Hum. Reprod. Advance Access published online on August 27, 2008
Human Reproduction, doi:10.1093/humrep/den297
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Adolescents conceived by IVF: parenting and psychosocial adjustment
Faculty of Psychology and Educational Sciences, Centre for School Psychology, University of Leuven (K.U.Leuven), Tiensestraat 102, PO Box 3717, 3000 Leuven, Belgium
1 Correspondence address. E-mail: hilde.colpin{at}psy.kuleuven.be
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Abstract |
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BACKGROUND: A follow-up study was conducted in mid-adolescence on parenting and the child's psychosocial development after in vitro fertilization (IVF). The first phase of the study had compared 31 IVF families and 31 families with a naturally conceived child when the children were 2 years old (Colpin et al., 1995
). Of these, 24 IVF families and 21 control families participated again when the children were 15–16 years old. METHODS: Fathers, mothers and adolescents completed questionnaires assessing parenting style and stress, and adolescent psychosocial adjustment.
RESULTS: No significant differences were found in self- or adolescent-reported parenting style, or in parenting stress between IVF mothers and mothers in the control group, nor between IVF fathers and fathers in the control group. Neither did we find significant differences in self- or parent-reported behavioural problems between adolescents conceived by IVF and those conceived naturally. Comparison of behavioural problems between IVF adolescents informed or not informed about the IVF conception did not reveal significant differences.
CONCLUSIONS: Parenting and 15–16-year-old adolescents' psychosocial adjustment did not differ significantly between IVF families and control families. This study is, to the best of our knowledge, the first psychosocial follow-up in mid-adolescence, and adds to the evidence that IVF children and their parents are well-adjusted. Large-scale studies in adolescence are needed to support these findings.
Key words: infertility/IVF/parent child relations/psychosocial/adolescents
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Introduction |
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Since 1978, birth year of the first ‘test tube baby’, there has been a permanent increase in the numbers of children born following in vitro fertilization (IVF) worldwide. Estimations point to 1 in 50 births in Sweden, 1 in 60 births in Australia and 1 in 80 births in the USA resulting from IVF (Van Voorhis, 2007
).
In the case of IVF, the transition to parenthood has a particular character. It has been suggested that the infertility problem and the assisted reproduction might be associated with long periods of parental stress, which could negatively affect adaptation to the parental role, parents' behaviour and the quality of the parent–child relationship, and children's subsequent social and emotional development. On the other hand, the strong parental investment in the child could be predictive for more positive parenting and child outcomes (e.g. Hammer-Burns, 1987; Colpin, 2002 for reviews). In the last 15 years, several studies have been published on parenting and children's psychosocial development following IVF (for reviews, see Colpin, 2002; Sutcliffe and Ludwig, 2007). Findings are encouraging: most measures have not revealed statistically significant differences between families with singleton children conceived by homologous IVF and families with naturally conceived children.
In the majority of studies, children were quite young, mostly not older than 5 years. A European study by Golombok et al. (2001, 2002a), following children up to 11–12 years of age, is the only one known to us on psychosocial adjustment and parenting of IVF (early) adolescent offspring.
The present study aimed at contributing to the research evidence about this developmental stage, by following up IVF children recruited at age 2 (Colpin et al., 1995) into their mid-adolescence.
In the first phase of our study, the parent–child relationship and parents' psychosocial functioning were compared between 31 IVF families and 31 families with a naturally conceived child (Colpin et al., 1995). The investigation included behavioural observations of mother–child interactions in the home and self-rating questionnaires for mother and father. The child's behaviour towards mother, the mother's behaviour towards the child and the mother's and father's parental attitudes and emotions did not differ significantly between IVF and control families. Neither did we find significant differences in mother's and father's personalities, developmental history and the quality of the marital relationship. In a second phase, a follow-up study on parenting and children's psychosocial development was conducted when the children were 8–9 years old, with 27 IVF families and 23 naturally conceiving families from the original sample (Colpin and Soenen, 2002). Written questionnaires were completed by the children's fathers, mothers and school teachers. Concerning parenting, no significant differences were found between IVF and control parents' reports of their own parenting behaviour, parenting stress and most parenting goals. The parenting goal ‘adjustment’ (to be obedient and kind in the relationship with the parents) was significantly more important for IVF than for control fathers, and religion was more important for IVF than for naturally conceiving mothers. Neither parental nor teacher ratings of the child's behaviour differed significantly between the two groups. At this stage, the question of disclosure (or non-disclosure) of the IVF status was studied too. All but one of the IVF couples had talked to other persons about the IVF conception and 25% of the couples had informed their children. IVF parents who had informed their child observed more internalizing (but not externalizing) behavioural problems in their child, compared with IVF parents who had not yet disclosed the IVF conception. Teacher ratings of informed and non-informed children were not significantly different.
