Paradoxical correlates of a facilitative parenting programme in prison—counter-productive intervention or first signs of responsible parenthood?
Abstract
Purpose Parenting programmes are rarely part of prisoners' rehabilitation, and evaluations of such programmes are lacking.
Methods The present mixed-methods study investigates the International Child Development Programme (ICDP) with 25 incarcerated fathers and a comparison group of 36 community fathers through questionnaires administered before and after parenting courses. Interviews with 20 incarcerated fathers were analysed using thematic analysis.
Results Before the course, the prison group self-reported better parenting skills and poorer psychosocial health than the comparison group. Both groups improved on parenting strategies. On several measures the comparison group improved, while the prison group revealed the same or lower scores. The incarcerated fathers described becoming more aware of their paternal role but also saw the course as emotionally challenging.
Conclusions Some of the self-reported scores of the prison participants related to parental skills and psychosocial health decreased from ‘before’ to ‘after’ ICDP sensitization, pointing to the possibility that the ICDP courses may have contributed to overcoming a ‘prisonization process’, where the prisoner identity overshadows the parental identity, by making them more aware of their parental responsibilities. Due to the emerging possibility of counter-productive influences, a randomized controlled study is needed in the future to ascertain the parenting and recidivism-related effects of this programme.
Keywords
Introduction
Research suggests that parenthood is important for incarcerated parents in their hope for, and expected, possible selves (Meek, 2011, p. 941). However, incarceration and separation from the family may imply less interaction with children and fewer possibilities for learning to adapt, resulting in parents with diminished emotional and physical well-being (Houck & Loper, 2002, p. 548). Identity, comprising a set of internalized meanings applied to the self in a social role or in a social situation (Burke & Tully, 1977, p. 883) may be affected by incarceration by interfering with prisoners' ability to conduct meaningful identity behaviours and carry out reflected appraisals (Burke, 1991, p. 840; Dyer, Pleck, & McBride, 2012, p. 34). This institutional-made process has been called ‘prisonization’ (Clemmer, 1940, p. 299, for an overview, see Dyer et al., 2012). The separation and inability to provide daily parental care are likely to make parents in prison repress or decrease the commitment to this part of their identity in order to reduce stress (Arditti, Smock, & Parkman, 2005). The prisoner role becomes most prominent, overshadowing other roles (Dyer, Wardle, & Day, 2004).
The lack of meaningful programmes deprives prisoners of prosocial and positive activities (Haney, 2003, p. 43). Through internalization of prison norms and reliance on the prison structure, prisoners' coping mechanisms may involve suspicion, interpersonal distrust, diminished sense of self-worth, emotional control, psychological distancing, alienation, and exploitative behaviour—which could translate into difficulties in organizing family life upon release (Haney, 2003, p. 41). Prisoners may find their behavioural and emotional stability threatened on the outside (Haney, 2003, p. 44), and they may experience displacement, rejection, and confusion about their family role (Hayes, 2009, p. 65), resulting in dysfunctional and even destructive behaviour (Haney, 2003, p. 47). Research emphasizes the importance of promoting family relationships and parental strategies in rehabilitation and adjustment after release (Couturier, 1995; Dowden & Andrews, 1999, p. 438; Farrington, 2009, pp. 629–631).
Parenting guidance is one recognized pathway to support the parental role of incarcerated parents. Most prison programme research has studied incarcerated mothers, yet studies suggest a greater course impact on incarcerated fathers on self-reported use of corporal punishment (Palusci, Crum, Bliss, & Bavolek, 2008, p. 86). Incarcerated fathers who followed parenting programmes show improved attitudes towards parenting (Harrison, 1997, p. 591), reduced parenting stress, increased empathic behaviour, and fewer problems with the child's behaviour (Landreth & Lobaugh, 1998, p. 164). However, such research is extremely limited (Purvis, 2011, p. 3), and several authors have pointed to a need for more research on the impact of incarceration on parenting and child development (e.g. Weiss & Sekula, 2008) and evaluations of parenting programmes for prisoners (e.g. Loper & Tuerk, 2006) to understand reintegration processes (Naser & La Vigne, 2006).
Most studies of parents in prison are from the United States or the United Kingdom and may not be generalizable to other countries. Approximately 0.6% of Norwegian children have an incarcerated parent (Hamsund & Sandvik, 2010, p. 5) compared to 2.3% in the USA (Glaze & Maruschak, 2008, p. 1), which may influence stigma related to incarceration (Anderson, 1999). In Norway, there is more emphasis on the father's role in parenting than in many other countries, exemplified by a parental leave policy which places equal responsibilities on fathers and mothers (Parrukoski & Lammi-Taskula, 2012, pp. 12–13; NAV, 2013). Fathers spend 1.38 hours a day on 0–6-year-old children, caregiving (Kitterød, 2012), compared to 1.04 hours a day in the USA (Parker & Wang, 2013). These differences in parenting policies and practices are likely to influence attitudes and family behaviour, as well as participation in and response to parenting programmes. There is thus a need for studies of parenting courses for incarcerated parents in countries with different family and prison policies, as well as a focus on wider inmate groups (Eddy, Powell, Szubka, McCool, & Kuntz, 2001, p. 61).
International Child Development Programme: a parenting sensitization programme
The International Child Development Programme (ICDP) is a preventive psychosocial early intervention programme designed to make caregivers more aware of their children's psychosocial needs and to increase their sensitivity, empathy, and response to these needs (Hundeide, 2001). The programme is based on psychological development research within a humanistic psychology framework, emphasizing the role of social interaction in children's development. The main aims are to support and promote caregivers' positive conceptions of their child and their emotional interactions (e.g. Bowlby, 1999), support caregivers in promoting their child's understanding of the world and their enculturation into society (e.g. Scaffer, 1996), and help parents regulate their child (e.g. Hoffman, 2000). These aims are formulated in three dialogues (emotion, comprehension, and regulation) and eight guidelines for good interaction illustrating these dialogues (Hundeide, 2001). ICDP courses are implemented in a group format including group discussions under the guidance of trained facilitators, caregiver assignments and discussing assignment experiences with the group, guided by trained ICDP facilitators (Hundeide, 2007).
