Children born very or extremely preterm transitioning to school: a cross-sectional study examining predictors of school readiness, school adjustment, and support needs

ABSTRACT

The transition to school is a sensitive developmental period for young children. Although children born very/extremely preterm have increased risk of health and developmental concerns, predictors of their school readiness and adjustment remain largely unexamined. Parents of very/extremely preterm-born children (aged 3–7 years; pre-transition n = 114, post-transition n = 112) completed an online survey assessing their perceptions of children’s school readiness (pre-transition) or adjustment (post-transition), support needs, child behaviour, parent distress, and parent confidence. Poorer school readiness and adjustment and greater needs for support correlated with child health/developmental condition/s; hyperactivity, peer problems, conduct problems, emotional symptoms, and less prosocial behaviour; and lower parent confidence. Using hierarchical linear regression, parent confidence emerged as the strongest common predictor of school readiness (pre-transition) and school adjustment (post-transition), followed by low hyperactivity, high parent education (tertiary), and no diagnosed child health/developmental condition/s. Results will be used to identify families needing support and develop tailored support strategies.

KEYWORDS:

• Child
• family
• parenting support
• premature
• preterm
• transition to school

Introduction

Approximately 14.9 million infants are born preterm (before 37 completed weeks of pregnancy) each year, representing 11.1% of all live births, and incidence is increasing (Blencowe et al., 2012; Harrison & Goldenberg, 2016). Although most (84.3%) preterm births occur between 32 and 36 completed weeks (moderate-to-late preterm), around 10.4% occur between 28 and <32 weeks (very preterm) and 5.2% occur at <28 weeks (extremely preterm; Blencowe et al., 2012). Despite increasing survival rates, children born very/extremely preterm remain at increased risk of short- and longer-term health and developmental concerns. These include neurodevelopmental conditions, such as cerebral palsy, cognitive and behavioural problems, inattention, language and social difficulties, and executive function difficulties (e.g. Johnson & Marlow, 2011; Mulder, Pitchford, Hagger, & Marlow, 2009).

Entry into formal schooling is a crucial time at which needs for additional support are often identified. Transition to school is not a one-time event, but spans several years, beginning with preparation prior to school entry and extending through the earliest years of schooling as adjustment takes place (Bohan-Baker & Little, 2002; Peters, 2010). ‘School readiness’ is a concept used to support children’s transition into school and promote successful school adjustment (UNICEF, 2012). UNICEF defines three dimensions of school readiness: ‘ready child’, ‘ready school’, and ‘ready family’. A ‘ready child’ has the necessary skills, abilities and dispositions to participate in academic and social activities in the school setting; a ‘ready school’ supports a smooth transition between home/early-learning and school environments; and a ‘ready family’ engages with school and supports their child’s transition and learning (UNICEF, 2012).

The ‘ready child’ dimension comprises five domains: physical development, social and emotional development, approaches to learning, language development and general knowledge and cognition (Williams et al., 2019). At least 50% of children born very/extremely preterm exhibit difficulties in school readiness domains, including academic and behavioural readiness (Anderson & Doyle, 2004; Roberts, Lim, Doyle, & Anderson, 2011). Even for children who experience few health or developmental difficulties beyond the neonatal period, it is important to foster positive early experiences of school to support development and well-being and set the tone for children’s future expectations and experiences (Entwisle & Alexander, 1998). It is therefore important to understand the factors that influence children’s school readiness and adjustment.

Parent perspectives on the transition to school

As recognised in UNICEF’s school readiness framework (UNICEF, 2012), parents have a vital role in preparing children for school and supporting their adjustment throughout the transition period (Besi & Sakellariou, 2019) and understanding ‘family ready’ factors is important to improving support for children and families. A recent systematic review (Morawska et al., under review) summarised existing research on parents’ perspectives and experiences at the transition to school, with themes including parental stress, uncertainty and anxiety (e.g. Choy & Karuppiah, 2016; Hatcher, Nuner, & Paulsel, 2021) and the importance of parents’ perceived skills and confidence in supporting their child academically in the home environment (Jose et al., 2022; Lau & Li, 2021). These results highlight the importance of parent factors (e.g. parent adjustment, parenting skills and confidence) for families of children transitioning to school. However, no research specifically examining the perspectives or experiences of parents of children born very/extremely preterm was found. Given the health and developmental vulnerabilities among children born very/extremely preterm, this represents a critical gap in current knowledge regarding ‘family ready’ factors that must be addressed to better support children and their families.

Parent adjustment

While increased likelihood of ongoing health and developmental concerns for children born very/extremely preterm is well recognized, parents may also face additional challenges and concerns that extend well beyond the early developmental period. Parents of children born very/extremely preterm can experience acute psychological distress while their baby is in the neonatal intensive care unit (NICU) and across the first year of life (Carson, Redshaw, Gray, & Quigley, 2015; Ionio et al., 2016; Jones, Rowe, & Becker, 2009; Pisoni et al., 2019). Beyond this, longitudinal studies indicate that premature birth can lead to chronic distress for parents, with Treyvaud, Lee, Doyle, and Anderson (2014) finding increased stress and anxiety and poorer family functioning for up to 7 years following preterm birth compared with families who had infants born at term. This is important, since parental mental health is causally linked to children’s well-being and development (e.g. Spairani et al., 2018; Zerach, Elsayag, Shefer, & Gabis, 2015). For example, longitudinal studies have shown that parental depression and stress at 2 years is associated with child behavioural problems at 3 years of age (Huhtala et al., 2012). Likewise, parenting stress among mothers and fathers of 4-year-old children who had been born preterm was associated with social, behavioural, and functional developmental problems at 5 years of age (Huhtala et al., 2014). Despite this, no research has explored parent adjustment in the context of school readiness or school adjustment for children born very/extremely preterm.

