauma-informed care (TIC; SAMHSA, 2014). Next, we highlight feasibility and accessibility data and outcomes. We end with reflections on challenges and opportunities in the transition to telehealth. While the adaptation process described herein was necessitated by COVID-19, telehealth interventions have potential to address treatment barriers and promote accessibility more broadly (Breitenstein et al., 2014). Establishing a framework for trauma-informed telehealth adaptation can support wider-scale efforts to increase the reach of quality care supporting family and child thriving. Finally, the increasing diversity of families receiving telehealth warrants careful consideration of culture and context when adapting practice.

What is Mom Power?

Mom Power (MP) is a group-based, multifamily intervention. It is rooted in attachment theory and trauma-informed practice and targeted for mothering under stress, including mothers facing depression, interpersonal trauma, early life adversity, and poverty. MP was co-designed through a culturally tailored process for delivery in community settings with attention to engagement (Muzik et al., 2014) and has shown stronger treatment effects with mothers with histories of interpersonal trauma or at high sociodemographic risk, with medium-sized effects for maternal depressive and posttraumatic stress symptoms and parenting stress (Cohen’s d = .40-.65; Rosenblum et al., 2018). The co-facilitated intervention consists of 13 sessions (10 group and 3 individual) targeting 5 pillars: 1) enhancing social support; 2) attachment-based parenting education; 3) self-care; 4) guided parent-child interactions; and 5) connecting to care. Typical service provision involves concurrent mother and child groups, bookended by a shared meal to open and a circle time to close, which offer opportunity for separation and reunion observation and coaching. While MP was not designed for telehealth, it is deployment-focused and designed to be flexibly delivered. Additionally, MP targets social support, shown to buffer against intergenerational trauma for both mothers (Schumm et al., 2006) and children (Hatch et al., 2020) and threatened by COVID-19. Other features, such as child groups and separation-reunion coaching, posed logistical challenges for adaptation.

Methods

Since 2015, our research team has had ongoing partnerships with two large Head Start centers in New Orleans, Louisiana, which were service delivery sites for an in-person MP pilot beginning in February 2020 disrupted by COVID lockdown. Over subsequent months, we planned for virtual adaptation and piloted between October 2020-February 2021.

Context

New Orleans is notable for its strong culture of family and community ties, with Louisiana documenting the nation’s highest rate of individuals residing in the state who were born in the state (U.S. Census Bureau, 2011). Community impacts from COVID-19 are also important to contextualize in light of disproportionately high rates of trauma exposure and lasting structural disenfranchisement secondary to Hurricane Katrina - another collective trauma marked by disruption of social connection and safety (Hawkins & Mauer, 2010) - as well as other syndemic and historical stressors, including racism-based stress, economic disparity, and violence (Drury et al., 2008). Digital connection provided a means of mitigating, but not replacing, lost social connection in the wake of Katrina (Schklovski et al., 2010). However, in New Orleans, 20% of families have no internet access, and in a city with limited public transportation, 19% of households do not have vehicle access (Losh & Plyer, 2020). CDC survey estimates ranked Louisiana among the 10 states with the highest levels of anxiety and depression during the entire period of our pilot, with 4 weeks at the highest rank (CDC, 2021).

Facilitators and research team

Our local research team is composed of the principal investigator (SG), a licensed psychologist and mother of two young children, as well as the project manager (VP) and two doctoral student facilitators (SM & EO), who were not mothers at the time of the pilot. All identify as cis-gendered, middle class white women. The local research team was trained in MP by intervention developers (KR & MM) and supported in our execution by two local child psychiatrists with expertise in infant mental health (CZ & SD). SG provided weekly reflective supervision to facilitators, with KR providing additional reflective consultation.