The ICDP is used in about 30 countries, in co-operation with local organizations, Ministries, and organizations such as UNICEF and the World Health Organization, with emerging evaluations in different contexts (ICDP, 2013; Sherr, Skar, Clucas, von Tetzchner, & Hundeide, 2013). ICDP is implemented nationwide as a preventive measure in Norway by the Ministry of Children, Equality, and Social Inclusion. An adapted version has been used in some Norwegian prisons since 2005 in co-operation with the Correctional Service of Norway Staff Academy (KRUS, 2013) to support parents' meaningful involvement and interaction with the child during incarceration and prepare them for reintegration into the family. Adaptations allow for the basic ICDP course to incorporate topics about the purpose of prisoners' contact with their children and parental guidance in prisons, psychological reactions to separation, and practical aspects of running groups for parents in prison (Egebjerg & Flakk, 2006). About 55% of the prison population, approximately 3,624 persons (95% males), have children (Friestad & Hansen, 2004, p. 69; Statistics Norway, 2010) and are eligible for parental guidance (Stortingsmelding 37, 2007–2008, p. 169).
Aim and scope of the current study
The present study evaluates ICDP courses provided to a sample of fathers in prisons and a comparison sample of fathers following the ordinary community courses in Norway, using self-completed questionnaires before and after the course and qualitative interviews after the course. It was hypothesized that the two groups would differ somewhat before attending the programme, and that attendance would influence the fathers' parental identity, confidence as caregivers, perceived parenting behaviour, perception of and attitudes towards their child, and their relationship with the child.
Methods
Participants: recruitment and design
The present mixed methods study uses a ‘pre-test, post-test’ design with a comparison group, including a group of incarcerated fathers (n = 25) compared to community male attenders (n = 36). The study included natural groups and not controlled groups as in randomized controlled trials. Both groups completed questionnaires incorporating standardized scales of parenting and psychosocial health before and after the course. In addition, qualitative data were gathered utilizing a semi-structured interview to a subgroup of 20 incarcerated fathers.
Recruitment followed the set procedures in the prisons. Information was posted on the prison bulletin board, and prisoners who wanted to attend would apply, conditional upon them being a father with some child contact or expressing a wish to resume such a contact, with attendance availability considering scheduled releases or transfers. Fathers in the community were invited through bulletin board information in kindergartens and family centres. Six prisons were providing ICDP courses on a regular basis during the project period between October 2008 and March 2010, with an average of three groups with 87 fathers in total. During the same period, there were 71 community-wide ICDP courses with 134 fathers.
All male caregivers who participated in the community or prison ICDP programme were invited to participate in the non-compulsory evaluation study. They were informed about the evaluation by a researcher at the first group meeting, providing consent and distributing questionnaires. Sixty-three fathers (72.4% of male attenders) from ICDP groups in prisons and 66 fathers attending ICDP courses in the community (49.3% of male attenders) completed questionnaires before the course. Follow-up data were available from 25 fathers in the prison group and 36 in the comparison group. Only fathers who completed both questionnaires were included in the present analyses. Twenty prison-based fathers were selected for qualitative interview.
Measures
The questionnaires were constructed to document demographics, emotional and parenting issues, and the child's strengths and difficulties. If the fathers had more than one child, they were asked to base their answers on a focus child closest in age to four. The scales used are listed in Table 1.
| Measure | Description |
|---|---|
| Positive discipline | Seven positive discipline items were created based on the Parent-Child Conflict Tactics Scales (Straus, Hamby, Finkelhor, Moor, & Runyan, 1998): Praised them for achieving something on their own, Explaining a better alternative behaviour, I rewarded my child for behaving well, I congratulated my child for finishing a difficult task, I told my child I was proud of her/him, Gave them a hug because they made you happy, and I praised my child for making a good choice. The caregivers indicated how frequently they engaged in the behaviours (0, 1–2, 3–10, or more than 10 times). A summed score was created by adding mid-points for the response categories, ranging from 0 to 105. All the items loaded on one factor in a principal component analysis (PCA) at first and second completion. Cronbach's α was 0.84 at first and 0.88 at second completion. |
| Parenting strategy | Twelve items, scored on a Likert scale from 1 (strongly disagree) to 6 (strongly agree), measured parental strategies with a focus on the comprehensive dialogue in the ICDP (e.g. I expand my child's experiences, I help my child focus attention for mutual experience, I provide meaning for my child's experience, I take the initiative when I play with my child, I adjust to my child's focus and interests). The items loaded on one factor in a PCA at first and second completion and were treated as representing a scale named ‘Parenting strategies’. Negatively phrased items were reverse-coded with strong disagreement being attributed a score of 6, such that a higher score was always better. The summed score ranged from 5 to 30 (α was 0.71 at first and 0.91 at second completion). |
| Child management | Six items measuring ability and perception of child management, scored on a Likert scale from 1 (agree completely) to 5 (completely disagree). The items loaded on one factor in a PCA (α = 0.86 at pre and 0.67 at post) and were treated as representing a scale named ‘Child management’ (e.g. I trust my ability to take good care of my child, Even when angry I listen to my child), with a mean score that could range from 0 to 30. Negatively phrased items were reverse-coded with complete agreement being attributed a score of 1, such that a higher score was always better. |
| Emotional engagement with the child | Six bipolar items, scored in counterbalanced order from 1 to 7: 1: good–bad, 2: loving–unloving, 3: adjusting–directing, 4: talkative–non-talkative, 5: teaching–unengaged, 6: sensitive–insensitive. At pre, the items loaded on one factor in a principal component analysis, labelled emotional engagement (α = 0.89 at pre and α = 0.84 at post). A scale with mean scores that could range from 0 to 42 was therefore created. A higher score on the scale represented greater emotional engagement. |
| Health and quality of life (Ware, Snow, Kosinski, & Gandek, 1993) | Two SF-36 VAS scales for health and quality of life were used, scored 0 on the extreme left and 100 on the extreme right. |