Parenting skills and confidence

Parent confidence, or self-efficacy, is another factor that is important to child development (Albanese, Russo, & Geller, 2019). Parenting confidence is defined as ‘the belief or judgement a parent holds about their ability to be successful in tasks associated with parenting’ (Vance & Brandon, 2017, p. 6). Parent confidence may play an important role in parents’ perceptions of their child’s school readiness and transition to school (Morawska et al., under review), as parents recognize their own need for adequate knowledge and skills to support their child’s development and functioning across multiple school readiness domains (Jose et al., 2022; McIntyre, Eckert, Fiese, DiGennaro Reed, & Wildenger, 2010). Parenting confidence is a strong predictor of parenting behaviour, and these two factors combine to explain variations in child outcomes across a broad variety of domains, including child behaviour (Morawska & Sanders, 2007).

Parenting support programs based on social learning theory commonly target parent self-efficacy as a necessary prerequisite to skill development in order to support parents to implement effective parenting strategies that lead to improved parent and child outcomes (Giallo, Treyvaud, Matthews, & Kienjuis, 2010; Mouton, Loop, Stiévenart, & Roskam, 2018). Thus, parental confidence is modifiable and can be readily targeted as a proximal factor to promote better child outcomes. However, no studies to our knowledge have examined parent confidence in the context of school readiness or school adjustment for children born very/extremely preterm.

The current study

Children born very/extremely preterm have heightened risk of difficulties in school readiness domains and adjustment to formal schooling. Identifying predictors of school readiness and adjustment may support early identification of at-risk children and inform the development of transition support interventions that are tailored to children’s specific strengths and vulnerabilities. As parent perspectives may change across the transition to school period (typically defined as starting approximately 2 years prior to the start of formal schooling and extending through the first 2 years of school), it was important that we capture the perspectives of parents in the ‘pre-transition’ phase to understand predictors of perceived school readiness, and the ‘post-transition’ phase to capture predictors of perceived adjustment to school.

Thus, the aims of this study were to examine the relationships between a range of child-, parent-, and family-level factors (demographic variables, child behaviour, parent distress, parent confidence with supporting their child’s development) and parents' perceptions of their children’s (i) school readiness (pre-transition), (ii) school adjustment (post-transition), and (iii) needs for support to be ready to start school. The following research questions were posed: (RQ1) What child-, parent- and family-level variables explain variation in children’s readiness to start school (pre-transition)? (RQ2) What child-, parent- and family-level variables explain variation in parents’ pre-transition perceptions of the need for support to be ready to start school? (RQ3) What child-, parent- and family-level variables explain variation in children’s adjustment to school (post-transition)? (RQ4) What child-, parent- and family-level variables explain variation in parents’ post-transition perceptions of the need for support to be ready to start school?

Materials and methods

A cross-sectional study design was used. The University of Queensland (UQ) and Mater Research-UQ Human Research Ethics Committees approved the research (#2020002191, HREC/MML/67900). Parents of 3- to 7-year-old children who were born very/extremely preterm (<32 weeks), aged 18 or older and currently residing in Australia were eligible to participate. There were no exclusion criteria. Families were recruited Australia-wide via parent and consumer support groups and associations (e.g. Miracle Babies, Life's Little Treasures Foundation, Mater Little Miracles, Australian Multiple Birth Foundation, Preterm Infants Parents Association). Advertisements (posted on organizations’ websites and/or social media and distributed via a Mater Research-UQ cohort study newsletter) directed interested parents to the project webpage, which provided detailed information about the study. Parents were able to contact the research team to ask any questions prior to making the decision to participate, there was no time limit on the decision about whether to take part, and their anonymity was assured. Parents gave consent to participate online and were immediately directed to the online survey, hosted by Qualtrics. Recruitment and data collection was undertaken over 12 months, from November 2020 to October 2021. Parents could withdraw at any point and were provided with contact details for support services (e.g. free-of-charge phone counselling services) to access if needed.

Measures

Demographics

The Family Background Questionnaire (Sanders & Morawska, 2010) collected demographic information, including parent and child age, child sex, cultural and linguistic background, and parents’ relationship status, education and employment, financial security, and postcode. An additional question assessed for change to usual arrangements due to the ongoing COVID-19 pandemic (Has any aspect of your family’s day-to-day life been impacted by the COVID-19 pandemic [e.g. increased/decreased employment or study, changed childcare or schooling arrangements?] If yes, please describe.).

Children’s health and development

A series of items developed for use in this study collected general information about children’s birth, health and development. Parents reported on their child’s diagnosed health and/or developmental conditions, National Disability Insurance Scheme (NDIS) support (yes/no/applying) and their child’s general health (excellent/good/fair/poor/very poor). Other items collected details of multiple births, birth weight and gestational age, need for supplemental oxygen, use of pre- and post-natal corticosteroid treatment, diagnosed complications of prematurity at birth, and age at discharge to home.

Transition to school

A series of items developed for use in this study collected information about whether children were pre-transition (i.e. had not yet started formal schooling) or post-transition (had already started formal schooling), current/planned schooling arrangements, type of school attended/expected to attend, any difficulties finding a suitable school, and experiences or expectations around provision of special assistance or learning support at school.

School readiness/adjustment, parent confidence, and support needs

Parent Perceptions of School Readiness (PPSR; McBryde, 1997) and Parent Perceptions of Adjustment to School (PPAS; McBryde, 1999) are 14-item questionnaires measuring parents’ perceptions of their child’s cognitive/intellectual, physical, personal-social, language and emotional development, temperament and behaviour related to school readiness (for pre-transition children) or adjustment to school (for post-transition children), respectively. In the original versions, children’s readiness or adjustment (‘How ready is your child to start school?’ [PPSR] or ‘How well has your child adjusted to the demands of school?’ [PPAS]) is rated for each item (e.g. ‘Academic readiness, e.g. knows letters, numbers, colours’) using a Likert-style response scale from 0 (not at all ready) to 6 (very ready). For use in the current study, the questionnaires were adapted (with permission from the author) to also include, for each item, (i) assessment of parents’ confidence with supporting their child’s development (‘How confident are you that you can support your child to develop these skills?’ [PPSR] or ‘How confident are you that you can support your child to further develop these skills?’ [PPAS]) with ratings from 0 (not at all confident) to 6 (very confident), and (ii) whether parents felt that they and/or their child require/d assistance to be ready to start school (‘Do you/your child need assistance in this area to be ready for school?’ [PPSR] or ‘Prior to starting school, could you/your child have benefited from assistance in this area?’ [PPAS]) from 0 (definitely no) to 6 (definitely yes) for each of the 14 items. Items within each scale are summed to generate total scale scores from 0 to 84 for each of PPSR Child Readiness, Parent Confidence, and Support Needs (for pre-transition families), and PPAS Child Adjustment, Parent Confidence, and Support Needs (for post-transition families). The original Child Readiness and Adjustment scales have shown good internal consistency and test-retest reliability, and factor analysis (principal components analysis) of the new Parent Confidence and Support Needs scales revealed clean, single-factor structures. Internal consistencies for the current sample were excellent for Readiness and Adjustment (α = .95 and .95) and Confidence (α = .95 and .94) and Needs (α = .95 and .92) scales of the PPSR and PPAS, respectively. Parents were also asked to indicate whether they are/were concerned about how best to support their child to be ready to start school, from 1 (not at all) to 6 (very much), and whether they would like/would have liked assistance with supporting their child to be ready for school (yes/no).