This paper reports on the third stage of our study, focusing on parenting and psychosocial adjustment in adolescence. In adolescence, development involves striving for autonomy—a sense of oneself as a separate, self-governing individual. Teenagers strive to rely more on themselves and less on parents for guidance and decision making. Nevertheless, parent–child relationships remain vital for helping adolescents become autonomous, responsible individuals (e.g. Berk, 2004).
As in the previous stages of our study, two levels were distinguished in the ‘parent–child relationship’, a behavioural level (parenting behaviour) and a representational level (mental level, i.e. parental cognitions and emotions) (Colpin et al., 1995; Colpin and Soenen, 2002).
At the representational level, parenting stress was studied. Previous studies have reported no significant differences or lower levels of parenting stress among (homologous) IVF parents with young children, compared with naturally conceiving parents (for a review, see Colpin, 2002; for more recent studies, see McMahon et al., 2003; Barnes et al., 2004; Hjelmstedt et al., 2004; Repokari et al., 2006). On the other hand, growing adolescent autonomy could provoke increased stress, especially among IVF parents (see also further).
At the behavioural level, we focused on the parenting style. Parenting style can be defined ‘as a constellation of attitudes toward the child that are communicated to the child and that, taken together, create an emotional climate in which the parents' behaviors are expressed.’ (Darling and Steinberg, 1993, p. 488). According to Darling and Steinberg (1993), parenting style can best be thought of as a contextual variable that determines the effect of specific parenting practices, in other words moderates the relationship between parenting practices or behaviours and child adjustment. Four dimensions of parenting style were studied (cf. Soenens et al., 2004; Beyers and Goossens, 2008). ‘Responsiveness’ refers to the love, warmth and support the parents show to their children. ‘Behavioural control’ concerns the setting of adequate rules and limits to the child's behaviour and the supervision of compliance. ‘Psychological control’ refers to parental behaviours that intrude upon the child's psychological world (e.g. guilt induction, shaming, love withdrawal, belittling). Finally, ‘autonomy support’ is conceptualized as the encouragement of adolescents' enactment upon their true personal interests and values. Research revealed that a high responsiveness, high behavioural control, low psychological control and high autonomy support are predictive for (different) positive developmental outcomes (e.g. Barber et al., 2005; Soenens et al., 2007).
The dimensions responsiveness and behavioural control correspond with the dimensions of warmth and control investigated by Golombok et al. (2002a) among early adolescents. In that study, most of the measures of parental warmth and control revealed no significant differences between assisted reproduction (IVF and donor insemination) families and natural conception families. Concerning parental warmth, several more optimal results were found in the parental self-reports (but not the children's reports). As far as control is concerned, there were some differences from the child's point of view. The assisted reproduction children reported less criticism by both parents and they perceived their father as more lenient in terms of discipline, than naturally conceived children. Golombok et al. (2002a) did not find any significant differences between IVF and donor insemination families. Unlike responsiveness and behavioural control, psychological control and autonomy support as such have never been studied before in research on parenting (older children or adolescents) following IVF. It could be assumed that both dimensions are relevant for IVF families as well. It has been suggested that, because of the infertility history and strong investment in the child, parents may become anxious and develop unreasonably high expectations (e.g. McMahon et al., 1997). This may result in difficulties around the issues of separation and autonomy. Limited evidence, e.g. on higher parental over protectiveness among IVF parents (Weaver et al., 1993; Hahn and DiPietro, 2001; Golombok et al., 2002a), have supported this assumption.