| The Satisfaction with Life Scale (Diener, Emmons, Larsen, & Griffin, 1985) | Five statements scored from 1 (disagree completely) to 7 (strongly agree). The summed score could range from 5 to 35. Cronbach's α was 0.88 at pre and α = 0.87 at post. |
| The Generalized Self-Efficacy Scale (Schwarzer & Jerusalem, 1995) | Ten items scored from 1 (not at all true) to 4 (exactly true). The summed score could range from 10 to 40. A higher score represents greater self-efficacy. Cronbach's α was 0.90 at pre and α = 0.90 at post. |
| The Basic Emotion Trait Test (BETT) (Vittersø, Dyrdal, & Røysamb, 2005) | Fifteen items, three for each of the five basic emotions (Pleasure, Explore, Anger, Fear and Sadness). Each item is scored from 1 (never) to 7 (all the time). The Pleasure, Sadness, and Fear subscales had good inter-item reliability (α = 0.88 at pre and α = 0.94 at post for Pleasure; α = 0.95 at pre and α = 0.91 at post for Sadness; and α = 0.85 at pre and α = 0.81 at post for Fear) and were therefore used with their original set of items. The Anger and Explore subscales did not have good inter-item reliability, and their results are therefore not reported. A negative emotions mean score (α = 0.91 at pre and α = 0.72) was also calculated. A positive emotions mean score was not calculated because of low inter-item reliability at post (α = 0.89 at pre and α = 0.27 at post). |
| The Hospital Anxiety and Depression Scale (HADS) (Zigmond & Snaith, 1983) | Seven anxiety and seven depression items, scored from 0 (not at all) to 3 (very often, most of the time, definitely, very much). Two summed scores were created, one for anxiety (α = 0.83 at pre and α = 0.83 at post) and one for depression (α = 0.79 at pre and α = 0.81 at post), each scored from 0 to 21. |
| The Strength and Difficulties Questionnaire (SDQ) (Goodman, 1999) | A behavioural screening questionnaire about the child, consisting of five subscales (Emotional symptoms, Conduct problems, Hyperactivity, Peer problems, Prosocial) and an impact supplement assessing whether the respondent thinks the child has a problem, and if so, assesses chronicity, distress, social impairment, and burden to others. Three scores were generated: total difficulties score (the sum of items from the first four subscales, α = 0.80 at pre and α = 0.81 at post), a prosocial score (the sum of items from the prosocial subscale, α = 0.75 at pre and α = 0.72 at post), and an impact score (derived from questions on overall distress and social impairment from the impact supplement). |
The open-ended qualitative interview dialogue with incarcerated fathers was informed by a flexible interview guide (Kvale, 1996, p. 129–132). This started with an open-ended question about participation followed by a series of questions on content, implementation, potential benefits, and recommendations for improvements.
Procedure
The procedures were explained thoroughly, and information sheets were provided to all participants. Consent was both oral and written. The study was approved by the Regional Committee for Medical and Health Research Ethics, the Norwegian Social Science Data Services, and the Norwegian Correctional Services with the possibility for referral if needed (in the event no referrals were necessary). The questionnaires were completed before and after the ICDP course.
The qualitative interviews took place within one week of the last group meeting. The fathers were interviewed by the first author in the ICDP meetings room or in the prison's visiting room. The interview guide was used flexibly to allow for exploration of responses and unanticipated answers. The interviews lasted on average for 30.4 minutes (range 13–60 minutes).
Programme delivery
The ICDP programme consisted of 10 two-hour group meetings. In three of the six prisons, the course was supplemented with visitation rights between group meetings, including overnight visits, with trips to a cabin or allowing father and child(ren) the use of a visiting house in the prison area. In the prisons where father–child contact was possible, the courses also included caregiver assignments later discussed in the group. The comparison group followed the regular ICDP course, without the additional content specifically tailored to the prison group.
Analysis
Chi-square and independent samples t tests were used to compare fathers who completed both questionnaires with fathers who only completed the first questionnaire, as well as the prison group and the comparison group. Paired samples t tests were carried out to investigate whether each group changed significantly from ‘before’ to ‘after’ the ICDP course. A 2 (group: prison/comparison) × 2 (time: before/after) mixed ANOVA with repeated measures was used to compare the changes in the prison group and the comparison group. A significant interaction indicates different patterns of score change in the two groups or that the group difference before the course was significantly different from the group difference after the course. Significant ANOVA interactions were followed up with independent samples t tests after the course.
The interviews were transcribed verbatim to capture the contextual features of the interviews, using a transcription program (HyperTranscribe, 2013) before being imported into a qualitative analysis program (NVivo, 2008) for sorting and data organization. The interviews were read and re-read to obtain a full and coherent sense of the interview discourse (Holloway, 1997). The procedures for coding and analysing the interviews followed the recommendations of Pratt (2009, p. 857–861). A thematic analysis approach was utilized where the data were sorted into categories and themes (Braun & Clarke, 2006) and higher-order themes were generated to organize the emerging concepts. Credibility checks of the categories and themes were made by a second analyst to guard against biases (Elliott, Fischer, & Rennie, 1999, p. 222). Interview excerpts were checked and modified so that the interviewees cannot be identified.
Results
Baseline comparisons of completers and non-completers
There were no significant differences between the backgrounds of fathers in the prison and community group who completed both questionnaires and those who completed the first questionnaire only, but prison completers were less emotionally engaged with their child than prison non-completers (M = 31.79 versus 36.73, t = − 2.59, P = 0.013), and community completers reported a higher SDQ (Strength and Difficulties Questionnaire) impact score than community non-completers (M = 0.85 versus 0.25, t = 2.08, P = 0.042).
Incarcerated fathers compared to community fathers
The incarcerated fathers were on average 37 years old (SD 7.18, range 23–48). They had 2.1 children (SD 1.27, range 1–5), and the focus child had an average age of 6.4 years (SD 4.39, range 2–15). They had an average of 2.67 persons in the home (SD 2.31, range 0–8). The comparison fathers were on the average 38 years old (SD 6.15, range 27–60). They had 2.0 children (SD 1.08, range 1–6), and the focus child had an average age of 5.1 years (SD 3.93, range 0.5–16). They had an average of 3.2 people in the home (SD 1.37, range 1–6). The groups did not differ significantly on any of these variables.