Participants and Procedures

Intervention participants (n=9) predominantly identified as African-American/Black and were mothers of children aged 3-5 years (see Table 1 for demographics). While in-person MP groups targeted mothers with histories of Adverse Childhood Experiences (ACEs) recruited on site at Head Starts, at pandemic onset, we chose to open enrollment to any family receiving services at sites; interested mothers responded to an email with an informational flyer advertising a research study for a support group for parents of young children. Mothers completed a structured intake engagement interview with project staff over Zoom and measures via REDCap. At intake and post assessments, mothers reported on demographics and family exposure to COVID-related life events (EPII; Grasso et al., 2020); their own depressive (PHQ-9; Lowe et al., 2004) and posttraumatic stress symptoms (PCL-5; Blevins et al., 2015), emotion dysregulation (DERS; Gratz & Roemer, 2004), and perceived social support (MSPSS; Zimet et al., 1988); and their child’s behavior problems (CBCL 1.5-5; Achenbach & Rescorla, 2000) and social competence (SCS; CPPRG, 1999). Mothers were compensated $50 per individual session and $15 per group attended. Procedures were reviewed by Tulane University’s Institutional Review Board (TU-2018-2012) and informed consent obtained from all participating mothers.

Table 1.

Mom Power Pilot Sample Descriptive Statistics for N=9 mother-child dyads

Age Range Mean (SD)
Mom Age (years) 23-40 30.11 (5.84)
Child Age (months) 36-71 52.16 (11.53)
Sex %
Child Sex (% female) 44% --
Race %
Maternal Race (% Black or African American) 89% --
Child Race (% Black or African American) 89% --
Additional Demographics %
Marital Status
 Single/Never Married 33% --
 Married 44% --
Maternal Education
 Completed 1-3 years college 44% --
 High School Diploma / GED 22% --
Maternal Employment
 Full-Time 33% --
 Currently Unemployed 44% --
Technology Supplied %
Family Supplied Tablets 78% --
Family Supplied Hotspots 44% --
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Consistent with existing data regarding disparities in COVID-19 impacts and the vulnerability of Black families, families with low incomes (Raifman & Raifman, 2020), and families with young children (Patrick et al., 2020), mothers reported pandemic-related family disruptions. At intake, 44% of mothers had lost jobs or had hours reduced; 55% reported having to continue to work even though they were in close contact with others who may be infected; 67% reported a lack of childcare when needed; and 55% reported being unable to pay important bills. Seven of the nine mothers reported an increase in child behavior, emotional, or sleep problems secondary to the pandemic, and all mothers reported an increase in their own mental health problems. Four of nine mothers reported the death of a close friend or family member due to COVID-19 at intake; at post assessment, this number rose to six of nine.

A Trauma-Informed Virtual Pivot

In our adaptation, we centered the five core components of MP: enhancing social support, attachment-based parenting education, self-care, guided parent-child interactions, and connection to care. We emphasized cultural humility as an overarching frame (Hook et al., 2013) and were further guided by the tenets of TIC (SAMHSA, 2014), including: cultural, historical, and gender issues; safety, trustworthiness, and transparency; collaboration and mutuality; empowerment, voice and choice; and peer support.

Bringing attention to culture, history, gender, and context in VMP

First, we reviewed the MP curriculum and our procedures and considered what elements required adaptation. Drawing from the literature on cultural adaptation, we assessed adaptation as focusing on surface structure needs (logistical or superficial components, e.g. technology; physical activities; connection to resources) and deep structure needs (core cultural values or contextual factors that might influence treatment response, e.g. parent-child interactions and responsiveness to poverty and racism-based stressors during the pandemic; Castro et al., 2010). Regarding surface structural features, to meet technological needs, we offered tablets and wi-fi hot spots to all participating mothers who required them. To counteract transportation barriers, our project coordinator delivered materials to participating mothers’ houses, such as printed handouts, self-care sensory tools, and a schedule of meeting times. Deliveries created an opportunity for distanced face-to-face interaction with the facilitating team.

