The CARING study: Examining biological, behavioral, and genetic mechanisms in the intergenerational transmission of toxic stress.

When children experience extreme or persistent stressors (e.g., maltreatment, housing insecurity, intimate partner violence), prolonged elevation of the stress-response system can lead to disrupted development of multiple physiological systems. This response, known as toxic stress, is associated with poor physical and mental health across the life course. Emerging evidence suggests that the effects of toxic stress may be transmitted through generations, but the biological and behavioral mechanisms that link caregivers' childhood history with the health of the children they care for remain poorly understood. The purpose of this report is to describe the research protocol for The CARING (Childhood Adversity and Resilience In the Next Generation) Study, a cross-sectional study of caregivers with children aged 3-5 years designed to (1) examine the intergenerational transmission of toxic stress and protective factors; (2) explore three hypothesized pathways of transmission: parenting, daily routines, stressors, and supports; and (3) explore the extent to which genotypic variation in candidate genes related to caregiving and stress contribute to caregivers' and children's susceptibility to the effects of early childhood experiences (i.e., gene × environment interactions). We expect that findings from this study will provide critical data needed to identify targets for precision health interventions, reduce health disparities related to toxic stress, and prevent cycles of adversity among families at risk.

Leveraging biosocial methods to examine and address structural determinants of health and promote health equity.

BACKGROUND: Biosocial approaches in nursing research have largely focused on the ways that social determinants of health influence individual-level outcomes, including symptom management, family and social support, and educational interventions. PURPOSE: Theoretical, methodological, and practical strategies are needed to expand current biosocial methods for nursing science and focus on upstream, structural determinants of health and the policies that underlie health inequities. METHODS: This paper summarizes presentations given at the 2023 Council for the Advancement of Nursing Science Advanced Methods Conference, Biosocial Methods to Advance Health Equity, in a panel titled "Individual, community, systems and policy related to biosocial methods." DISCUSSION: Nurses are uniquely positioned to examine upstream, structural determinants of health by leveraging expertise in biosocial methods, collaborating with interdisciplinary researchers and community members, and advocating for policy change. By conducting theory-grounded biosocial research, nurse researchers can significantly advance scientific knowledge and promote health equity for individuals and communities. CONCLUSION: Nurse scientists are conducting research using biosocial methods and provide recommendations for expansion of this approach in the field.

Adapting the Health Stigma and Discrimination Framework to understand the association between stigma and sleep deficiency: A systematic review.

OBJECTIVE: Sleep deficiency and sleep disorders disproportionally affect socially disadvantaged and marginalized individuals and groups. Recent evidence suggests that stigma, a social process characterized by labeling, stereotyping, and prejudice, is associated with sleep characteristics. PURPOSE: Guided by the Health Stigma and Discrimination Framework, the purpose of this systematic review is to describe associations between dimensions of stigma and sleep deficiency and to identify future directions for research. METHODS: We searched the OVIDPsycINFO, OVIDEMASE, OVIDMEDLINE, and CINAHL databases for empirical research studies that reported relationships between the 3 dimensions of stigma-internalized, perceived, and anticipated-and characteristics of sleep deficiency-duration, continuity/efficiency, timing, alertness/sleepiness, quality, and disorders. RESULTS: Of 1717 articles, 15 met our inclusion criteria. The most frequently assessed dimensions of stigma were internalized and perceived stigma. Characteristics of sleep deficiency were measured by self-report and included sleep quality, duration, trouble sleeping, and insomnia symptoms. We found consistent evidence that stigma, whether internalized, perceived, or anticipated, is associated with self-reported characteristics of sleep deficiency. CONCLUSIONS: This evidence base can be further strengthened with prospective studies that incorporate both multidimensional measures of stigma and objective measures of sleep characteristics. We outline research implications that can clarify underlying mechanisms and more precisely define the relationships between stigma and sleep and inform interventions to address stigma, improve sleep, and reduce the health inequities that disproportionately affect individuals from socially disadvantaged and marginalized groups.

Early life adversity and males: Biology, behavior, and implications for fathers' parenting.