Concerning ‘adolescents' psychosocial adjustment’, internalizing and externalizing behavioural problems have been studied. In the study by Golombok et al. (2002a), among families with early adolescents, no significant differences were found between assisted reproduction and naturally conceived children concerning emotional or behavioural problems, interest and confidence in school work and quality of peer relations.
Finally, we intended to further follow-up parents' practices and attitudes towards informing the adolescent about the nature of his/her conception, and the relationship between disclosure on the one hand and the adolescent's psychosocial adjustment on the other.
In sum, the research question included three issues:
- A comparison of the parent–child relationship between IVF and naturally conceiving families. Both parental stress and parenting style (responsiveness, behavioural control, psychological control and autonomy support) were studied.
- A comparison of psychosocial adjustment (internalizing and externalizing behavioural problems) between IVF and naturally conceived adolescents.
- An exploration of the IVF parents' practices and attitudes towards informing their offspring about the nature of the conception, and the relationship with adolescent psychosocial adjustment.
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Materials and Methods |
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Subjects
In the first phase of our study, the sample consisted of 31 IVF families and 31 families with a naturally conceived child (cf. supra). All children were first-born singletons and aged 2 years at the time of the first phase. The IVF group consisted of primiparous women who became pregnant by (homologous) IVF between May 1989 and July 1990 in the academic hospital of Leuven (Belgium). Each IVF child was matched to a naturally conceived child, randomly drawn from the children born on the same day in the same hospital (for further details, see Colpin et al., 1995
). All mothers and fathers were first-time parents and were native Belgians. A second phase of the study was conducted when the children were 8–9 years old, with 27 IVF families and 23 naturally conceiving families from the original sample (Colpin and Soenen, 2002). For the third phase of the study in adolescence, the 50 families participating in the second phase were contacted again when the adolescents were 15–16 years old. A letter was sent to the parents by the researcher of the first and second phase of the study (H.C.), including an explanation of the nature of this next phase of the study, an informed consent form, self-report questionnaires for the mother, father and adolescent, and stamped envelopes for parents and adolescents to return questionnaires. In the case of agreement, parents were asked to sign the informed consent, complete questionnaires and give the questionnaires to their adolescent child. The study was approved by the ethical committee of the Faculty of Medicine (K.U.Leuven) (21 February 2006).
Informed consent was obtained from 24 IVF families and 21 control families, respectively, 77.4% and 67.7% of the sample who participated in the first phase of the study 13–14 years earlier. Numbers of mothers, fathers and adolescents in both groups are reported in Table II. We did not find any significant differences in age between the mothers, fathers and adolescents from families participating in the third phase of the study and the mothers, fathers and adolescents from families who dropped out since the first phase of the study.
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Among the families participating in this third phase of the study, the number of one-child families was larger in the IVF (37.5%) than in the control group (25.0%), but the difference was not statistically significant. The proportion of boys was somewhat higher in the control group (66.7%) than in the IVF group (54.2%), but the difference was not significant. Mean age did not differ significantly between IVF adolescents (16.05 years, SD = 0.40) and naturally conceived adolescents (15.95 years, SD = 0.30). The IVF mothers' mean age (46.45 years, SD = 3.93) was significantly different from the control mothers' mean age (43.43 years, SD = 2.59) (t = 3.08, df = 40.09, P < 0.01). A significant difference between the groups was found for the fathers' age as well. The fathers' mean ages were 47.33 years (SD = 3.79) and 44.68 years (SD = 3.89) in the IVF and control groups, respectively (t = 2.32, df = 43, P < 0.05). The proportion of mothers with a higher educational degree was significantly lower in the IVF group than in the control group (
2 = 6.63, P < 0.05). A similar tendency was found for the fathers, although the proportions were not significantly different.
Instruments
Table I presents an overview of the instruments completed by mothers, fathers and adolescents, respectively, and Cronbach's alpha coefficients (the latter being a measure of the scales' internal consistency).