Weekly reflective supervision (Tomlin et al., 2014) that began during adaptation planning was our main tool for repeatedly returning attention to deep structure. Guided by cultural humility, we used reflective supervision to attend to our own intersectional identities and biases, track salient cultural and current events, and cultivate responsiveness to mothers as experts in their own experiences, in order to intentionally co-construct our adaptation with participants. It was particularly important for us facilitating from a place of relative power and privilege, as white women operating out of a predominantly white higher education institution, to acknowledge our social identities and strive to position ourselves alongside mothers in their exploration of their experiences relative to curriculum content, rather than acting as prescriptive experts. While this stance is a feature of MP as traditionally delivered, the online delivery platform demanded heightened attention to power dynamics, as nonverbal and embodied communication is challenging to track virtually (Cook et al., 2021). Participant reflections from individual sessions suggest success. As one mother described in an individual session, “It’s a community thing. We just look at the stigma of you know ‘oh that’s somebody getting in my business, they’re gonna tell me how to raise my child,’ and that’s, [Mom Power’s] not it.” “As a Black woman,” she explained, “we have to get out of our own way,” describing her reluctance to participate in parenting groups that might be experienced as directive, or what another mother referred to as “feeling judged.” As another example of a deep structural adaptation, we wanted to ensure that we reflected the cultural value of hospitality and food-centered nurturance, present in traditional MP through communal meals. We felt that in New Orleans - a culture that emphasizes ties between food, culture, and connection - it was important to find a way to demonstrate care through food. To meet this need while maintaining distancing, we delivered a Thanksgiving meal to participants between weeks two and three.

Ensuring Safety, Transparency, & Trustworthiness

A trauma-informed lens highlights the importance of participants feeling physically, socially and emotionally safe and involved in an open and transparent process. Unlike some trauma-focused treatments, MP does not focus on trauma processing, which has been noted as a challenge for safety and privacy in telehealth (Racine et al., 2020). To address safety, during intake, staff discussed telehealth privacy concerns, encouraging mothers to find a private space within homes for groups. In the first group sessions, facilitators and members discussed together privacy-related group norms (i.e., to not repeat what was shared outside of the group).

While initially our clinical ethics led us to prioritize privacy, we underestimated both the extent to which mothers would log into sessions from public places as well as participant comfort with others being present in the background. Evidence that mothers felt safe was suggested in choices to Zoom from public spaces and intimate spaces, including but not limited to work offices, cars, medical appointments, and personal bedrooms following overnight work shifts. These actions communicated a prioritization of being present for group, despite competing external demands. In conversation with mothers, it became clear that attending to transparency was more valued by group members than strict privacy. Accordingly, it became important for facilitators to use reflective supervision to explore loosening our control and identifying where we could be flexible with our own boundary-setting. With this support, we were able to support mothers in coming “as they are” and prioritize mothers’ value of transparency over strict privacy. At group opening, mothers shared where they were Zooming from and who else was present, and alerted everyone when they needed to turn off their screen to interact with someone coming into their office or a child needing help. Many noted during individual sessions that the ease of being able to join from various places throughout the day outweighed concerns about privacy and made participation possible. In our post assessment, 100% of mothers “agreed a lot” that they “felt [their] information was kept private during group sessions.”

Engaging in Collaboration and Mutuality

Collaboration and mutuality within a trauma-informed framework involves promoting shared decision-making. In our adaptation, we consulted with 1) previous clinicians from our team who had provided in-person MP pre-COVID regarding experiences with our specific partner sites and parent population; 2) clinicians from other teams nationally who were also adapting MP; and 3) the developers of MP to ensure we remained true to the core components. A benefit of service delivery via technology platform was the opportunity to enhance measurement-based care (Mochari-Greenberger & Pande, 2021). We embedded a 22-item weekly survey at the end of group, distributed via Zoom chat, which briefly assessed pillars of MP and treatment targets (e.g., single item assessment of mood and parent-child relationship satisfaction) as well as participant satisfaction and group cohesion. Data from these surveys were used in weekly supervision to track who might benefit from additional clinician contact or referrals.