Table 2 shows background information for both groups. Compared to the community group, the fathers in the prison group were significantly less likely to be married or with a partner (56.0% versus 80.6%), to have full-time employment (prior to sentencing) (48.0% versus 86.1%), and to have higher education (16.0% versus 69.4 %). The groups did not differ on gender of the focus child or place of birth.
| Prison group (n = 25) | Comparison group (n = 36) | |||||
|---|---|---|---|---|---|---|
| Categorical variables | n | % | n | % | Chi-square | P |
| aFisher's exact test. | ||||||
| Born in Norway | 2.88a | 0.142 | ||||
| Yes | 19 | 76 | 33 | 91.7 | ||
| No | 6 | 24 | 3 | 8.3 | ||
| Education | 16.90 | < 0.001* | ||||
| No higher education | 21 | 84 | 11 | 30.6 | ||
| Higher education | 4 | 16 | 25 | 69.4 | ||
| Employment | 10.72 | 0.001* | ||||
| Full time | 12 | 48 | 31 | 86.1 | ||
| Not full time | 12 | 48 | 4 | 11.1 | ||
| Missing | 1 | 4 | 1 | 2.8 | ||
| Civil status | 4.33 | 0.037* | ||||
| Married/partner | 14 | 56 | 29 | 80.6 | ||
| Separated/divorced/widower/single | 10 | 40 | 6 | 16.7 | ||
| Missing | 1 | 4 | 1 | 2.8 | ||
| Gender of focus child | 1.16 | 0.282 | ||||
| Male | 9 | 36 | 16 | 44.4 | ||
| Female | 4 | 16 | 15 | 41.7 | ||
| Missing | 12 | 48 | 5 | 13.9 | ||
The interviewed fathers
The 20 incarcerated fathers who were interviewed were aged 27 to 45 years and had an average of two children (range 1–7). Thirteen fathers were ethnic Norwegians, one was born in another European country, one in America, and five in three different Asian countries. Most of the fathers in prison had an unstable family situation, including repeat incarcerations. Various relationship types were described, including marriage, remarriage, single, shared custody, and sporadic child contact.
Imprisonment itself affected relationships, triggering separations, interruptions, or potential divorces. Visitation varied from regular contact to infrequent contact, and three had no family visits in prison. In the interviews, some of the prisoners reported fatherhood and incarceration as a turning-point that made them want to give up delinquency. The separation from their children, and for many a perceived threat of losing them more permanently, may have influenced the fathers' motivation. However, the criminal life-style and associated problems inside the prison represented a challenge for being a responsible father: ‘It is a tough environment […], drugs everywhere, and when you come in here, it is all about talking about what you will do [criminal behaviour] when you are released’ (father 3).
Parenting
Table 3 shows that the prison group scored significantly higher than the comparison group on child management before attending ICDP (M = 26.90 versus 23.40), and the effect size was high (Cohen, 1992). Both the prison and the comparison group changed significantly on the parenting strategy scale (M = 22.08 and 23.17 versus 20.97 and 22.53), and effect sizes were moderate, indicating improved parenting strategies after the course (Table 3). Only the comparison group showed significant change after the course with higher emotional engagement (M = 30.12 and 32.84) and more positive discipline (M = 32.26 and 39.54), and effect sizes were high to moderate.
| Before ICDP | Group changes from ‘before’ to ‘after’ course | Interactions | ||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Measure | n | M | SD | t | P | Cohen's d | n | M | SD | M | SD | t | P | Cohen's d | F | P | ηp2 | |
| Note: Because the fathers tended to miss a few items, the scores used to calculate change within each group are slightly different from scores used to calculate the group differences. | ||||||||||||||||||
| P = significance level (* ≤ 0.05); Cohen's d = effect size; F = ANOVA, interaction between group and time, measuring the difference in change scores between the two groups; ηp2 = effect size. | ||||||||||||||||||
| Emotional engagement | Prison | 19 | 31.79 | 8.10 | − 0.51 | 0.613 | − 0.14 | 17 | 31.12 | 8.28 | 33.59 | 6.19 | − 0.96 | 0.350 | 0.34 | 0.01 | 0.914 | 0.00 |
| Comparison | 28 | 30.75 | 5.92 | 25 | 30.12 | 5.87 | 32.84 | 3.45 | − 3.55 | 0.002* | − 0.56 | |||||||
| Child management | Prison | 21 | 26.90 | 2.45 | − 3.15 | 0.003* | − 0.91 | 17 | 27.06 | 2.16 | 26.18 | 2.24 | 2.15 | 0.047* | 0.40 | 8.72 | 0.005* | 0.19 |
| Comparison | 25 | 23.40 | 4.87 | 22 | 22.86 | 4.88 | 24.95 | 3.05 | − 2.54 | 0.019* | − 0.51 | |||||||
| Parenting strategy | Prison | 14 | 22.29 | 2.05 | 1.4 | 0.169 | − 0.49 | 12 | 22.08 | 2.07 | 23.17 | 1.53 | − 2.60 | 0.025* | − 0.60 | 0.51 | 0.478 | 0.01 |
| Comparison | 30 | 20.97 | 3.22 | 30 | 20.97 | 3.22 | 22.53 | 2.57 | − 4.00 | < 0.001* | − 0.55 | |||||||
| Positive discipline | Prison | 13 | 34.08 | 17.06 | 0.31 | 0.760 | 0.10 | 10 | 38.70 | 16.43 | 28.95 | 10.95 | 1.81 | 0.104 | 0.70 | 6.14 | 0.019* | 0.17 |
| Comparison | 30 | 35.95 | 18.81 | 23 | 32.26 | 18.12 | 39.54 | 20.01 | 2.25 | 0.035* | − 0.38 | |||||||
The interaction indicated different change patterns on child management in the two groups, with an increase in the comparison group and a decrease in the prison group (F = 8.72, P = 0.005, ηp2 = 0.19). Furthermore, a significant interaction effect on positive discipline (F = 6.14, P = 0.019, ηp2 = 0.17) reflects a reduction in the frequency of positive discipline in the prison group and an increase in the comparison group (Table 3). Follow-up analyses showed that there were no significant differences between the prison and comparison groups after the ICDP course on child management (M = 26.05 versus 25.03, t = − 1.26, P = 0.214) and positive discipline (M = 43.29 versus 37.79, t = − 0.70, P = 0.491).
Interview themes on parenting—prison fathers
An enabling opportunity
The prison fathers described that the constraints of the prison environment reduced their possibilities for being a father, and commented positively upon the ICDP groups to talk about their children: ‘This was the best service I have ever received from the prison’ (father 2). Another father said: ‘My children appreciate it as well […] and my oldest daughter said to me “daddy, you have changed a lot”. And it was nice to hear that from her’ (father 12).
Parenting skills
Several fathers said that they gave higher priority to their children after they started to attend the ICDP course, for example over previously dominating discussions of practical issues, and the course had helped them to organize the visit and initiate joint activities, evidencing higher parental confidence and emotional presence as well as improved parental strategies.