Fathers have an important and unique influence on child development, but influences on fathers' parenting have been vastly understudied in the scientific literature. In particular, very little empirical research exists on the effects of early life adversity (ELA; e.g. childhood maltreatment, parental separation) on later parenting among fathers. In this review, we draw from both the human and non-human animal literature to examine the effects of ELA, specifically among males, in the following areas: 1) neurobiology and neurocognitive functioning, 2) hormones and hormone receptors, 3) gene-environment interactions and epigenetics, and 4) behavior and development. Based on these findings, we present a conceptual model to describe the biological and behavioral pathways through which exposure to ELA may influence parenting among males, with a goal of guiding future research and intervention development in this area. Empirical studies are needed to improve understanding of the relationship between ELA and father's parenting, inform the development of paternal and biparental interventions, and prevent intergenerational transmission of ELA.

Birth-Related Outcomes for Second Children Following Home Visiting Program Enrollment for New Parents of First Children.

INTRODUCTION: Home visiting (HV) programs aim to promote child and family health through perinatal intervention. HV may benefit second children through improving subsequent pregnancy and birth outcomes. However, HV impacts on birth outcomes of second children have not been examined in a naturalistic setting. METHODS: Using data from Connecticut Nurturing Families Network (NFN) home visiting program of families enrolled from 2005 to 2015, we compared birth-related outcomes (birthweight, preterm birth, Cesarean section delivery, prenatal care utilization) of second children (n = 1758) to demographically similar propensity-score-matched families that were not enrolled in NFN (n = 5200). We examined whether the effects of NFN differed by maternal age, race and ethnicity, or visit attendance pattern. RESULTS: There was no program effect for the full sample. The effect of NFN did not differ by maternal age or visit attendance pattern but did differ by maternal race and ethnicity. Black women in NFN were more likely to receive adequate prenatal care during their second pregnancy (OR 1.05; 95% CI 1.01, 1.09) and Hispanic women in NFN were less likely to deliver by Cesarean section for their second birth (OR 0.97; 95% CI 0.94, 0.99), compared to Black and Hispanic women in the comparison group respectively. There was a protective program effect on prematurity of the second child (OR 0.92; 95% CI 0.85, 0.996) for women with a preterm first birth. DISCUSSION: These findings suggest that benefits of HV extend to subsequent birth-related outcomes for women from marginalized racial/ethnic groups. HV may help buffer some harmful social determinants of health.

Racial Discrimination, Mental Health, and Parenting Among African American Mothers of Preschool-Aged Children.

OBJECTIVE: Indirect exposure to racism experienced by a caregiver (ie, vicarious racism) is associated with poor outcomes for children, but mechanisms of vicarious racism transmission are poorly understood. The purpose of this study was to examine the relationship between experiences of racial discrimination and parenting among African American mothers and to identify psychological mediators and moderators of this relationship. METHOD: African American mothers (N = 250) with young children (mean age = 3.7 years old) reported on perceived racial discrimination (Race-Related Events Scale), parenting (Parenting Stress Index, Parenting Styles and Dimensions Questionnaire), coping (Coping Strategies Index), and mental health (Stress Overload Scale, Beck Depression Inventory). Multivariable linear regression was used to examine associations between perceived racial discrimination and parenting and to test coping as a moderator of these relationships. Ordinary least-squares regression-based path analysis with bootstrapping was used to examine mediation by stress overload and depressive symptoms. RESULTS: At least one experience of racial discrimination was reported by 57% of women. Experiences of racial discrimination were associated with increased parenting stress (ß = 0.69, p = .02), and this relationship was mediated by stress overload (95% CI [0.35, 1.09]) and depressive symptoms (95% CI [0.27, 1.18]). Racial discrimination was not associated with parenting styles, and coping strategies largely did not moderate the relationships examined. CONCLUSION: Racial discrimination has harmful intergenerational effects on African American children and families. Systemic-level interventions are needed, including adoption of policies to promote racial justice and eliminate structural racism in the United States. Future research on coping strategies specific to racism-related stress is needed to inform approaches to intervention.

Examining Mothers' Childhood Maltreatment History, Parental Reflective Functioning, and the Long-Term Effects of the Minding the Baby® Home Visiting Intervention.

