Cluster Randomized Controlled Trial of Intervention to Increase Participant Retention and Completed Home Visits in the Nurse-Family Partnership.

We conducted a cluster-based randomized controlled trial of an intervention designed to improve participant retention in community replication sites of the Nurse-Family Partnership (NFP). We registered 26 sites and randomized them into three groups: retention intervention (RI, N = 9), delayed RI (DRI, N = 6), or control (C, NFP as usual, N = 11). The RI consisted of training nurses to give more explicit control over the frequency of visits and content of the program to the parent participants. Two of the sites assigned to the RI, two assigned to the DRI, and two out of four nurses in one other site assigned to the DRI chose not to participate in the intervention. Primary analyses (intention to treat) contrasted changes in participant retention and completed visits (the primary outcomes) in the two intervention groups (RI and DRI) compared to control sites, focusing on differences in performance among baseline cohorts compared to cohorts enrolled during the first year during which the retention intervention was implemented. Compared to baseline, retention declined in the control sites over time but stayed the same in the RI and DRI sites (p value for interaction = 0.099). Compared to baseline, the number of completed home visits declined over time in the control sites but did not in the RI and DRI sites, producing a significant treatment difference in change in mean completed home visits over time (2.71 visits, SE = 1.164, p = 0.020). The intervention offset a decline over time in retention and completed home visits found in the control group during the time covered by this trial. Quantitative and qualitative evaluation of the intervention indicated that improvements are needed to promote its uptake.

Quasi-experimental pilot study of intervention to increase participant retention and completed home visits in the nurse-family partnership.

We evaluated an intervention to increase participant retention and engagement in community practice settings of the Nurse-Family Partnership (NFP), an evidence-based program of nurse home visiting for low-income, first-time parents. Using a quasi-experimental design (6 intervention and 11 control sites that delivered the NFP), we compared intervention and control sites on retention and number of completed home visits during a 10-month period after the intervention was initiated. Nurses at the five intervention sites were guided in tailoring the frequency, duration, and content of the visits to participants' needs. NFP nurses at the control sites delivered the program as usual. At the intervention sites, participant retention and completed home visits increased from the pre-intervention to intervention periods, while at the control sites, these outcomes decreased from the pre-intervention to intervention periods, leading to a significant intervention-control difference in change in participant retention (hazard ratio, 0.42; p = 0.015) and a 1.4 visit difference in change in completed home visits (p < 0.001, ES = 0.36). We conclude that training nurse home visitors to promote adaptation of program dosage and content to meet families' needs shows promise as a way to improve participant retention and completed home visits.

Mixed methods analysis of participant attrition in the nurse-family partnership.

Participant attrition is a major influence on the effectiveness of evidence-based interventions. Assessing predictors of participant attrition and nurse and site characteristics associated with it could lay a foundation for increasing retention and engagement. We examined this issue in the national expansion of the Nurse-Family Partnership, an evidence-based program of prenatal and infancy home visiting for low-income, first-time mothers, their children, and families. Using a mixed methods approach, we examined participant, nurse, and site predictors of participant attrition and completed home visits. We used mixed multivariate regression models to identify participant, nurse, program, and site predictors of addressable attrition and completed home visits during pregnancy and the first year of the child's life for 10,367 participants at 66 implementation sites. We then conducted semi-structured interviews with nurse home visitors and supervisors at selected sites with the highest (N = 5 sites) and lowest (N = 6 sites) rates of participant addressable attrition and employed qualitative methods to synthesize themes that emerged in nurses' descriptions of the strategies they used to retain participants. Mothers who were younger, unmarried, African American, and visited by nurses who ceased employment had higher rates of attrition and fewer home visits. Hispanic mothers, those living with partners, and those employed at registration had lower rates of attrition. Those who were living with partners and employed had more home visits. Nurses in high retention sites adapted the program to their clients' needs, were less directive, and more collaborative with them. Increasing nurses' flexibility in adapting this structured, evidence-based program to families' needs may increase participant retention and completed home visits.

Conduct problems, depressive symptomatology and their co-occurring presentation in childhood as predictors of adjustment in early adolescence.