Promoting Empowerment, Voice, and Choice

To elicit mothers’ voices, weekly surveys included an open-ended comment box for feedback, and to compensate for loss of casual conversation that typically accompanies MP mealtime, VMP sessions were scheduled to be two hours, with facilitators available on Zoom for 30 minutes before groups so that mothers could check-in early. Participant feedback informed structural features, such as rescheduling and modes of contact (e.g., text message), as well as session content. For example, in response to feedback, beginning of session check-ins related to weekly stressors and joys were extended. Relatedly, mothers consistently provided feedback indicating appreciation for self-care skills in light of significant stressors. In response, facilitators adapted later sessions to incorporate additional self-care skills rehearsals at the beginning of each session, in addition to the end of each session per the original curriculum.

In addition to these broad and ongoing promotions of voice and choice, a few additional examples highlight how attention to voice and choice promoted culturally responsive care. “Hot topics” are a component of the curriculum in which mothers are invited to bracket concerns not addressed in weekly content for a specified session during Week 9. For “hot topics,” we tracked in supervision issues that mothers raised in individual sessions, but that were not explicitly addressed by the curriculum, and elevated these for group discussion during Week 9. Critically, this approach allowed us to be more attentive to issues of culture, gender, and race, as intersectional race and gender-based socialized expectations for children and adults were central to “hot topics.” Specifically, mothers provided each other support in unpacking frustration around feeling a lack of parenting support from male co-parents, which they aligned with societal expectations of women as caregivers. Further, in line with national conversations regarding structural racism and police violence, in one of the groups where all mothers had Black sons, participants supported each other in exploring fears regarding how society, and in particular police, would view their sons’ aggressive behaviors. Mothers shared concerns about balancing warm and kind parenting with a fear that if they did not strongly discipline their Black sons and teach emotional display rules regarding anger, their sons would face danger. Empowering mothers to share experiences via hot topics facilitated discussion of personally salient subjects that may not have been prioritized in a more prescriptive administration of a parenting curriculum. As a reflection of participants’ experience of voice and choice, one mother described in her post interview, “I like the fact that you even sometimes, we may get off subject, you all let us say what we need to say, and then we find our way back to the group.”

Facilitating Connections to Peer and Additional Supports

A final tenet of both TIC and MP is connection to peers and other systems of support. In transitioning to Zoom, we realized that sharing visual information via slides or screen sharing made it difficult for participants to see one anothers’ faces, so we minimized visual materials, choosing to maximize opportunities for “face-to-face” interactions that we hoped would promote group cohesion and connection. Evidence that group cohesion and connection were fostered was demonstrated by mothers’ requests to share phone numbers, the frequency with which participants used each others’ names and spoke directly to other participants during group, their willingness to share community knowledge and connections (e.g. Christmas toy drives, school advocacy resources), and their request to initiate a VMP Facebook group after groups ended. One mother reflected, “I think the group is really good, especially for people with…I do have mom friends that live far away. Because of Katrina everything has been scattered. So, to meet some moms, especially moms with kids from [partner site], you know, just to meet moms locally.” Facilitators scaffolded mothers’ connections by setting aside time for sharing numbers and resources and creating the requested Facebook. Additionally, when participants or facilitators identified resource needs beyond VMP, they were referred (e.g., family services at Head Starts; outpatient mental health).

Finally, aligned with work highlighting parallel processes (Mothersole, 1999), it is important to acknowledge how facilitators were supported, which in turn allowed them to support participants. Co-facilitators were graduate student colleagues and friends for years prior to the start of VMP, enabling professional and peer support. While we are not suggesting that VMP must or should be led by co-facilitators with close relationships, attention to our relationship and our own attachment patterns enhanced our facilitation. Initially, we recognized the necessity of exploring our attachment patterns with support from our supervisor. Specifically, a core component of MP involves exploring each mother’s comfort engaging in “warm and kind” caregiving and “strong and in charge” caregiving (Powell et al., 2016). Given our prior knowledge of one another, we used reflective supervision to explore how one of us tended to embody “warm and kind” more often while the other took the role of “strong and in charge.” We used supervision to seek opportunities to demonstrate balanced facilitating and move beyond our typical patterns. Our relationship also allowed us to co-regulate and support each other during exploration. Ultimately, the support we drew from each other and our supervision allowed us to model components of MP and helped us avoid burnout by ensuring there was a safe haven to return to for processing group dynamics and personal reflections. Broadly, our process was reflective of concentric systems of support, including the support we offered each other, the support we offered our participants, the support our participants offered one another, and connections to outside supports.