Overcoming secrecy and fostering openness
Some fathers had not told their children that they were in prison, and others had lied about the reasons for incarceration. One father said: ‘The youngest one, he didn't know I was in prison. For 10, 11 months, I was in custody in [name of town], and we lied, didn't tell him the truth, said that I worked here and things like that’ (father 6). Their stories suggest that the secrecy sometimes increased the actual separation from the child(ren) and that the fathers had received support from the ICDP group to be more open and honest about their imprisonment. One serving a several years long sentence had told his children that he had moved to his country of birth and thus did not have any visits by his children. Another father reported that his children had thought he had remarried and did not want to be with them, and how relieved they were when he told them the truth. They understood that their father wanted to but could not be with them.
Others said they had become more open about their feelings when communicating with their child, and for some this resulted in more positive child regulation.
… Last year, if she [teenage daughter] had done anything wrong, I would be angry at her without explaining what is right and what is wrong. But I started this course and something happened. I was on leave and bought a pack of cigarettes, and went out to smoke, and my wife put it in the cupboard. When my wife was out, she [daughter] took a cigarette and smoked it. […] When she came here visiting, she said ‘sorry’, and I said, ‘it is okay. You are not allowed to smoke, but I understand’. First she thought I would hit or beat her or something, and was very scared. (father 12)
This suggests improvements related to comprehension, through helping the child to make sense of her/his world, and improvements related to regulation, with positive ways of helping the child to learn limits.
Child's strengths and difficulties and fathers' psychosocial functioning
Table 4 shows that, before the course, the prison group gave significantly higher scores than the comparison group on child prosocial behaviour (M = 8.19 versus 6.90), lower scores on pleasure (M = 4.07 versus 4.80), life quality (M = 64.79 versus 74.43), and life satisfaction (M = 19.76 versus 23.68), and higher scores on sadness (M = 2.98 versus 2.20), anxiety (M = 8.00 versus 5.82), and depression (M = 6.48 versus 3.85). Effect sizes were moderate.
| Before ICDP | Group changes from ‘before’ to ‘after’ course | Interactions | ||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Measure | n | M | SD | t | P | Cohen's d | n | M | SD | M | SD | t | P | Cohen's d | F | P | ηp2 | |
| Note: Because the fathers tended to miss a few items, the scores used to calculate change within each group are slightly different from scores used to calculate the group differences. | ||||||||||||||||||
| P = significance level (* ≤ 0.05); Cohen's d = effect size; F = ANOVA, interaction between group and time, measuring the difference in change scores between the two groups; ηp2 = effect size. | ||||||||||||||||||
| SDQ prosocial score | Prison | 21 | 8.19 | 1.4 | 2.51 | 0.016* | − 0.68 | 18 | 8.22 | 1.52 | 8.06 | 1.47 | 0.34 | 0.740 | 0.11 | 0.12 | 0.731 | 0.00 |
| Comparison | 31 | 6.90 | 2.30 | 31 | 6.90 | 2.30 | 6.94 | 2.31 | − 0.10 | 0.923 | − 0.02 | |||||||
| SDQ total difficulties | Prison | 16 | 8.88 | 6.67 | 0.51 | 0.610 | − 0.15 | 15 | 9.07 | 6.86 | 8.93 | 5.27 | 1.15 | 0.270 | 0.02 | 0.15 | 0.704 | 0.00 |
| Comparison | 31 | 9.77 | 5.13 | 30 | 9.70 | 5.20 | 10.23 | 5.54 | 1.62 | 0.117 | − 0.10 | |||||||
| SDQ impact score | Prison | 23 | 0.65 | 1.67 | 0.47 | 0.638 | − 0.13 | 16 | 0.94 | 1.95 | 0.56 | 1.55 | 1.15 | 0.270 | 0.22 | 0.00 | 0.976 | 0.00 |
| Comparison | 34 | 0.85 | 1.50 | 31 | 0.74 | 1.24 | 0.35 | 1.08 | 1.62 | 0.117 | 0.34 | |||||||
| Negative emotions | Prison | 21 | 2.90 | 1.11 | 1.12 | 0.266 | − 0.29 | 19 | 2.95 | 1.16 | 3.47 | 1.19 | − 1.82 | 0.085 | 0.44 | 7.38 | 0.009* | 0.13 |
| Comparison | 35 | 2.61 | 0.86 | 34 | 2.64 | 0.85 | 2.47 | 0.87 | 1.62 | 0.116 | 0.20 | |||||||
| Pleasure | Prison | 23 | 4.07 | 1.32 | 2.49 | 0.016* | − 0.64 | 19 | 4.07 | 1.43 | 3.91 | 1.09 | 0.71 | 0.485 | 0.13 | 1.33 | 0.254 | 0.03 |
| Comparison | 35 | 4.80 | 0.91 | 35 | 4.80 | 0.91 | 4.87 | 0.96 | − 0.84 | 0.407 | − 0.07 | |||||||
| Sadness | Prison | 22 | 2.98 | 1.55 | − 2.33 | 0.024 | 0.60 | 20 | 3.12 | 1.56 | 3.62 | 1.43 | − 1.40 | 0.177 | − 0.33 | 2.52 | 0.118 | 0.05 |
| Comparison | 35 | 2.20 | 1.00 | 34 | 2.24 | 0.99 | 2.22 | 1.03 | 0.14 | 0.889 | 0.02 | |||||||
| Fear | Prison | 23 | 2.52 | 1.17 | − 0.69 | 0.495 | 0.19 | 19 | 2.58 | 1.12 | 3.68 | 1.68 | − 3.33 | 0.004* | − 0.77 | 2.14 | 0.150 | 0.04 |
| Comparison | 35 | 2.32 | 0.95 | 34 | 2.34 | 0.97 | 2.99 | 1.28 | − 4.49 | < 0.001 | − 0.57 | |||||||
| Health | Prison | 24 | 75.42 | 17.13 | − 1.72 | 0.090 | 0.45 | 19 | 73.95 | 16.71 | 53.63 | 28.46 | 3.11 | 0.006* | 0.87 | 8.46 | 0.005* | 0.14 |
| Comparison | 35 | 82.29 | 13.47 | 34 | 81.76 | 13.31 | 77.50 | 16.48 | 2.18 | 0.037* | 0.28 | |||||||
| Life quality | Prison | 24 | 64.79 | 21.69 | − 2.04 | 0.046* | 0.52 | 19 | 65.53 | 23.68 | 39.11 | 26.38 | 3.30 | 0.004* | 1.05 | 21.11 | < 0.001* | 0.29 |
| Comparison | 35 | 74.43 | 14.59 | 34 | 73.97 | 14.55 | 77.50 | 12.87 | − 1.77 | 0.086 | − 0.26 | |||||||
| Life satisfaction | Prison | 21 | 19.76 | 7.84 | − 2.09 | 0.041* | 0.56 | 18 | 20.00 | 7.10 | 15.83 | 5.35 | 2.79 | 0.012* | 0.66 | 13.72 | 0.001* | 0.22 |