Research is needed to better understand how childhood maltreatment history affects parental reflective capacities, and whether early childhood interventions help mitigate these effects. We examined associations between childhood maltreatment and current parenting (parental reflective functioning, parenting behaviors) among mothers who participated in a follow-up study (N = 97) of the Minding the Baby® (MTB) randomized control trial. MTB is a home visiting program that aims to help mothers understand their child's mental states (feelings, intentions, needs) by promoting parental reflective functioning. Mothers retrospectively reported childhood maltreatment using the Childhood Trauma Questionnaire. Endorsing a higher number of childhood maltreatment subtypes was associated with less supportive/engaged parenting and higher pre-mentalizing modes, or difficulty with appropriately reflecting on the child's mental states. These relationships were not moderated by participation in the MTB intervention. However, exploratory analyses of individual maltreatment subtypes revealed that participation in MTB may mitigate the harmful effects of childhood emotional abuse on pre-mentalizing modes, specifically. Further research is needed to understand the mechanisms through which early childhood interventions may prevent intergenerational cycles of maltreatment.

Maternal Experiences of Racial Discrimination, Child Indicators of Toxic Stress, and the Minding the Baby Early Home Visiting Intervention.

BACKGROUND: Racism is a significant source of toxic stress and a root cause of health inequities. Emerging evidence suggests that exposure to vicarious racism (i.e., racism experienced by a caregiver) is associated with poor child health and development, but associations with biological indicators of toxic stress have not been well studied. It is also unknown whether two-generation interventions, such as early home visiting programs, may help to mitigate the harmful effects of vicarious racism. OBJECTIVE: The purpose of this study was to examine associations between maternal experiences of racial discrimination and child indicators of toxic stress and to test whether relationships are moderated by prior participation in Minding the Baby (MTB), an attachment-based early home visiting intervention. METHODS: Ninety-seven maternal-child dyads (n = 43 intervention dyads, n = 54 control dyads) enrolled in the MTB Early School Age follow-up study. Mothers reported on racial discrimination using the Experiences of Discrimination Scale. Child indicators of toxic stress included salivary biomarkers of inflammation (e.g., C-reactive protein, panel of pro-inflammatory cytokines), body mass index, and maternally reported child behavioral problems. We used linear regression to examine associations between maternal experiences of racial discrimination and child indicators of toxic stress and included an interaction term between experiences of discrimination and MTB group assignment (intervention vs. control) to test moderating effects of the MTB intervention. RESULTS: Mothers identified as Black/African American (33%) and Hispanic/Latina (64%). In adjusted models, maternal experiences of racial discrimination were associated with elevated salivary interleukin-6 and tumor necrosis factor-α levels in children, but not child body mass index or behavior. Prior participation in the MTB intervention moderated the relationship between maternal experiences of discrimination and child interleukin-6 levels. DISCUSSION: Results of this study suggest that racism may contribute to the biological embedding of early adversity through influences on inflammation, but additional research with serum markers is needed to better understand this relationship. Improved understanding of the relationships among vicarious racism, protective factors, and childhood toxic stress is necessary to inform family and systemic-level intervention.

A systematic review of the association between sleep health and stress biomarkers in children.

Sleep is intimately linked with the stress response system. While the evidence for this connection has been systematically reviewed in the adult literature, to our knowledge no studies have examined this relationship in young children. Recent scientific interest in understanding the effects of adverse environments in early childhood, including an emphasis on understanding the role of sleep, highlights the importance of synthesizing the current evidence on the relationship between sleep and the stress response system in early childhood. The aim of this systematic review is to examine the relationship between sleep health and biomarkers of physiologic stress (neuroendocrine, immune, metabolic, cardiovascular) in healthy children ages 0-12 y. Following PRISMA guidelines, we identified 68 empirical articles and critically reviewed and synthesized the results across studies. The majority of studies included school-age children and reported sleep dimensions of duration or efficiency. Overall, evidence of associations between sleep health and stress biomarkers was strongest for neuroendocrine variables, and limited or inconsistent for studies of immune, cardiovascular, and metabolic outcomes. Gaps in the literature include prospective, longitudinal studies, inclusion of children under the age of 5 y, and studies using objective measures of sleep.

The Association Between Neighborhood Social Vulnerability and Cardiovascular Health Risk Among Black/African American Women in the InterGEN Study.