Results

Consistent with meta-analytic evidence that telehealth improves access (Breitenstein et al., 2014), recruitment and retention was strong; 10 mothers completed eligibility screenings, 9 completed intake assessments, and all 9 mothers completed VMP; 4 participants attended 100% of sessions, 2 attended 90%, 2 attended 80%, and 1 attended 50%. On our study measure of treatment acceptability, 88% of mothers said it was “true” and 12% “somewhat true” that “MP did a good job addressing challenges that can make participating in services hard for me.”

Feasibility and acceptability data were promising. On an adapted Telehealth Satisfaction Questionnaire (TSQ; Stewart et al., 2017) for group intervention, 100% of mothers “agreed a lot” (highest Likert rating) that they “liked the zoom groups using the phone/tablet,” that they “were comfortable interacting with the group on the phone/tablet,” that “receiving groups over Zoom helped me to feel better,” and that they “would recommend virtual groups to family or friends who need support.” All mothers also agreed a little (13%) or a lot (87%) that “having groups over Zoom is as good as having groups in person.” Eight of nine of mothers “agreed a lot” that they “felt as connected to my group leaders as I would if groups had been in person.” Critically, eight of nine mothers reported they were “only able to attend groups because they were offered via Zoom,” with only one mother disagreeing with this statement. Qualitatively, mothers reported that barrier reduction from telehealth was not just logistical, but also psychological; one mother reported, “Because of my anxiety…I go through times where I can’t drive because I can’t focus,” so online groups facilitated her engagement in a manner that felt safe to her.

Our study-developed measure of acceptability and feasibility of VMP suggested that participants perceived change on the five pillars of Mom Power. Eight of nine mothers “strongly agreed” and the other mother “agreed” that they “learned useful coping strategies for [themselves]” and that they had “an improved understanding of how to handle my child’s behavior when upset” and were “more content in my relationship with my child.” All mothers agreed or strongly agreed that their “child’s behavior has improved,” and all strongly agreed that they “have some new caregiving abilities” and “have more confidence in [themselves] as a mother.” Qualitative data from parent interviews was consistent with improvements in reflective functioning and using an attachment lens to observe children’s behavior. Referring to a key MP metaphor of the parent-child relationship symbolized as a tree, with both branches (need for exploration) and roots (need for connection), one mother described, “I think the tree really explained a lot about where I stand as a parent and how I navigate my relationship with my son. So I’m like, ‘okay, am I being a helicopter parent?’ Ima stand back and Ima let him do his thing, but I’m still going to be here, you know, if he runs off or if he falls down or something like that. He needs me, I’m here.” Regarding the target of social support, 100% of mothers strongly agreed that they “made social connections with other group participants.” All mothers agreed that they were “more likely to seek out other support services for [their] children.” Regarding culture-specific acceptability of VMP, 100% of mothers agreed that VMP “incorporated culturally-relevant discussions about parenting” and “acknowledged and addressed the diversity of experiences and identities among group members and facilitators.” Finally, all mothers agreed that they would recommend VMP to others.

Table 2 displays means and significance testing for outcomes of VMP; bias-corrected effect sizes (Hedges’ g) are reported, which perform better in smaller samples. Of note, post data were collected during the “winter surge” of COVID-19, during which time CDC statewide estimates of anxiety and depression were comparable to estimates observed during intake (CDC, 2021). For outcomes for which prior data were available, effect sizes were comparable to what has been observed in in-person service delivery (Rosenblum et al., 2018). Significant change, with large effect size, was observed for mothers’ depressive (g=.92; PHQ-9, Lowe et al., 2004) and posttraumatic stress symptoms (g=.81; PCL-5; Blevins et al., 2015); regarding clinical significance, PHQ-9 pre-treatment mean was in the “moderate depression” range (10.78) and post-treatment mean in the “minimal” to “mild” depression range (4.89). Although the effect did not meet statistical significance, a medium effect size reduction was observed for improvements in mothers’ emotion regulation (g=.44, DERS; Gratz & Roemer, 2004). For child outcomes, mothers reported statistically significant improvement in children’s social competence (social skills and emotion regulation), again with large effect (g=.94; SCS, CPPRG, 1999). Additionally, although it did not meet statistical significance, a medium effect size reduction was observed for mothers’ report of children’s emotional reactivity (g=.46; CBCL, Achenbach & Rescorla, 2000). Finally, mothers reported medium effect size improvements in perceived social support (g=.45; MSPSS; Zimet et al., 1988), although this did not meet statistical significance.