| Comparison | 34 | 23.68 | 5.99 | 32 | 23.50 | 6.14 | 24.19 | 5.59 | − 1.32 | 0.196 | − 0.12 | |||||||
| Self-efficacy | Prison | 22 | 29.64 | 7.05 | − 0.35 | 0.730 | 0.09 | 19 | 29.32 | 7.29 | 29.11 | 6.69 | 0.15 | 0.879 | 0.03 | 0.86 | 0.359 | 0.02 |
| Comparison | 34 | 29.09 | 4.78 | 33 | 29.03 | 4.84 | 31.03 | 4.99 | − 3.73 | 0.001* | − 0.41 | |||||||
| Anxiety | Prison | 22 | 8.00 | 4.08 | 2.19 | 0.033* | − 0.59 | 17 | 7.65 | 3.48 | 8.41 | 3.74 | − 1.14 | 0.272 | − 0.21 | 10.75 | 0.002* | 0.19 |
| Comparison | 33 | 5.82 | 3.27 | 31 | 5.84 | 3.36 | 4.39 | 2.89 | 4.27 | < 0.001* | 0.46 | |||||||
| Depression | Prison | 23 | 6.48 | 4.87 | 2.39 | 0.023* | − 0.68 | 20 | 6.40 | 5.16 | 6.70 | 4.93 | − 0.43 | 0.670 | − 0.06 | 0.010 | 0.922 | 0.00 |
| Comparison | 33 | 3.85 | 2.43 | 33 | 3.85 | 2.43 | 4.21 | 2.69 | − 1.29 | 0.206 | − 0.14 | |||||||
Table 4 also shows that neither the prison group nor the comparison group changed significantly on negative emotions from ‘before’ to ‘after’ the ICDP course, although a significant interaction effect of group and time on negative emotions (F = 7.38, P = 0.009, ηp2 = 0.13) shows that the difference in change between the two groups was significant. Both the prison group and comparison group scored significantly higher on fear (M = 2.58 and 3.68 versus 2.34 and 2.99) and lower on health after the course (M = 73.95 and 53.63 versus 81.76 and 77.50). A significant interaction effect of group and time on health (F = 8.46, P = 0.005, ηp2 = 0.14) shows that the decline in health was more pronounced in the prison group. The effect sizes were high for both groups for fear but high for the prison group and low for the comparison group for health. The prison group scored significantly lower after than before the course on both life quality (M = 65.53 and 39.11) and life satisfaction (M = 20.00 and 15.83) and effect sizes were medium and high, whereas the scores of the comparison group increased and approached significance for life quality (M = 73.97 and 77.50) and did not change significantly for life satisfaction. This was reflected in significant interaction effects on quality of life (F = 21.11, P < 0.001, ηp2 = 0.29) and life satisfaction (F = 13.72, P = 0.001, ηp2 = 0.22). The comparison group scored significantly higher on self-efficacy (M = 29.03 and 31.03) and lower on anxiety after the course (M = 5.84 and 4.39) and the effect sizes were small to moderate, whereas the prison group did not change significantly for self-effiacacy and showed a non-significant increase in anxiety scores (M = 7.65 and 8.41). This was also reflected in a significant interaction effect on anxiety (F = 10.75, P = 0.002, ηp2 = 0.19) (Table 4).
Follow-up analyses show that the prison group continued to score significantly higher than the comparison group after the ICDP course on child prosocial behaviour (M = 8.15 versus 6.94, t = 2.40, P = 0.020), higher on negative emotions (M = 3.48 versus 2.48, t = 3.80, P < 0.001) and sadness (M = 3.56 versus 2.24, t = 3.88, P < 0.001), lower on pleasure (M = 3.80 versus 4.87, t = 3.71, P < 0.001), health (M = 53.95 versus 77.86, t = − 3.52, P = 0.002), life quality (M = 39.15 versus 77.86, t = − 6.31, P < 0.001), and life satisfaction (M = 16.27 versus 24.32, t = − 5.55, P < 0.001), and higher on anxiety (M = 7.70 versus 4.32, t = 3.34, P = 0.002).
Interview themes on psychosocial functioning—prison fathers
Changes in their children
In the interviews, some fathers reported noticeable changes in their child(ren) due to the imprisonment and separation, and that the increased father–child contact that was part of the ICDP course had led to improved mental health in the child. One father said:
She [daughter] started to be like emotionally disturbed at school, and hit her little brother and was sick a lot and things like that. […] They [doctors] said it was because I was in jail, which makes her this way, or ill, psychologically. But after these trips [with the group] I notice that she is getting better. And that is positive. (father 5)
Growth of insight
According to some fathers, the programme opened up fields of knowledge that they had lacked in their parenting repertoire, motivating them to make a bigger effort in parenting. Some realized that they had failed to regulate their child's emotions and behaviour before they were incarcerated, and gave examples of prior parenting practices that they in retrospect realized had not been optimal.
We had shared custody, right, she had him one week, and had just implemented routines, put him to bed at the right time and got him up in the morning, right. And then he came to me and we slept until lunch, and yeah… So … Because he is so spoiled, it is incredible. Five years old, and he's got a lap-top, x-box, PlayStation and… But … I didn't think there and then, you know. It didn't matter, right. Now I think that maybe it wasn't that good. (father 20)
Another father said:
I have given him everything. … Because I didn't want to see him cry. […] But after the course I have learned that you should have some limits. (father 11)
For some, the new awareness of their father role also changed the way they related to the child's mother and other adults: ‘I will need to work up more confidence before I get approval from her [to meet the child], and I just need to think of it as positive that the mother is sceptical. Then I know that at least the kid is fine’ (father 4).