Child behaviour

The Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997) is a 25-item questionnaire measuring parents’ perceptions of children’s emotional symptoms, conduct problems, inattention/hyperactivity, peer problems and prosocial behaviour. Parents rate each statement according to how true it is for their child, 0 (not true), 1 (somewhat true), or 2 (certainly true), positive (strength) items are reverse-scored, and scores are summed to generate a score of 0–10 for each scale. Internal consistency was acceptable for the current sample for Emotional Symptoms (α = .74), Conduct Problems (α = .67), Hyperactivity (α = .81), Peer Problems (α = .70), and Prosocial (α = .78) scales, as well as for the Total Difficulties score (α = .85).

Parent distress

The Depression Anxiety Stress Scales – 21 (DASS-21; Lovibond & Lovibond, 1995) is a 21-item measure of depression, anxiety and stress symptoms in adults. Each scale comprises 7 items which are rated from 0 (did not apply to me at all) to 3 (applied to me very much, or most of the time), and scores are summed and then doubled (to maintain consistency with the full-length DASS-42) to generate scores that range from 0 to 42 for each individual scale and 0–126 for the Total score. The internal consistency in the current study was excellent for Depression (α = .91), Anxiety (α = .83), Stress (α = .89), and the Total score (α = .95).

Procedure

Parents completed the online questionnaire anonymously. Those with more than one child in the target age range (3–7 years) who was born very/extremely preterm were asked to complete the survey thinking about the youngest child. If the youngest child was one of a multiple birth (e.g. twin), parents focused on the child that they were most concerned about regarding the transition to school. Parents took a mean 31 minutes to complete the survey. At the end of the survey, parents could opt-in to enter a draw to win an AUD$20 Coles/Myer gift voucher, with one gift voucher drawn for every 50 completed surveys.

Statistical analyses

SPSS version 27 was used for data analysis. Overall, 6.8% and 3.5% of data were missing for pre- and post-transition families, respectively. Data were missing completely at random (Little’s MCAR tests χ²= 47.36, df = 40, p = .197; χ²= 43.65, df = 41, p = .359). Missing values were handled using estimation maximization. Descriptive statistics were used to report on demographic information, health history, child behaviour, parent distress, parenting confidence, and parents’ perceptions of school readiness/adjustment and needs for support. Pearson’s correlations were used to examine relationships between continuous variables, and t-tests and chi-squared analyses were used to examine differences between subgroups on continuous and categorical variables, respectively. Hierarchical linear regression models were used to test relationships between key variables and (RQ1) children’s school readiness (pre-transition), (RQ2) pre-transition parents’ perceptions of needs for support, (RQ3) children’s school adjustment (post-transition), and (RQ4) post-transition parents’ perceptions of needs for support. Independent variables were selected for inclusion in the model based on zero-order correlations with one or more of the dependent variables. P-values of < .05 were considered statistically significant.

Results

Participant characteristics

Of 341 parents who started the survey, 26 were ineligible (child age, n = 4; gestation at birth, n = 22), six were duplicate responses, 42 did not complete beyond the demographic and child health background sections, and a further 41 did not complete any sections relevant to their child’s transition to school or school readiness. The remaining 226 eligible parents comprised the sample for this study.

Baseline demographic characteristics of participants and their children are provided in Table 1. There were approximately equal numbers of parents of children who were pre-transition (n = 114, aged 3–5 years) and post-transition (n = 112, aged 4–7 years). There were slightly more boys than girls, and most were living with their original family. Most respondents were university-educated mothers in domestic partnerships, engaged in paid employment, and able to meet essential expenses. Approximately equal proportions of pre-transition (46.5%, n = 53) and post-transition (46.4%, n = 52) parents reported changes to day-to-day life due to the COVID-19 pandemic at the time of the survey. These included changes to childcare arrangements due to closure of childcare centres and schools; changes to work arrangements for self or partner, including reduced, lost, or left employment; reduced family income; and financial stress.

Table 1. Demographic characteristics of participants.

Variables		Pre-transition (n = 114)	Post-transition (n = 112)
		M (SD)	M (SD)
Parent’s age (years)		35.09 (5.55)	38.02 (5.06)
Child’s age (years)		3.73 (0.72)	5.84 (0.86)
		% (n)	% (n)
Child’s sex	Male	57.0 (65)	55.4 (62)
	Female	43.0 (49)	44.6 (50)
Parent’s relationship to child	Mother	96.5 (110)	99.1 (111)
	Father	2.6 (3)	0.9 (1)
	Other	0.9 (1)	–
Household	Original family	86.8 (99)	82.1 (92)
	Step-family	2.6 (3)	5.4 (6)
	Sole parent family	9.6 (11)	12.5 (14)
	Other	0.9 (1)	–
First Nations origin (child)	No	92.1 (105)	98.2 (110)
	Yes	7.9 (9)	1.8 (2)
Parent’s country of birth	Australia	87.7 (100)	76.8 (86)
	Other	12.3 (14)	23.2 (26)
Language spoken at home	English	89.5 (102)	89.3 (100)
	Other	10.5 (12)	10.7 (12)
Parent’s education	High school or less	17.6 (20)	12.5 (14)
	Trade/college	22.8 (26)	23.2 (26)
	University degree	37.7 (43)	36.6 (41)
	Postgraduate degree	21.9 (25)	27.7 (31)
Relationship status	Married/de facto	87.7 (100)	85.7 (96)
	Separated/divorced/single	12.3 (14)	14.3 (16)
Parent’s employment	Full-time/part-time	71.0 (81)	75.9 (85)
	Not working	28.9 (33)	24.1 (27)
Able to meet essential expenses^a	Yes	86.0 (98)	87.5 (98)
	No	14.0 (16)	12.5 (14)
After expenses can afford^b	Not much	13.2 (15)	7.1 (8)
	Some things	34.2 (39)	39.3 (44)
	Most things	50.9 (58)	53.6 (60)

^a Able to meet living expenses over past 12 months.