BACKGROUND: Black/African American women in the United States are more likely to live in neighborhoods with higher social vulnerability than other racial/ethnic groups, even when adjusting for personal income. Social vulnerability, defined as the degree to which the social conditions of a community affect its ability to prevent loss and suffering in the event of disaster, has been used in research as an objective measure of neighborhood social vulnerability. Black/African American women also have the highest rates of hypertension and obesity in the United States. OBJECTIVES: The purpose of this study was to examine the relationship between neighborhood social vulnerability and cardiovascular risk (hypertension and obesity) among Black/African American women. METHODS: We conducted a secondary analysis of data from the InterGEN Study that enrolled Black/African American women in the Northeast United States. Participants' addresses were geocoded to ascertain neighborhood vulnerability using the Centers for Disease Control and Prevention's Social Vulnerability Index at the census tract level. We used multivariable regression models to examine associations between objective measures of neighborhood quality and indicators of structural racism and systolic and diastolic blood pressure and obesity (body mass index > 24.9) and to test psychological stress, coping, and depression as potential moderators of these relationships. RESULTS: Seventy-four percent of participating Black/African American women lived in neighborhoods in the top quartile for social vulnerability nationally. Women living in the top 10% of most socially vulnerable neighborhoods in our sample had more than a threefold greater likelihood of hypertension when compared to those living in less vulnerable neighborhoods. Objective neighborhood measures of structural racism (percentage of poverty, percentage of unemployment, percentage of residents >25 years old without a high school diploma, and percentage of residents without access to a vehicle) were significantly associated with elevated diastolic blood pressure and obesity in adjusted models. Psychological stress had a significant moderating effect on the associations between neighborhood vulnerability and cardiovascular risk. DISCUSSION: We identified important associations between structural racism, the neighborhood environment, and cardiovascular health among Black/African American women. These findings add to a critical body of evidence documenting the role of structural racism in perpetuating health inequities and highlight the need for a multifaceted approach to policy, research, and interventions to address racial health inequities.

The prefrontal cortex in a pandemic: Restoring functions with system-, family-, and individual-focused interventions.

The COVID-19 pandemic is an unanticipated and uncontrollable chronic stressor that is detrimental to the mental and behavioral health of children and families, particularly those from disadvantaged and marginalized backgrounds. Chronic stress impairs a myriad of prefrontal cortical functions, important for coping with the COVID-19 pandemic, and has consequences on dyadic parent-child functioning. Informed by neuroscience and clinical evidence, sensitive parenting is a vital avenue of intervention that buffers against the toxic effects of COVID-19 on parent-child mental health. In the context of the COVID-19 pandemic, we first discuss the neurobiological, psychological, and behavioral mechanisms behind exacerbated mental health risks in families. We then highlight the role of sensitive parenting as a buffer against stress-related mental health problems, and conclude with recommendations for systemic-, family-, and individual-interventions to most effectively address stress-related mental health problems and their impact on children and families during the COVID-19 pandemic. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Acceptability and Feasibility of Hair and Salivary Biomarker Collection Among Multiethnic School-Age Children.

OBJECTIVE: As noninvasive biological markers gain increasing popularity in pediatric research, it is critical to understand how study participants perceive these measures, especially among groups underrepresented in biobehavioral research, like children and people of color. The purpose of this study was to examine acceptability and feasibility of hair and salivary biomarker collection in an urban community sample of ethnically diverse children (age 4 to 10 years). METHODS: Ninety-seven mother-child dyads were recruited for a cross-sectional follow up study of the Minding the Baby® home visiting intervention. Children were Hispanic (63%), Black (34%), and multi-racial (3.1%). A conventional content analysis was conducted using two sources of data: (1) mothers' responses to open-ended interview questions on their views and suggestions regarding biomarker collection, and (2) field notes recorded by investigators. RESULTS: Forty-four percent of mothers reported biomarker-related questions or concerns, including questions about the purpose of biomarker testing, and concerns about cosmetic issues, child discomfort, and future use of biomarker data. Mothers also offered positive feedback and advice for collection. Issues affecting feasibility included children's hair length and style, refusal to participate, and behavioral or developmental issues. CONCLUSIONS: Hair and salivary biomarker collection was largely acceptable and feasible in this sample. Strategies for promoting ethical and sensitive biomarker collection include respectful explanations and parental involvement, creating a comfortable and safe environment for the child, flexible collection strategies, and attention to development, cultural preferences and perspectives.

A systematic review of the effectiveness of interventions designed for mothers who experienced child sexual abuse.