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Parenting
To assess the parenting style, the ‘Louvain Adolescent Perceived Parenting Scale’ (LAPPS; Soenens et al., 2004
; Beyers and Goossens, 2008) was used. This questionnaire consisting of 28 items, derived from the Children's Report on Parent Behavior (CRPBI; Schaefer, 1965; Schludermann and Schludermann, 1988; Lamborn et al., 1991) and the Perceptions of Parents Scales (POPS; Grolnick et al., 1997), was completed by the adolescents, separately for their mother and father. In addition, the mother and father filled out a self-report version of this questionnaire. Each of the four dimensions of the parenting style, mentioned above, was measured with seven items. Responsiveness refers to warmth and control provided by the parents (e.g. ‘My mother/father makes me feel better after talking over my worries with her/him’). Behavioural control measures the setting of adequate rules and limits to the child's behaviour (e.g. ‘My mother/father allows me to go out as often as I please’, reverse coding). Psychological control refers to parents' use of intrusive and manipulative control (e.g. ‘My mother/father will avoid looking at me when I have disappointed her/him’). Finally, autonomy support is conceptualized as the encouragement of adolescents' enactment upon their true personal interests and values (e.g. ‘My mother/father allows me to make my own decisions’).
Parenting stress was assessed with the ‘Parenting Stress Index (PSI)’ short form (Abidin, 1983; de Brock et al., 1992). This self-report questionnaire consists of 25 items and refers to two major (parenting) stress domains: a parent domain (with items referring to sense of competence, attachment, depression and health) and a child domain (with items referring to child adaptability, mood, distractibility/hyperactivity, demandingness and reinforcement). The PSI short-form yields one total stress score.
Adolescents' psychosocial adjustment
To assess behavioural and emotional problems, the ‘Child Behaviour Checklist’ (CBCL/4–18; Achenbach, 1991a; Verhulst et al., 1996) and the ‘Youth Self-Report’ (YSR/11–18) (Achenbach, 1991b; Verhulst et al., 1997) were completed by the parents and the adolescent, respectively. Both questionnaires consist of two parts: competence and problems. Only the latter part was used in the present study. The CBCL and YSR behaviour profiles provide scores for total problems, two broad-band syndromes (internalizing and externalizing) and eight narrow-band syndromes. For the purpose of the present study, the total problem score and the two broad-band (internalizing and externalizing) scores were calculated. Norms are available.
Informing adolescents about the IVF conception
IVF mothers were asked to complete the question (cf. Colpin and Soenen, 2002): ‘Do you intend to inform your child about the conception mode?’ Answering codes were: (i) we have already informed the child; (ii) we intend to inform the child; (iii) we do not intend to inform the child; (iv) we are not sure what we will do.
Statistical analyses
When comparing IVF and control families, statistical analyses for data obtained from mothers and fathers were similar to those in the second phase of the study (Colpin and Soenen, 2002). For data obtained from the mothers, differences between the IVF group and the naturally conceiving group were tested using univariate analysis of covariance (ANCOVA), with the conception mode as the independent variable and mother's age and educational level as covariates. For data obtained from the fathers, univariate ANCOVA was used as well, with the difference that there was only one covariate, the father's age. Because no significant interaction effects of the independent variable and covariates were found, the ANCOVAs were performed with the main effects (cf. Tabachnik and Fidell, 1989). For data obtained from the adolescents, we first tested interaction effects of the conception mode and the adolescents' sex (boy or girl). In one case, this interaction was significant (see below). In all other cases, univariate analysis of variance was used, with the conception mode as the independent variable.
To compare behavioural problems between IVF adolescents who were informed and not informed about the IVF conception, t-tests for independent samples were used.
Owing to the small number of families, the chance for statistical type II errors (accepting the null hypothesis while it is not true) is considerably high in this study (cf. Moore and McCabe, 1999). Therefore, effect sizes were calculated as well (cf. Lane, 2003).
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Results |
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Means, standard deviations and effect sizes for the variables referring to parenting and the adolescents' psychosocial adjustment are presented in Table II.