^b Missing: pre-transition n = 2.

Children’s birth and health characteristics are presented in Table 2. Children were born between 23- and 31-weeks’ gestation, most at very/extremely low birth weight. Most of the multiple births were twins (n = 45; triplet n = 1). Approximately half of the pre- and post-transition children had been diagnosed with at least one health or developmental condition: developmental delay and communication difficulties were the most common diagnoses in the pre-transition group, whereas behavioural/attention difficulties and learning difficulties were the most common diagnoses in the post-transition group. Almost 1 in 3 pre-transition children were receiving or in the process of applying for support through the NDIS compared to 1 in 4 post-transition children. The vast majority (>90%) of parents from both groups rated their children as being in good or excellent health.

Table 2. Children’s birth and health characteristics.

Variables		Pre-transition (n = 114)	Post-transition (n = 112)
		M (SD)	M (SD)
Gestation at birth (weeks)		27.67 (2.43)	28.20 (2.25)
		% (n)	% (n)
Birth weight	1,500–2,499 g (LBW)	16.7 (19)	17.0 (19)
	1,000–1,499 g (VLBW)	37.7 (43)	47.3 (53)
	< 1,000 g (ELBW)	45.6 (52)	35.7 (40)
Multiple birth	No	79.8 (91)	79.3 (88)
	Yes	20.2 (23)	20.7 (23)
Home on supplemental O2	No	72.6 (77)	86.1 (93)
	Yes	27.4 (29)	13.9 (15)
Diagnosed health/ developmental condition/s	No	50.9 (58)	46.4 (52)
	Yes	49.1 (56)	53.6 (60)
	Developmental delay	31.6 (36)	17.0 (19)
	Communication difficulties	21.9 (25)	14.3 (16)
	Behavioural/attention difficulties	12.3 (14)	23.2 (26)
	Learning difficulties	10.5 (12)	23.2 (26)
	Physical disability	7.0 (8)	7.1 (8)
	Vision impairment	7.0 (8)	17.0 (19)
	Hearing impairment	6.1 (7)	2.7 (3)
	Developmental disability	3.5 (4)	7.1 (8)
	Intellectual impairment	1.8 (2)	4.5 (5)
	Other	5.3 (6)	10.7 (12)
NDIS support	No	67.0 (75)	74.8 (83)
	Not yet, but applying	3.6 (4)	7.2 (8)
	Yes	29.5 (33)	18.0 (20)
General health	Excellent	43.0 (49)	45.5 (51)
	Good	47.4 (54)	49.1 (55)
	Fair	7.9 (9)	5.4 (6)
	Poor	–	–
	Very poor	1.8 (2)	–

Note. LBW = low birth weight, VLBW = very low birth weight, ELBW = extremely low birth weight, NDIS = National Disability Insurance Scheme.

Scores on measures of school readiness/adjustment, parent confidence, and support needs (PPSR/PPAS), child behaviour (SDQ) and parent distress (DASS-21) are presented in Table 3. Among both pre- and post-transition parents, high (moderate/severe/very severe) levels of anxious symptoms were most common, followed by stress and then depressive symptoms. Among both pre- and post-transition children, approximately half scored in the high range for Hyperactivity and at least 1 in 4 scored in the high range for Conduct Problems, Peer Problems, and/or Emotional Symptoms. T-tests showed no statistically significant differences between pre- and post-transition group scores for parent or child adjustment, except for SDQ Emotional Symptoms scores which were slightly higher for post-transition children, t(224) = −2.04, p = .043.

Table 3. Children’s school readiness/adjustment, parent confidence, needs for support, parent distress, and child behaviour.

Variables	Categories	Pre-transition (n = 114)		Post-transition (n = 112)
		M (SD)	% (n)	M (SD)	% (n)
Transition to school
Child Readiness/Adjustment		47.93 (18.95)		56.68 (18.6)
Parent Confidence		58.68 (16.09)		61.89 (15.27)
Support Needs		34.84 (20.32)		38.31 (18.25)
Child behaviour
Emotional Symptoms		3.12 (2.54)		3.76 (2.65)
	Normal		61.7 (50)		54.3 (51)
	Borderline		12.3 (10)		10.6 (10)
	High		25.9 (21)		35.1 (33)
Conduct Problems		3.06 (2.20)		3.09 (2.27)
	Normal		50.0 (41)		56.4 (53)
	Borderline		20.7 (17)		16.0 (15)
	High		29.3 (24)		27.7 (26)
Hyperactivity		6.33 (2.71)		6.00 (2.82)
	Normal		39.5 (32)		42.6 (40)
	Borderline		7.4 (6)		10.6 (10)
	High		53.1 (43)		46.8 (44)
Peer Problems		2.62 (2.28)		2.49 (2.27)
	Normal		51.2 (42)		58.5 (55)
	Borderline		22.0 (18)		10.6 (10)
	High		26.8 (22)		30.9 (29)
Prosocial		6.46 (2.38)		6.99 (2.38)
	Normal		65.9 (54)		71.3 (67)
	Borderline		19.5 (16)		16.0 (15)
	High		14.6 (12)		12.8 (12)
Total Difficulties		15.17 (7.08)		15.14 (7.22)
	Normal		46.9 (38)		44.7 (42)
	Borderline		13.6 (11)		16.0 (15)
	High		39.5 (32)		39.4 (37)
Parent distress
Depression		6.25 (8.09)		6.09 (9.39)
	Normal		84.0 (68)		87.0 (80)
	High		16.0 (13)		13.0 (12)
Anxiety		6.15 (7.25)		4.87 (6.89)
	Normal		70.4 (57)		79.3 (73)
	High		29.6 (24)		20.7 (19)
Stress		13.31 (9.90)		11.52 (10.08)
	Normal		71.6 (58)		81.5 (75)
	High		28.4 (23)		18.5 (17)
Total Distress		26.08 (19.81)		22.22 (22.20)
	Normal		93.9 (107)		93.8 (105)
	High		6.1 (7)		6.3 (7)