BACKGROUND: Past experiences of child sexual abuse (CSA) have been shown to have a pernicious effect on the parenting behaviors of mothers. As a result, interventions have been developed to address these effects. However, a systematic synthesis of the effectiveness of such interventions has not been conducted. OBJECTIVE: To conduct a systematic review of existing literature on interventions that have been developed and evaluated for mothers who experienced CSA. METHODS: Studies were located through a sensitive search strategy in nine academic databases and search engines, and through handsearching reference lists of included studies and their subsequent citations. Two authors independently completed screening, full text review, data extraction, and quality appraisal. RESULTS: Searches revealed a paucity of literature, with four intervention studies located. All four interventions consisted of therapy, with three of these interventions using a group-based format. One of the included intervention studies used reiki as an adjunct to therapy. Decreases in negative mental health symptoms were reported through both validated measures and interviews. No validated measures to assess parenting were used in any intervention, though some qualitative results indicated changes in parenting. Qualitative results also suggested that most mothers were satisfied with the interventions. Studies were of limited quality - none used a randomized trial design, and only one a control group. CONCLUSIONS: Given the limitations of the identified intervention studies for mothers who experienced CSA, there is a clear need to develop evidence-based interventions for this population given the unique detrimental effects of CSA on parenting. Avenues for future intervention development are discussed.

A mixed methods investigation of the association between child sexual abuse and subsequent maternal parenting.

BACKGROUND: Child sexual abuse (CSA) is associated with a number of pernicious outcomes, including adverse parenting outcomes among mothers who experienced CSA (MCSA). Despite the large literature on these outcomes, gaps and uncertainties in the literature exist. Specifically, while previous literature has shown that some MCSA have their parenting negatively affected by CSA, others do not, and potential mechanisms explaining these variations, such as mental health and characteristics of the CSA experience, have not been fully explored. OBJECTIVES: To investigate (1) how MCSA believe their CSA experiences have affected their parenting, if at all; (2) what factors may be contributing to these perceived effects; and (3) what resources or intervention components MCSA believe they need to cope with their experiences. PARTICIPANTS AND SETTING: Participants were MCSA primarily from the UK and the Republic of Ireland. METHODS: MCSA were recruited through partner organizations specializing in parenting, child abuse, and mental health to complete an online survey with both qualitative and quantitative components. Qualitative data were thematically synthesized and subgroup analyses were conducted. RESULTS: MCSA reported that their CSA experiences most affected their desire to protect their child from experiencing abuse. Additionally, breastfeeding, child-rearing practices, the mother-child relationship, and perceptions of motherhood and the child were reported to be affected. CONCLUSIONS: Given that MCSA have reported their CSA experiences to negatively affect several aspects of parenting, evidence-based interventions are needed. Participant concerns regarding parenting and suggestions made by participants in this study for interventions may aid in intervention development.

Parenting Among Mothers Who Experienced Child Sexual Abuse: A Qualitative Systematic Review.

Child sexual abuse (CSA) represents a significant public health problem. While CSA is associated with several adverse outcomes, recent attention has been given to its effect on maternal parenting. Despite a growing literature on this topic, a comprehensive systematic review has not been conducted. Thus, this review aimed to fill this gap. Several search strategies were used, including searches in academic databases. Two reviewers completed screening, full-text review, data extraction, and quality determinations. Extracted qualitative data were synthesized for the 108 studies meeting inclusion criteria. The primary themes emerging from women's accounts of the effects of CSA on their current parenting included abuse of child, breastfeeding, child-rearing practices, coping related to parenting, mother-child relationship, perceptions of child, perceptions of motherhood, and protection of children from abuse. Given the current lack of interventions designed for these mothers, the results of this review may aid in the development of evidence-based interventions.

Associations Between Maternal Experiences of Discrimination and Biomarkers of Toxic Stress in School-Aged Children.

OBJECTIVE: To examine associations between maternal experiences of discrimination and child biomarkers of toxic stress in a multiethnic, urban sample of mothers and children (4-9 years). METHODS: Data were drawn from a cross-sectional study of maternal-child dyads (N = 54) living in low-income neighborhoods in New Haven, Connecticut, USA. Mothers reported experiences of discrimination. Noninvasive biomarkers of toxic stress were collected to assess neuroendocrine (hair cortisol), immune (salivary cytokines, c-reactive protein), and cardiovascular (blood pressure) functioning in children. RESULTS: Maternal experiences of discrimination were associated with increased log-transformed salivary interleukin-6 (IL-6) levels in children (ß = 0.15, p = 0.02). CONCLUSIONS: Vicarious racism, or indirect exposure to discrimination experienced by caregivers, is associated with poor health outcomes for children. Immune pathways may be a biological mechanism through which racial discrimination "gets under the skin," but additional research is needed to fully understand these relationships. Uncovering the physiological mechanisms linking vicarious racism with child health is an important step towards understanding possible early roots of racial and ethnic health inequities.