Table 2.

Mean differences of Mom Power outcomes at pre and post intervention

Pre___
Post___
Outcome Variable N M (SD) M (SD) Mean
Difference		 t p Effect size (g)
PHQ-9 Maternal Depressive Symptoms 9 10.78 (6.91) 4.89 (4.26) 5.89 2.91 .02* .92
DERS Maternal Difficulties in Emotion Regulation 8 89.75 (26.68) 78.38 (19.39) 11.38 1.32 .23 .44
PCL-5 Maternal Posttraumatic Stress Symptoms 9 27.33 (18.40) 17.22 (19.76) 10.11 2.55 .03* .81
CBCL Child Emotion Reactivity 8 2.13 (3.23) .63 (.92) 1.50 1.36 .22 .46
SCS Child Social Competence 9 22.67 (7.97) 28.89 (7.10) −6.22 −2.96 .02* .94
SCS Child Emotion Regulation 9 9.22 (3.19) 12.00 (3.80) −2.78 −2.21 .06 .70
MSPSS Maternal Social Support -Overall 9 53.67 (24.84) 64.33 (12.95) −10.67 −1.42 .19 .45
MSPSS Maternal Social Support- Friends 9 17.11 (9.53) 22.22 (5.12) −5.11 −1.86 .10 .59
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Note.

*

indicates p<.05. PHQ: Patient Health Questionnaire; DERS: Difficulties in Emotion Regulation; PCL-5: PTSD Checklist for DSM-5; CBCL: Child Behavior Check List; SCS: Social Competence Scale; MSPSS: Multidimensional Scale of Perceived Social Support.

Conclusion

In this small pilot study (n = 9) of a virtual adaptation of Mom Power targeting economically marginalized mothers of young children, we observed pre-post changes in maternal depressive symptoms and posttraumatic stress symptoms with effect sizes comparable to or exceeding previous work with in-person delivery of Mom Power (Rosenblum et al., 2018); mothers also reported significant improvements in child competence from pre to post. While the lack of a comparison group greatly limits any conclusions about intervention effectiveness, it is notable that CDC data estimating statewide prevalence of anxiety and depressive disorders in Louisiana were not notably different across the period of the pilot (CDC, 2021), and that the pilot also coincided with a winter surge of COVID-19 cases nationwide. Additionally, feasibility and acceptability data suggest that virtual service delivery was acceptable to parents, and indeed that they perceived telehealth services as decreasing barriers to treatment engagement. These findings are consistent with other recent work in this area highlighting the acceptability of group parenting interventions delivered remotely during COVID-19, which also have noted the potential for increased engagement (Zayde et al., 2021). However, providing parents both access to and support with technology was conceptualized as a part of our trauma-informed adaptation; others have noted that dissemination of telehealth services without intentional support risks limiting engagement for vulnerable families with young children (Barnett et al., 2021). Taken together, while very preliminary due to lack of a control comparison and a very small sample, findings are promising and highlight the value of more rigorous evaluation using randomized controlled trial methodology, multi-method and multi-informant outcome assessment, and follow up over a longer time period to track if treatment gains persist.