Note. Transition to school ‘readiness’ for pre-transition children, ‘adjustment’ for post-transition children assessed by PPSR and PPAS. Parent distress assessed by DASS-21; ‘high’ indicates scores in the moderate, severe, or very severe range based on published clinical cut-offs (Depression ≥14, Anxiety ≥10, Stress ≥19, Total Score ≥60). Child behaviour assessed by SDQ; score categories (normal/borderline/high) based on published ranges.

Transition to school

Pre-transition

At the time of the survey, pre-transition children were most commonly attending a centre-based childcare/daycare (50.0%, n = 57) or a community-based kindergarten (16.7%, n = 19) or preschool (14.9%, n = 17; school-based kindergarten 7.9%, n = 9; family daycare 4.4%, n = 5; early childhood school 3.3%, n = 4; pre-prep 0.9%, n = 1; no out-of-home care 7.9%, n = 9; other 9.6%, n = 11). Most parents expected their child to transition to school at the start of the next school year (53.2%, n = 58) or the year after (36.7%, n = 40; in 3 years 6.4%, n = 7; unsure 3.7%, n = 4). Most (57.8%, 63) expected that their child would attend a public school (private 29.4%, n = 32; independent 4.6%, n = 5; unsure 8.3%, n = 9). Some parents (11.1%, n = 12) were having difficulty finding a school for their child. Around half (48.6%, n = 51) anticipated that their child’s future school would provide some special assistance/learning support for their child. Most parents (89.9%, n = 98) were concerned about how best to support their child to start school (much/very much 32.1%, n = 35), and 70.6% (n = 77) wanted assistance with supporting their child to be ready to start school.

Post-transition

At the time of the survey, post-transition children were most commonly attending prep (48.2%, n = 54) or grade 1 (25.9%, n = 29), which are the first and second years of formal schooling in Australia respectively (grade 2 17.0%, n = 19; grade 3 0.9%, n = 1). Most (92.9%, n = 104) had transitioned to a mainstream primary school although some attended a special school (4.5%, n = 5) or were home-schooled (1.8%, n = 2). Most schools were public (64.3%, n = 72; private 21.4%, n = 24; independent 8.9%, n = 10). Some parents (11.6%, n = 13) had experienced difficulty finding a school for their child, 6.3% (n = 7) had moved to a different school since transitioning to primary school, and 5.4% (n = 6) had repeated their first year of schooling. Around a third (37.3%, n = 41) of children received special assistance/learning support from school for their child. Most parents (58.6%, n = 65) reported having been concerned about how best to support their child to be ready to start school and 51.4% (n = 57) would have liked additional assistance with supporting their child to be ready to start school prior to transition.

Predicting school readiness and support needs

Correlations among dependent variables (school readiness/adjustment and support needs) and independent variables (demographics, child and parent variables) are summarized in Table 4. Full correlation tables are provided in Supplementary Tables S1 and S2. Parent confidence with supporting children’s development (PPSR Confidence and PPAS Confidence) were the variables most strongly correlated with school readiness/adjustment and support needs for pre-transition and post-transition families. There were mostly moderate-strong correlations between child behaviour (SDQ) scores and the dependent variables for pre-transition and post-transition families, whereas parent distress (DASS-21) scores only weakly correlated with scores for support needs and did not correlate with readiness/adjustment for pre- or post-transition families. There were weak-moderate relationships between diagnosed health/developmental condition/s and dependent variables for pre-transition and post-transition families; gestation at birth and other demographic variables correlated with dependent variables for pre-transition families only.

Table 4. Correlations between key variables and children’s school readiness/adjustment and needs for support.

Variables	Pre-transition (n = 114)		Post-transition (n = 112)
	Child Readiness	Support Needs	Child Adjustment	Support Needs
Demographics
Child age (years)	.43***	−.11	−.17	−.13
Gestation at birth (weeks)	.33**	−.33***	.06	−.04
Condition/s^a	−.37***	.42***	−.36***	.22*
Parent age	.29**	−.22*	.15	−.02
Parent education^a	.31***	−.20*	.15	.10
Financial stress^a	−.19*	.20*	.03	.06
Child variables
Emotional Symptoms	−.22*	.38***	−.50***	.42***
Conduct Problems	−.28**	.45***	−.43***	.38***
Hyperactivity	−.60***	.53***	−.65***	.45***
Peer Problems	−.49***	.46***	−.53***	.47***
Prosocial	.56***	−.43***	.54***	−.32***
Total Difficulties	−.55***	.63***	−.76***	.59***
Parent variables
Depression	.01	.12	−.11	.26**
Anxiety	.02	.21*	−.09	.20*
Stress	−.11	.29**	−.18	.26**
Total Distress	−.04	.23*	−.14	.26**
Parent Confidence	.70***	−.75***	.85***	−.55***

Note. Pearson’s correlations, two-tailed, unless otherwise specified. Child and parent age in years. Gestation at birth in weeks. Parent education: tertiary education = 1, no tertiary education = 0. Condition/s: any diagnosed child health or developmental condition = 1, no conditions = 0.

^a Point-biserial correlations.

*p < .05 **p < .01 ***p < .001.

Pre-transition families

Two separate hierarchical multiple regressions were used to test predictors of PPSR Child Readiness and Support Needs for families of children approaching the transition to school (Table 5). Step 1 controlled for demographic variables; child behaviour variables were added in Step 2; parent distress and confidence were added in Step 3. There was no evidence of multicollinearity. One and two multivariate outliers were found for the Child Readiness and Support Needs models, respectively, and were excluded listwise.