The parent–adolescent relationship
No significant main effect of the conception mode was found for either self- or adolescent-reported parenting style, or for parenting stress. One significant interaction effect of conception mode and sex was found for the adolescents' perception of their father's psychological control [F(1,42) = 6.32, P = 0.016, R2 = 0.14). IVF boys [Mean (M) = 2.77, SD = 0.18) perceived their father as more psychologically controlling than naturally conceived boys (M = 2.16, SD = 0.19), whereas IVF girls (M = 1.82, SD = 0.14) perceived their father as less psychologically controlling than naturally conceived girls (M = 2.25, SD = 0.25).
The adolescents' behaviour
All mean values for both groups on CBCL and YSR fell within the normal range (cf. Verhulst et al., 1996, 1997). IVF parents' ratings of adolescents' behavioural problem were not significantly different from control parents' ratings. Neither did we find significant differences in self-reported behavioural problems between adolescents conceived by IVF or naturally.
Disclosing the IVF status (or not) and its relationship with adjustment
According to the IVF mothers, 16 adolescents (66%) were informed by their parents about the assisted character of the conception. In two (8%) of the families, parents intended to inform their adolescent later on; in one family, parents did not intend to provide this information at all and in five families (21%), parents were undecided. Families with informed and non-informed adolescents did not differ significantly on background characteristics (parents' age, adolescent age and sex, number of children in the family). Table III shows means, standard deviations and effect sizes for the variables referring to the adolescents' psychosocial adjustment in our study, separately for adolescents informed and not informed about their IVF status. We did not find any significant differences between informed and non-informed IVF adolescents for internalizing, externalizing or total behavioural problems. All means fell within the normal (non-clinical) range (cf. Verhulst et al., 1996, 1997).
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Discussion |
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As far as we know, this is the first psychosocial study following up IVF families into children's mid-adolescence and the first to investigate adjustment level by disclosure status in this age group. Moreover, it is one of the first to use, next to parent reports, data from IVF-offspring and naturally conceived peers. Neither the parent nor the adolescent reports revealed significant differences in parenting and adolescent psychosocial adjustment between the IVF and control groups. We did find an interaction effect of sex and conception mode for the adolescents' perception of the father's psychological control: IVF boys reported a higher and IVF girls a lower level of father's psychological control, compared with controls of the same sex. We cannot exclude that this finding is an artefact of multiple testing.
Our findings support those from the two previous stages of our study, when the children were 2 years and 8–9 years old, respectively (Colpin et al., 1995; Colpin and Soenen, 2002). At neither occasion did we find significant differences in parental behaviour and child adjustment between IVF and control families. When the children were 8–9 years old, the parenting goal adjustment was more important for IVF than for control fathers and the parenting goal religion was more important for IVF than for control mothers. These differences were not reflected in parental behaviour or child adjustment in mid-adolescence.
More in general, our results add further support for the findings that, on average, IVF children and their families are psychologically well-adjusted, even when children grow older and more independent and autonomous (cf. Golombok et al., 2002a; Sutcliffe and Ludwig, 2007). The most obvious explanation for these positive results is that the stress that accompanies infertility is compensated for by the birth and growing up of the child (Colpin, 2002). Moreover, between the start of our study and today, IVF has become a widely used and publicly accepted reproduction technique. As a consequence, it may have lost a lot of the emotional charges of the early days, leading to a ‘normalization’ of (the perception of) this conception mode. Another explanation for the absence of differences might be that, nowadays, natural conception is also heavily planned (Colpin, 2002). More generally, today's naturally conceived children and adolescents are surrounded with much attention and great care as well, as was shown in several studies in our region (Rispens et al., 1996; Vandoorne et al., 2000).