Despite promising initial data, our implementation was not without challenges. Parent-child interaction guidance, a crucial component of many parent-child interventions, was challenged by the virtual pivot. Traditionally in MP, mothers are observed during separations from and reunions with their children at the beginning and end of sessions, and facilitators provide in-vivo scaffolding to support transitions, offering an opportunity for mothers to try out new patterns of behavior and for facilitators to gain first-hand understanding of parent-child relationships. Virtually, it was at times difficult for facilitators and mothers to “hold the child in mind,” or maintain focus on participants’ children and their specific behaviors. This felt particularly challenging for parent-child dyads we perceived as having more avoidant attachment styles, as the lack of child presence in session seemed to collude with dyads’ tendencies towards dismissing the importance of the relationship; for these dyads in particular, the opportunity to observe and describe child behavior in vivo with parents was missed. Additionally, due to pandemic-heightened stress, many mothers communicated that increasing their own self-care behavior was of greater priority than changing separation-reunion behaviors, especially because the number of separations had decreased due to COVID mitigation. Simultaneously, COVID mitigation increased demands on moms’ time and created new and challenging roles for them to fill (i.e., virtual school teaching). Ultimately, choosing to prioritize maternal self-care over parent-child interaction scaffolding aligned with tenets of TIC; of note, the approach of prioritizing parents’ self-regulation is also consistent with systems theory and prior research demonstrating that adversity and contextual risk in the distal environment impacts children through proximal processes (e.g., relationships with caregivers) and shifts in family processes (Prime, Wade, & Brown, 2020). However, in our next implementation, we intend to attempt new strategies learned from consultation with other VMP groups to keep children “in the room,” such as distributing materials for parent-child activities. Work coming out of behavioral training programs with parents of young children have noted the benefit of naturalistic skill rehearsal facilitated by telehealth in the context of COVID-19 (Barnett et al., 2021), suggesting that incorporation of more in vivo parent child interaction guidance is feasible.

Aligned with existing research, we, like many other therapists, noted that maintaining professional boundaries during telehealth was a significant challenge (Békés et al., 2020); however, fluidity in boundaries simultaneously created opportunity. In VMP, it was difficult for us to enforce transparency and privacy related to muting and unmuting and location of group members, as mothers were navigating environmental demands while showing up for group sessions. However, our perception was that our loosening of these boundaries in the context of VMP, coupled with an emphasis on transparency, led to increased co-construction of therapeutic space, provided an opportunity for facilitator modeling of positive and balanced caregiving, and decreased barriers to participation. Although many manualized interventions demand strict adherence to practices and boundaries to ensure fidelity, existing literature supports a “flexibility within fidelity” stance that simultaneously prioritizes attention to core components of intervention and tailoring to individual participant needs (Kendall et al., 2008). We were supported in developing this flexibility through our attention to TIC tenets and reflective supervision. Reflective supervision provided space to develop our tolerance for ambiguity in virtual treatment and to hone our capacity to prioritize group members empathically. As we moved away from a directive, “strong and in charge” role and leaned into being “warm and kind,” we allowed group members to show up authentically, ask for the skills they wanted, and share the experiences they felt were most relevant to weekly topics.

Overall, guided by the principles of TIC (SAMHSA, 2014) with particular attention to culture, context and barriers (Castro et al., 2010), the transition of multifamily, attachment-informed preventive intervention, to telehealth is supported by these preliminary pilot data. We would be remiss not to acknowledge the support of grant funding, which allowed us to pace our adaptation, with time for reflective supervision and consultation and acquisition of materials to create a more tailored experience for participants. Additionally, MP is a “soft-safe entry” program, designed in part to overcome engagement hesitancy and encourage felt security in service provision; it is not an intensive intervention, and other services that address trauma-related content more directly through processing, or that target more severe mental illness, would confront different challenges in telehealth adaptation (Racine et al., 2021). Together, our pilot data provide preliminary evidence that VMP was acceptable to participants, holds promise for reducing maternal psychopathology symptoms and increased family wellbeing, and that virtual service delivery may reduce barriers to participation – logistical and psychological – faced by economically marginalized mothers trying to access supportive services.

Acknowledgments

There are no conflicts of interest to report. This work was supported by the National Institutes of Health (K23MH119047, SG). Data are available by request from the first author.

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