Emotional concerns
Increased awareness and knowledge about children and their management sometimes led to more concerns. Some found being in prison harder after they had become fathers. One said: ‘It gets tougher. There are many more concerns, more thoughts. Before you had only yourself to focus on, and then you blocked the world out, closed’ (father 19). Some told about feelings of uselessness, not being needed and lack of involvement in the everyday care of their child(ren). The fathers were generally afraid to be left out of the family, being deprived of information and losing their child(ren), stating: ‘I'm scared to death to be forgotten’ (father 15); ‘I don't know what is going on. What they tell me is just what they choose to tell me, right’ (father 20). Other worries were linked to fears of deportation, guilt at their absence and separation. These experiences led to a feeling of dehumanization: ‘We are only prisoners. We are only a number in the queue’ (father 10). Following the ICDP course, they reported reduced experiences of dehumanization and enhanced ability to feel human, with strengthened relationships with ICDP facilitators/prison officers: ‘This concept [ICDP] is really good. It's unique. They [ICDP facilitators] take care of us in such a good way, I can't even believe it. […]. You can be yourself here, quite simply. Even if you are in the position that you are… we are also humans, despite what we have done’ (father 52).
These rather paradoxical impacts of the programme were described by the continuation from this father, whose narrative clearly demonstrates how the course made him more conscious and thereby increased negative emotions but at the same time motivated him to take an active stance.
It is hard. Really hard [cries a little, sniffle]. The group was very good. To be able to talk about absolutely everything. […] I need to do, so much… And I also have a lot myself that I am thinking about, things that I need to do for myself and things I need to do for the child, in order to be a good father. This will be the most important for me now. […] So I have started with treatment…. I have my own psychiatrist and substance abuse consultant. […] I can do it! This is my only goal now. To do this and give her [daughter] a safe … [sniffles again] childhood, and a good father. (father 52)
Visitation and implementation of learning
Many of the incarcerated fathers had few or no possibilities for trying out what they had learned. Visiting conditions were important, and visits in the prison visiting room were often hampered or avoided as a result of the poor quality of these facilities.
Many expressed a desire for longer-term follow-up, while some argued that they would have needed the course at an earlier stage when they became a father for the first time, and one said: ‘It is crucial. Then I would have been a total different father, and my children would have another life’ (father 61).
Discussion
Main findings
Nearly all of the incarcerated fathers in the present study had lived with their children prior to imprisonment and expected to continue to live with them on release. Some had been stable caregivers prior to imprisonment, but most described a pre-prison life-style characterized by crime, drugs, and instability. Yet, paradoxically the self-reported scores of the incarcerated fathers before attending the ICDP course indicate that they had a more positive image of themselves as fathers than the fathers in the community group, with better self-rated child management skills. These group differences narrowed after the course because the scores decreased in the prison group and increased in the comparison group, probably reflecting more realistic appraising. This suggests that the fathers in the comparison group believed that they had become more competent in their parenting after the ICDP course, while the scores of the incarcerated fathers, supplemented by the interviews, suggest that they had become more realistic and aware of how they had filled their father role. Other studies have found that incarcerated fathers may have unrealistic, ambiguous, and unclear ideas about their relationships with their spouses and children (Day, Acock, Bahr, & Arditti, 2005, p. 183), and that they may be ‘faking good’ through unrealistically high self-images in their self-reports (Frye & Dave, 2008, p. 105; Shamai & Kochal, 2008). This may be a way of protecting the self and hence reflect the importance they attributed to being a good father. Due to a prisonization process (Haney, 2003), where the incarcerated fathers might have internalized prison norms as a coping mechanism, they may have suppressed their father role. From the perspective of identity theory, this would imply that the incarcerated fathers strived to verify a positive identity, and the lower commitment may have made them less able to see how their delinquency and incarceration affected the child (cf. Dyer, Pleck, & McBride, 2012, p. 35). The ICDP course may have ‘opened their eyes’, interfered with the process of ‘prisonization’ by transcending the singular identity as ‘a prisoner’, and made them more realistic towards some aspects of their paternal role. The hypothesis of empowerment is consistent with the fact that the scores indicated positive changes in parenting strategies, which also was apparent in the interviews.
In the interviews, the ICDP groups were positively endorsed, with high demand for the courses, appreciation of the content, and endorsement of the increased visiting benefits. Meaningful interaction in prison is of importance, and the opportunity to talk about these sensitive issues was valued. The importance of supporting meaningful inmate–prison officer relationships has also been addressed in previous research (e.g. Shamai & Kochal, 2008, p. 337) and been found related to less anxiety, depression, and hopelessness of the incarcerated (Biggam & Power, 1997). Some fathers reported increased awareness related to their relationship with the mother of the child. Lange (2001, p. 10) found that the relationships between incarcerated fathers and their child(ren)'s mothers were characterized by mistrust, confrontation, and threats. Through intervention, the fathers in Lange's study learned more positive and constructive ways of communicating with the mother. This suggests that parental guidance can influence co-parenting among incarcerated parents.
The incarcerated fathers also said that they felt better able to initiate and organize activities during family visits after the ICDP course. This is important, as studies suggest that difficult visitation experiences may have long-lasting traumatic effects on children (Arditti, 2012, p. 193). Some fathers said that they noticed changes in their relationship with the child, as well as in the child, which may be explained by more active parenting and more open father–child communication. Several fathers reported that they had become more open in communication with their children, including giving them true information about their own imprisonment. Studies suggest that inadequate explanations to children may increase the negative effects of parental incarceration (Murray, Farrington, & Sekol, 2012, p. 178). Some also expressed increased awareness related to regulation of the child. Data from a Norwegian population study have shown that poor parental monitoring is predicting crime development in children; hence this change could have a positive impact of their children's risk of delinquency (Pedersen, 2000, p. 87).
It is not surprising, given their imprisonment and difficult life situation, that the prison group before the course reported lower well-being, quality of life, and life satisfaction, and more negative emotions, depression, and anxiety than the comparison group. It was clear from the interviews that the separation from the family because of imprisonment was a psychological strain on all the fathers. In line with previous research (e.g. Arditti, Smock, & Parkman, 2005, p. 288), the fathers in the present study reported that they often felt powerless and that their status as incarcerated represented a barrier to parenting. The ICDP course supported the incarcerated fathers' concept of being important persons in their child's life, increasing parenting motivation, awareness, and knowledge. For some this represented a reappraisal of the meaning of fatherhood which on the one hand enlightened and empowered them, and, on the other, opened up for negative emotions related to conscience, anxiety, and longing. Whereas the comparison group had the same or better scores after the course on measures of mental health and psychosocial measures, the prison group generally scored lower, and the fathers in the prison group continued to score lower on mental health and psychosocial functioning despite attending the ICDP course. Greater awareness of their presumed lack of attention to the psychological needs of the child and on the negative consequences of being in prison may have evoked negative emotions and feelings of guilt in the fathers. This might have resulted in a decrease in their well-being scores, but also perhaps a positive step regarding the theoretical protective factors associated with guilt and subsequent empathy and lower levels of externalization of blame and hostility, compared to less guilt-prone prisoners (Tangney, Stuewig, Mashek, & Hastings, 2011, p. 722).