A systematic review of the association between the childhood sexual abuse experiences of mothers and the abuse status of their children: Protection strategies, intergenerational transmission, and reactions to the abuse of their children.

Child sexual abuse (CSA) represents a significant public health concern. Research shows an association between the CSA status of mothers and the abuse status of their children, how they react to the abuse of their children, and behaviors they engage in to protect their children from abuse. However, a systematic review of this literature has yet to be conducted, and this review aimed to fill that gap. Seven databases and search engines were searched for relevant studies from inception until March 2017. Reference lists of included studies and titles of studies that cited included studies were also searched. Two authors independently completed study screening, data extraction, and quality determinations. Ninety-three studies were identified and narratively synthesized by significant, non-significant, and descriptive results. These results were further elaborated on in the context of the methods used. Though some heterogeneity existed, results showed that status as a mother with a CSA history (MCSA) was associated with having children who experienced CSA. There was no evidence that MCSA status was associated with a greater likelihood of believing their children when they disclosed abuse, although MCSA status was associated with increased emotional distress. Results were mixed regarding whether MCSA status was associated with perpetrating maltreatment broadly, perpetrating individual forms of maltreatment, such as emotional abuse or neglect, or having the potential to abuse. Most studies found no association between MCSA status and use of corporal punishment. However, when mothers and others were combined, because the main perpetrator was not listed, it was found that belonging to this combined group was associated with increased risk of engaging in maltreatment behaviors. Finally, few studies on protective behaviors of MCSA were located. Future research is needed with larger, more diverse samples using validated instruments. This information will be critical for future intervention development.

Birth outcomes of second children after community-based home visiting: A research protocol.

Birth-related outcomes, such as birth weight, have lifelong impacts on health. Home visiting (HV) is an established approach to improve the health of children and families, parenting practices, and connections to social and health services. Many HV programs target first-time mothers, in part because HV activities related to a first-birth may improve birth outcomes for subsequent children, but few researchers have examined these effects. We will link data from a statewide HV program (Nurturing Families Network [NFN]) to birth certificate data to create comparison groups and measure outcomes in this observational study. Specifically, we will compare birth outcomes for NFN second-children (n = 3000) to those for: (a) first-child older siblings whose birth/gestation led to NFN enrollment (n = 3000); (b) second children of families who were screened as eligible for NFN, but not offered the program due to home visitor availability and other logistical reasons (n = 650); and (c) non-NFN second children in a propensity-score-matched group created using the likelihood of enrollment in NFN based on maternal health, demographics, and neighborhood characteristics (n = 6000). The outcomes we will examine are birth spacing, prenatal care received, cesarean section rate, gestational age, and birth weight in second-children. We will also examine the associations between program attendance (i.e., missed visits, dropout) and birth outcomes, that will generate evidence that may be used in programmatic decisions regarding continued funding and/or modification of NFN, prioritization of specific retention efforts, and targeting of first-time mothers. Use of this evidence should improve outcomes for future NFN families and may inform similar programs.

Maternal, Infant, and Early Childhood Home Visiting: A Call for a Paradigm Shift in States' Approaches to Funding.

Early home visiting is a vital health promotion strategy that is widely associated with positive outcomes for vulnerable families. To expand access to these services, the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program was established under the Affordable Care Act, and over $2 billion have been distributed from the Health Resources and Services Administration to states, territories, and tribal entities to support funding for early home visiting programs serving pregnant women and families with young children (birth to 5 years of age). As of October 2018, 20 programs met Department of Health and Human Services criteria for evidence of effectiveness and were approved to receive MIECHV funding. However, the same few eligible programs receive MIECHV funding in almost all states, likely due to previously established infrastructure prior to establishment of the MIECHV program. Fully capitalizing on this federal investment will require all state policymakers and bureaucrats to reevaluate services currently offered and systematically and transparently develop a menu of home visiting services that will best match the specific needs of the vulnerable families in their communities. Federal incentives and strategies may also improve states' abilities to successfully implement a comprehensive and diverse menu of home visiting service options. By offering a menu of home visiting program models with varying levels of service delivery, home visitor education backgrounds, and targeted domains for improvement, state agencies serving children and families have an opportunity to expand their reach of services, improve cost-effectiveness, and promote optimal outcomes for vulnerable families. Nurses and nursing organizations can play a key role in advocating for this approach.