School readiness

Demographic variables added at Step 1 made a significant contribution to the model, F(6,106) = 14.87, p < .001. Older child age, no health/developmental diagnoses, parent tertiary education, and later gestation at birth were all significant predictors of school readiness. Addition of child behaviour at Step 2 improved the model, F_change(5,101) = 18.63, p < .001, and less hyperactivity and greater prosocial behaviour were additional predictors of school readiness. Addition of parent variables at Step 3 made the greatest contribution to the model, F_change(2,99) = 40.16, p < .001. The final model explained 84.4% of variation in PPSR Child Readiness scores. Greater parent confidence, older child age, less hyperactivity, less parent distress, parent tertiary education, and no health/developmental diagnoses and were all unique predictors of school readiness, and accounted for 10.2%, 8.0%, 5.1%, 2.5%, 1.4%, and 0.7% of unique variation in school readiness scores, respectively.

Table 5. Hierarchical multiple regressions predicting children’s school readiness/adjustment and needs for support.

Variables	Pre-transition				Post-transition
	Child Readiness (n = 113)		Support Needs (n = 112)		Child Adjustment (n = 111)		Support Needs (n = 112)
	R^2= .844		R^2= .781		R^2= .820		R^2= .488
	β	95% CI	β	95% CI	β	95% CI	β	95% CI
Step 1: Demographics
Child age	.33***	.18, .47	<.01	−.16, .17	−.09	−.26, .09	.08	−.11, .27
Gestation at birth	.18*	.03, .33	−.21*	−.38, – .03	.03	−.15, .21	−.07	−.27, .12
Condition/s	−.33***	−.48, –.19	.40***	.23, .57	−.36***	−.54, –.18	.21*	.02, .40
Parent age	.08	−.07, .24	−.06	−.24, .12	.14	−.05, .33	−.02	−.23, .18
Parent education	.22**	.07, .38	−.09	−.27, .09	.09	−.11, .29	.17	−.04, .37
Financial stress	−.08	−.23, .07	.10	−.07, .27	.10	−.09, .29	.08	−.11, .28
ΔR^2	.457***		.293***		.194**		.080
Step 2: Child variables
Child age	.29***	.18, .40	.06	−.08, .21	−.12*	−.23, –.01	.07	−.09, .23
Gestation at birth	.08	−.05, .20	−.18*	−.33, –.03	−.04	−.15, .07	−.01	−.17, .15
Condition/s	−.15*	−.27, –.04	.21**	.07, .36	−.14*	−.25, –.02	.04	−.13, .20
Parent age	.02	−.10, .14	.02	−.13, .17	−.03	−.15, .09	.13	−.04, .30
Parent education	.17**	.05, .29	−.05	−.20, .11	.11	−.01, .23	.19*	.02, .36
Financial stress	−.01	−.13, .10	<.01	−.14, .14	.14*	.03, .25	.05	−.11, .21
Emotional Symptoms	.05	−.09, .19	.09	−.08, .26	−.15*	−.27, –.03	.21*	.05, .38
Conduct Problems	.02	−.12, .16	.21*	.04, 39	−.10	−.24, .04	.20	−.01, .40
Hyperactivity	−.37***	−.51, –.23	.23*	.05, .40	−.37***	−.50, –.23	.17	−.02, .36
Peer Problems	−.08	−.22, .06	.21*	.03, .39	−.15*	−.27, –.02	.30**	.12, .48
Prosocial	.30***	.16, .44	−.06	−.24, .12	.31***	.18, .44	−.02	−.21, .18
ΔR^2	.261***		.255***		.533***		.350***
Step 3: Parent variables
Child age	.30***	.22, .39	.07	−.04, .17	−.05	−.14, .04	.05	−.11, .21
Gestation at birth	.01	−.08, .10	−.05	−.16, .06	−.03	−.11, .06	−.04	−.19, .12
Condition/s	−.09*	−.18, –.01	.13*	.02, .23	−.13**	−.22, –.04	.02	−.14, .18
Parent age	.05	−.04, .14	.02	−.08, .13	−.05	−.14, .05	.16	<−.01, .33
Parent education	.14**	.05, .23	−.01	−.12, .10	.12*	.02, .21	.16	−.01, .33
Financial stress	.04	−.05, .12	−.08	−.18, .03	.14*	.03, .25	−.06	−.26, .14
Emotional Symptoms	<.01	−.10, .10	.13*	<−.01, .25	−.08	−.17, .02	.15	−.01, .32
Conduct Problems	.06	−.05, .16	.14*	.02, .27	.08	−.04, .19	.08	−.12, .29
Hyperactivity	−.30***	−.41, –.20	.10	−.03, .22	−.24***	−.35, –.13	.13	−.07, .32
Peer Problems	−.06	−.17, .05	.11	−.02, .24	−.07	−.17, .03	.25**	.08, .43
Prosocial	.11	−.01, .22	.19**	.06, .33	.17**	.05, .28	.01	−.19, .21
Parent Distress	.18***	.09, .27	−.04	−.14, .07	−.10	−.21, .01	.24*	.04, .44
Parent Confidence	.47***	.36, .59	−.73***	−.87, –.59	.54***	.40, .68	−.23	−.48, .02
ΔR^2	.127***		.223***		.115***		.058**

Notes. Child and parent age in years. Gestation at birth in weeks. Parent education: tertiary education = 1, no tertiary education = 0. Condition/s: any diagnosed child health or developmental condition = 1, no conditions = 0.

*p < .05 **p < .01 ***p < .001.

Support needs

Demographic variables added at Step 1 made a significant contribution to the model, F(6,105) = 7.25, p < .001, and health/developmental diagnoses and earlier gestation at birth were unique predictors of support needs. Child behaviour variables at Step 2 improved the model, F_change(5,100) = 11.29, p < .001, and hyperactivity, conduct problems, and peer problems were additional unique predictors of support needs. Addition of parent variables at Step 3 also made a significant contribution to the model, F_change(2,98) = 51.91, p < .001. The final model explained 78.1% of variation in PPSR Support Needs scores. Less parent confidence, less prosocial behaviour, health/developmental diagnoses, conduct problems, and emotional symptoms were all significant unique predictors of perceived need for support, and accounted for 23.2%, 1.7%, 1.3%, 1.1% and 0.9% of variation in need for support, respectively(Table 5).