Study limitations
The study employed a pragmatic research design, which seeks to incorporate the strength of both quantitative and qualitative methods (Onwuegbuzie & Leech, 2005, p. 385), which might decrease some of the general methodological limitations when using singular methods (Victora, Habicht, & Bryce, 2004). The implementation was addressed in addition to the impact of the course on the participants, which may give a more thorough understanding of the programme's accomplishments and how the programme can be improved (Lin, 2000). However, the present study did not use a randomized controlled methodology and did not include a prison control group, and is therefore not an effects study. This makes conclusions about change being due to the ICDP course difficult as the changes in the prison group compared to the community group may have been caused by other time-related trajectories related to the prison environment. As measures of global/general perceptions of quality of life and health, the VAS scale may be sensitive to response bias. However, these measures have been validated, and there is also a significant effect of life satisfaction as well as a trend for negative emotions increasing. Furthermore, the study used self-reported measures only, which limits the objective assessment of the effectiveness of ICDP in the present samples. The item content of many of the scales was quite psychological-minded (e.g. ‘I provide meaning for my child's experience’). Given that educational level probably is related to people's ability to respond accurately to such questions, it should be noted that the prison group was considerably less educated than the community group, which might account for some of the group differences. Furthermore, the prison group contained several fathers from non-Western countries, and the questions may have been culturally biased against this group. The sample size was rather small in the questionnaire study. For the qualitative data, concept saturation was reached indicating adequate sampling. The results may be generalizable to other incarcerated fathers attending ICDP courses; however, the fathers who completed both questionnaires had lower engagement scores than those who did not complete the second questionnaire, which might imply that many of the fathers who most needed parenting guidance stayed in the study—maybe also in the course. It is possible that the extra visiting benefits received in some of the prisons influenced the results through supporting meaningful interaction and hence parental identity. A prison comparison group was initially recruited but was unavailable for study at follow-up, revealing the challenges of research in this context as a result of access limitations, frequent transfers, and discharges. Finally, a large number of statistical analyses increases the chance of type 1 errors, although the small sample size may have given the study less power to detect statistically significant differences.
Policy and research implications
The current study was exploratory and tentative and may have implications for policy and future research related to the rehabilitation of prisoners. The results reflecting declined scores on parenting, health, quality of life, and life satisfaction suggest that certain adaptations should be made when implementing the ICDP programme in a prison context. For example, previous research points to a need for activity-based approaches (Salas & Cannon-Bowers, 2001, p. 482) and adapted material (Purvis, 2011, p. 17), suggesting that future implementation of the ICDP in prisons should strive to adjust for parent–child interaction and practices of new skills between the group meetings, and prison-adjusted ICDP manuals should be made. Incarceration is negatively associated with the father's ability to co-parent, share responsibilities in parenting, and be engaged (Turney & Wildeman, 2013, p. 21), as well as negatively related to the likelihood of marriage (Huebner, 2005). An ICDP manual for prisons should have an increased focus on co-parent co-operation and communication (Lange, 2001), and the challenges of distant parent–child relationships need to be targeted. Furthermore, based on the current findings, future courses should also address psychosocial health issues. Parenting courses should take into account reduced recidivism (Cullen, Jonson, & Nagin, 2011), the importance of family ties in the process of rehabilitation, skills for re-entry and transition, and resuming roles as parents (Haney, 2003, p. 58)—which may be needed after release as well (Haney, 2003, p. 59). Courses after release might mix offenders and non-offenders as this could reduce the probability of reoffending (Minke, 2011).
In the present study, it is not possible to conclude that changes in scores from ‘before’ to ‘after’ the ICDP course were due to the programme itself, and not to the passage of time or environmental events not related to course attendance. Randomized controlled trials are necessary to ascertain the true effects of the programme, for example to study more explicitly whether the ICDP serves as a useful tool in the rehabilitation programme for incarcerated parents and assist in preparing for the daily caregiving responsibilities through increased awareness, knowledge, and strengthened parental identities, or whether the programme reduces the parenting skills and psychosocial health of incarcerated parents in the long run. The present difficulties following up the incarcerated fathers are similar to the problems reported in other studies (Eddy et al., 2001, p. 61). Co-operation between prisons for follow-up may be one way of increasing participation in future studies, and another intervention than parenting courses might make it easier to retain a prison comparison group. Norway is a rather small country with a small prison population, and a long-term randomized controlled trial that included the majority of long-term incarcerated parents would add valuable information about the long-term individual and socio-economic effects of parental education when compared with register-based outcome variables on ex-offenders post-release life. The randomized controlled trial should have a longer follow-up time after release in order to be able to look at the change process in relation to parenting, psychosocial health, and release success and failures, including recidivism. The results should be followed up with larger studies in various cultural settings, and the shift from a criminal identity to a parental identity should be investigated, as a criminal social identity is linked to violent criminal behaviour (Boduszek, Hyland, Bourke, Shevlin, & Adamson, 2013).
Acknowledgements
The authors want to thank the Ministry of Children, Equality and Social Inclusion; the Norwegian Directorate for Children, Youth and Family Affairs; and the Correctional Service of Norway Staff Academy for their support and positive collaboration. We are thankful to the fathers and ICDP facilitators who gave of their time to fill in questionnaires and take part in interviews. The authors would also like to thank Trine Gerlyng, Ylva Snekkvik, Marit Reer, Hilde Breck, and Kristina Aas Fure for their contribution to data collection and preparations.
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Published In
Volume 15 • Number 1 • 2 January 2014
Pages: 35–54
Copyright
© 2014 Taylor & Francis.
History
Received: 5 November 2013
Published online: 2 January 2014
Issue date: 2 January 2014
Accepted: 8 February 2014
Authors
Funding
This work was supported by the Norwegian Ministry of Children, Equality and Social Inclusion. The funders had no role in study design, data collection, data analysis, or writing up the manuscript.
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