In the second phase of our study, when the children were 8–9 years old, most of the parents had not informed their IVF offspring about the way they were conceived (Colpin and Soenen, 2002). Similar findings had been obtained in other studies among families with young IVF children (e.g. Greenfeld et al., 1996; Braverman et al., 1998). As in the other studies, most parents reported that they intended to inform the child later on. In the present stage of our study, two out of three adolescents knew about their IVF conception. In the study by Golombok et al. (2002a), among families with 11–12 year-olds, 50% of the IVF parents had informed the child (versus 8.6% of donor insemination parents). It may be surprising that in our study, at the age of 15–16, one-third of the IVF adolescents were not informed, given the fact that the adolescents are genetically related to both their parents. Moreover, almost all parents informed others, outside the family (Colpin and Soenen, 2002). Both when the children were 8–9 years old and in the current phase of our study, one set of parents said they would certainly not inform the child. The proportion of parents who had either informed their child or intended to do it later on decreased from the second to the third phase of the study (from 85% to 74%); the proportion of undecided parents increased (from 11% to 21%). These findings suggest that between the child's ages of 8 and 15 years, some parents shift from intending to tell the child towards not knowing what to do. In studies on donor insemination families, it was found that a lot of parents do not know when and how to tell the children (e.g. Lindblad et al., 2000; Brewaeys, 2001). It is possible that, as children grow older, it becomes more and more difficult to start with the revealing of this issue. The longer parents wait with telling, the more this information may receive the status of a ‘secret’. In a study by Scheib et al. (2005), among donor insemination adolescents with open identity donors (donors who are willing to reveal their identity to adult offspring), most adolescents reported to be more or less comfortable with their conception status, and that knowing had a neutral or positive impact on their relationship with their birth mother and their other parent. More than three out of four of these adolescents reported always knowing about their donor insemination origins. Golombok et al. (2002b) found that several donor insemination parents, while regretting not having informed their 11–12-year-old child, felt that it was too late to tell at this stage. They expected this information to be too disturbing for the child. Although the information to be revealed is much more fundamental in the case of donor insemination, a similar kind of reasoning may apply to homologous IVF as well. In any case, whether or not parents had informed their children about the IVF conception did not seem to make a significant difference for adolescents' psychosocial adjustment. The findings of increased internalizing problems among children informed in the second phase of the study (Colpin and Soenen, 2002) were not supported in mid-adolescence.
Given the time passed since the first phase of the study, 13 years or more, it is striking that more than three out of four IVF families and two out of three naturally conceiving families were willing to participate again, and that parents agreed with their adolescent child's participation. However, the absolute number of participating families was small. The small sample size is a consequence of the small number of families in the first phase of the study, which in turn is related to the recruitment in one medical centre, at a time when IVF was not as widely used as it is today. Moreover, data collection in this first phase was intensive (e.g. home observations). In this perspective, the absence of significant differences in parenting and adolescents' psychosocial development between IVF and naturally conceiving families is not surprising. Because of the high risk for type II errors, and as in the second phase of our study (Colpin and Soenen, 2002), effect sizes were calculated as well. When looking at the effect sizes, it appeared that the differences between IVF families and naturally conceiving families were indeed (very) small for all variables, 6.8% being the highest proportion of variance explained by conception mode.
Families in the IVF group and the control group were not completely comparable. In particular, IVF parents were significantly older than parents by natural conception. Moreover, the proportion of mothers with a higher educational degree was significantly lower in the IVF group than in the control group. As was mentioned earlier, the difference for educational level is most likely due to a bias in recruitment characteristics rather than to a general difference in educational level between IVF parents and naturally conceiving parents. Whereas the IVF families were recruited from all over the Flemish region, most families in the control group lived in the area of Leuven, a university town with a disproportionally large number of highly qualified inhabitants (Colpin et al., 1995; Colpin and Soenen, 2002). These types of recruitment biases are common in IVF studies (e.g. Van Balen, 1998). The effects of the parents' age and the mothers' educational level were controlled by ANCOVA (cf. Colpin et al., 1995; Colpin and Soenen, 2002).
Further multisource research, among larger groups of adolescent offspring, is needed to underpin our conclusions. Concerning parenting, it is recommended to study not only parental representations, but also parenting behaviour. Recent developments in theories of parenting style, as described above, provide relevant concepts and measures. Concerning adolescents' psychosocial adjustment, we only studied behavioural problems. Identity development, which, according to some (e.g. Mushin et al., 1985; Bydlowski, 1990), might be affected by the IVF conception, was not included and would be a relevant concept in future research (e.g. Luyckx et al., 2006, for recent theoretical and measurement issues).
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Submitted on February 1, 2008; resubmitted on July 3, 2008; accepted on July 9, 2008.
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