Post-transition families

Two separate hierarchical multiple regressions were also used to test predictors of PPAS Child Adjustment and Support Needs for families of children who had already transitioned to school (Table 5). Once again, Step 1 controlled for demographic variables; child behaviour variables were added in Step 2; parent distress and confidence were added in Step 3. There was no evidence of multicollinearity, and there was only one multivariate outlier (for the Child Adjustment model) which was excluded listwise.

School adjustment

Although the block of demographic variables added at Step 1 made a significant contribution to the model, F(6,104) = 4.17, p < .001, lack of health/developmental diagnoses was the only significant unique predictor. Addition of child behaviour variables at Step 2 made the largest contribution to the model, F_change(5,99) = 38.58, p < .001, and less hyperactivity, greater prosocial behaviour, fewer peer problems, fewer emotional symptoms, lack of financial stress, and older child age were all additional predictors of school adjustment. Addition of parent variables at Step 3 also made a significant contribution to the model, F_change(2,97) = 35.04, p < .001. The final model explained 84.1% of variation in PPAS Child Adjustment scores. Greater parent confidence, less hyperactivity, greater prosocial behaviour, no health/developmental diagnoses, lack of financial stress, and parent tertiary education explained 9.6%, 3.1%, 1.4%, 1.3%, 1.0% and 1.0% of variation in adjustment to school (Table 5).

Support needs

The block of demographic variables added at Step 1 did not significantly predict support needs, F(6,105) = 1.52, p = .179. Child behaviour variables added at Step 2 made the largest contribution to the model, F_change(5,100) = 12.28, p < .001, and peer problems, emotional symptoms, and parents’ tertiary education were additional significant predictors. Addition of parent variables at Step 3 also made a significant contribution to the model, F_change(2,98) = 5.60, p = .005. The final model explained 48.8% of variation in PPAS Support Needs scores. Only peer problems and parent distress predicted greater perceived need for support and accounted for 4.3% and 2.9% of unique variation in need for support, respectively (Table 5).

Discussion

The transition to formal schooling represents an important milestone in any child’s development. To best support children and families, we need to understand parents’ perspectives on their child’s school readiness (pre-transition), adjustment to school (post-transition), and needs for support across the transition period. This may be particularly important for children with special health or developmental needs, such as children who are born very/extremely preterm.

This study is one of the first to examine parents’ perceptions of school readiness/adjustment and support needs for children born very/extremely preterm. Parent confidence with supporting children’s development emerged as the strongest predictor of perceived school readiness (pre-transition) and school adjustment (post-transition) over and above other demographic, child and parent variables. These results are congruent with systematic reviews of the broader parenting and child development literature, which identify parent self-efficacy as a strong predictor of parenting behaviour which, in turn, causally links parent self-efficacy to child developmental outcomes (e.g. Albanese et al., 2019). Parenting self-efficacy and parenting behaviour can also mediate and/or moderate the influence of other external factors (e.g. parenting or family stress, social disadvantage) that can either benefit or undermine children’s health and development (Albanese et al., 2019; Morawska & Sanders, 2007). Confident and skilled parenting is associated with better emotional, behavioural, social, academic, and health outcomes for children across numerous cross-sectional, longitudinal and experimental studies (Albanese et al., 2019; Doyle et al., 2023) and is therefore associated with improved child development relevant to many school readiness domains.

Although not tested in this study, systematic reviews identify numerous factors associated with variations in parent self-efficacy (e.g. parent mental health, parenting knowledge, social support; Albanese et al., 2019). Within the context of children’s transition to school, parent self-efficacy may plausibly be influenced by any of these factors, and may, in turn, influence what types of activities or approaches parents use to support their child’s development and readiness for school (e.g. engagement in early learning activities in the home, scaffolding behavioural and emotional regulation, social skills building, building independence with self-care activities). Importantly, parenting skills and confidence (self-efficacy) are readily modifiable through intervention such as evidence-based parenting support programs (Doyle et al., 2023). Our results have therefore pinpointed an important and highly modifiable variable that can be targeted in future intervention development and testing to provide an avenue to supporting children and families at the transition to school.

Our results also showed that low parent confidence with supporting children’s development was the strongest predictor of perceived need for support for children to be ready to start school. Parents with high parenting self-efficacy tend to use more effective (less ineffective) parenting strategies, implement parenting strategies more consistently, feel generally confident in their ability to guide their child’s development, and persist despite being faced with obstacles or challenging situations (Albanese et al., 2019; Vance & Brandon, 2017). In contrast, parents with low self-efficacy tend to feel less confident in their ability to guide their child’s development and may therefore perceive the need for additional support. It is also plausible that parents with high self-efficacy may already have successfully navigated and accessed support services that they and/or their child need, thus reducing perceived need for additional support over and above what has already been obtained. Alternatively, parents of children with significant developmental difficulties or special needs may reasonably lack the confidence that they can provide their child with the amount or type of support that they need to be ready for the transition to school. However, self-efficacy remained the strongest predictor of perceived needs for support even after adjusting for other child variables (emotional, behavioural, and social functioning, diagnosed health/developmental conditions, gestation at birth), suggesting that self-efficacy is strongly and independently related to perceived needs for support. Regardless, bolstering parents’ skills and confidence through intervention can lead to parenting and child successes and mastery experiences (e.g. child developmental gains, goal attainment) which may act via feedback loops to further increase parents’ sense of confidence in their ability to support their child’s development (Albanese et al., 2019; Doyle et al., 2023; Vance & Brandon, 2017). Our results therefore suggest that self-efficacy is a worthwhile target for future interventions that seek to support parents in their parenting role around the transition to school.

Other parent characteristics were also unique predictors of school readiness/adjustment and perceived needs for support. Less distress and higher education predicted greater perceptions of school readiness, whereas lack of financial stress and higher education predicted better perceptions of school adjustment. Parent distress also predicted greater perceived needs for support, but only for post-transition (not pre-transition) parents. These results highlight the importance of identifying families who may be in need of additional practical and emotional support at the transition to school, including parents experiencing psychological distress or financial stress or with less formal education. Identifying and addressing psychological distress may be particularly important since this group of parents are already at increased risk of mental health difficulties (Singer et al., 1999) and the transition to school can contribute to additional anxiety and stress (Blackburn & Harvey, 2020). Future research should explore potential pathways of effect to explain links between parent distress, self-efficacy, and perceived needs for support among this group of parents, and test intervention approaches to supporting parents’ mental health and coping around the transition to school.

Child characteristics also contributed to the prediction of school readiness/adjustment. For pre-transition families, older child age and less hyperactivity predicted greater school readiness, while for post-transition families less hyperactivity and greater prosocial behaviour predicted better adjustment. Child characteristics were also important to the prediction of parents’ perceived needs for support. Conduct problems, emotional symptoms, and less prosocial behaviour were associated with greater perceived needs for support to be ready to start school for pre-transition families, although only peer problems were still associated with greater perceived needs for support for post-transition families. The differences in perceptions of parents pre- and post-transition may reflect the perceived importance of different skills prior to and following school entry. While the study was cross-sectional and we cannot infer change over time, it is possible that prior to school entry, parents are focused on ‘learning’ and most concerned about how ready their child is in their ability to pay attention, follow instructions and classroom rules, and manage their emotions, including separation anxiety. As children adjust to the classroom environment, parents’ focus may shift to friendships and their child’s enjoyment of school. Another possible explanation is that parents may be unaware of the impact of difficulties with social skills on school adjustment until their child is in the school environment.

Health/developmental diagnoses predicted poorer school readiness and adjustment scores, even after adjusting for other variables, and were associated with greater perceived needs for support to be ready to start school. Interestingly, health/developmental diagnoses (a non-modifiable factor) accounted for only a relatively small percentage of variance compared to the other significant predictors, most of which were potentially modifiable factors. This implies that while children’s health/developmental diagnoses do explain variation in parents’ perceptions of needs for support, this alone is unlikely to be a particularly important marker of need for support. Future studies should explore relationships between school readiness/adjustment and the types of diagnoses, and how these are linked to specific support needs around the transition to school.

Limitations

The sample was self-selected and mostly comprised university-educated, employed mothers in domestic partnerships; thus, results should only be considered generalizable to similar populations, particularly considering that socioeconomic disadvantage is a risk factor for preterm birth (McHale et al., 2022). The study used a cross-sectional design, precluding any inferences of causal association between predictor and outcome variables in the regression models. Pre-transition and post-transition families were sampled simultaneously, and any differences in results between pre- and post-transition families represent differences at a single point in time; a longitudinal study design is needed to test for any within-group changes in predictors of parent perceptions of support needs from pre- to post-transition.

Conclusion

A mix of child-, parent-, and family-level factors predict parents’ perceptions of children’s pre-transition school readiness, post-transition school adjustment, and needs for support. Results can be used to identify children and families who are most likely to be in need of support, and reveal potential targets for intervention (e.g. parents’ self-efficacy, children’s emotions and behaviours, parent distress) to improve outcomes for children born very/extremely preterm and their families.

Acknowledgements

Sincere thanks to the parents who took part in this study, and to the organizations (Miracle Babies, Life's Little Treasures Foundation, Mater Little Miracles, Australian Multiple Birth Foundation, Preterm Infants Parents Association) who supported this study by distributing study information to families.

Disclosure statement

The Parenting and Family Support Centre is partly funded by royalties stemming from published resources of the Triple P – Positive Parenting Program, which is developed and owned by The University of Queensland (UQ). Royalties are also distributed to the Faculty of Health and Behavioural Sciences at UQ and contributory authors of published Triple P resources. Triple P International (TPI) Pty Ltd is a private company licensed by Uniquest Pty Ltd on behalf of UQ, to publish and disseminate Triple P worldwide. The authors of this report have no share or ownership of TPI. Dr Morawska receives royalties from TPI. TPI had no involvement in the study design, collection, analysis or interpretation of data, or writing of this report. All authors except Dr Etel are employees or affiliated with UQ. Dr Etel was an employee at UQ at the time this research was conducted.

Data availability statement

The participants in this study did not give written consent for their data to be shared publicly, so due to the sensitive nature of the research supporting data are not available.

Additional information

Funding

This work was supported by a University of Queensland Faculty of Health and Behavioural Sciences Research Collaboration Seeding Grant; Children's Hospital Foundation Early Career Fellowships (AEM) under award ref. [Grant Number 50223, ECF0112020]; and the Australian Research Council Centre of Excellence for Children and Families over the Life Course (AM; CE200100025).

Notes on contributors

Amy E. Mitchell

Dr Amy Mitchell is a paediatric nurse whose research aims to identify modifiable targets for intervention to improve health and developmental outcomes for children and their families.

Rebecca Armstrong

Dr Rebecca Armstrong is a speech pathologist whose research focuses on a range of paediatric areas of speech pathology practice including speech, language, literacy and special needs in communication.

Cathy McBryde

Dr Cathy McBryde is an occupational therapist whose research interests include children with developmental conditions and enhancing the skills and confidence of parents of children with developmental challenges.

Alina Morawska

A/Prof Alina Morawska is a clinical psychologist whose research focuses on the central role of parents in influencing all aspects of children’s development, and parenting intervention as a tool for prevention and early intervention to promote lifelong health and well-being.

Evren Etel

Dr Evren Etel is a developmental psychologist whose research interests include social and cognitive development in children.

Elizabeth M. Hurrion

Dr Elizabeth Hurrion is a senior neonatologist with clinical expertise and research interest in developmental outcomes after preterm birth.

Tomomi McAuliffe

Dr Tomomi McAuliffe is an occupational therapist whose research focuses on parental health and well-being, particularly in families of children with special needs.

Leanne Johnston

A/Prof Leanne Johnston is a physiotherapist whose research aims to improve access to high quality health care and reduce health care inequality for children and their families.