The present study investigated patterns in the development of conduct problems (CP), depressive symptoms, and their co-occurrence, and relations to adjustment problems, over the transition from late childhood to early adolescence. Rates of depressive symptoms and CP during this developmental period vary by gender; yet, few studies involving non-clinical samples have examined co-occurring problems and adjustment outcomes across boys and girls. This study investigates the manifestation and change in CP and depressive symptom patterns in a large, multisite, gender-and ethnically-diverse sample of 431 youth from 5th to 7th grade. Indicators of CP, depressive symptoms, their co-occurrence, and adjustment outcomes were created from multiple reporters and measures. Hypotheses regarding gender differences were tested utilizing both categorical (i.e., elevated symptom groups) and continuous analyses (i.e., regressions predicting symptomatology and adjustment outcomes). Results were partially supportive of the dual failure model (Capaldi, 1991, 1992), with youth with co-occurring problems in 5th grade demonstrating significantly lower academic adjustment and social competence two years later. Both depressive symptoms and CP were risk factors for multiple negative adjustment outcomes. Co-occurring symptomatology and CP demonstrated more stability and was associated with more severe adjustment problems than depressive symptoms over time. Categorical analyses suggested that, in terms of adjustment problems, youth with co-occurring symptomatology were generally no worse off than those with CP-alone, and those with depressive symptoms-alone were similar over time to those showing no symptomatology at all. Few gender differences were noted in the relations among CP, depressive symptoms, and adjustment over time.

Neighborhood disadvantage, parent-child conflict, neighborhood peer relationships, and early antisocial behavior problem trajectories.

This study examined relations among neighborhood disadvantage, parent-child conflict, deviant peer involvement in the neighborhood, and early-starting antisocial trajectories. Antisocial group patterns were identified in 218 low-income boys followed from ages 5 to 11, and neighborhood and family variables were evaluated as predictors in early and middle childhood. Four trajectory groups emerged: one increasing pattern that corresponded with developmental theories of early-starting antisocial behavior; one with initially high and decreasing problems over time; and two low antisocial groups. Parent-child conflict and neighborhood disadvantage were significantly associated with trajectory patterns, with youth in the 2 higher antisocial behavior groups characterized by more neighborhood problems and parent-child conflict than other groups. The results suggest that in early childhood, neighborhood disadvantage and family conflict place children at risk for early-starting trajectories, and that involvement with deviant peers in the neighborhood takes on an increasingly important role in patterns of antisocial behavior over middle childhood.

Trajectories leading to school-age conduct problems.

The present study applied a semiparametric mixture model to a sample of 284 low-income boys to model developmental trajectories of overt conduct problems from ages 2 to 8. As in research on older children, 4 developmental trajectories were identified: a persistent problem trajectory, a high-level desister trajectory, a moderate-level desister trajectory, and a persistent low trajectory. Follow-up analyses indicated that initially high and low groups were differentiated in early childhood by high child fearlessness and elevated maternal depressive symptomatology. Persistent problem and high desister trajectories were differentiated by high child fearlessness and maternal rejecting parenting. The implications of the results for early intervention research are discussed, with an emphasis on the identification of at-risk parent-child dyads.

Neighborhood contextual factors and early-starting antisocial pathways.

This paper examines research investigating the effects of neighborhood context on the onset and persistence of early-starting antisocial pathways across middle and late childhood. The review begins by presenting theory and research mapping the early-starting developmental pathway. Next, sociologically and psychologically based investigations linking neighborhood context and early antisocial behavior are examined, in order to posit and evaluate the effects of community economic disadvantage, exposure to neighborhood violence, and involvement with neighborhood-based deviant peer groups on the development of antisocial behavior. It is suggested that middle childhood may represent a critical developmental period during which children are at heightened risk for neighborhood-based effects on antisocial behavior problems. Key methodological issues are addressed, and recommendations for future research integrating developmental pathways and neighborhood theory and research are advanced.

The Aftercare and School Observation System (ASOS): Reliability and Component Structure.

This study examines the psychometric properties and component structure of a newly developed observational system, the Aftercare and School Observation System (ASOS). Participants included 468 children drawn from a larger longitudinal intervention study. The system was utilized to assess participant children in school lunchrooms and recess and various afterschool environments. Exploratory factor analyses examined whether a core set of component constructs assessing qualities of children's relationships, caregiver involvement and monitoring, and experiences in school and aftercare contexts that have been linked to children's behavior problems would emerge. Construct validity was assessed by examining associations between ASOS constructs and questionnaire measures assessing children's behavior problems and relationship qualities in school and aftercare settings. Across both settings, two factors showed very similar empirical structures and item loadings, reflecting the constructs of a negative/aggressive context and caregiver positive involvement, with one additional unique factor from the school setting reflecting the extent to which caregiver methods used resulted in less negative behavior and two additional unique factors from the aftercare setting reflecting positivity in the child's interactions and general environment and negativity in the child's interactions and setting. Modest correlations between ASOS factors and aftercare provider and teacher ratings of behavior problems, adult-child relationships, and a rating of school climate contributed to our interpretation that the ASOS scores capture meaningful features of children's experiences in these settings. This study represents the first step of establishing that the ASOS reliably and validly captures risk and protective relationships and experiences in extra-familial settings.

Review of Interventions to Improve Family Engagement and Retention in Parent and Child Mental Health Programs.

Engaging and retaining families in mental health prevention and intervention programs is critically important to insure maximum public health impact. We evaluated randomized-controlled trials testing methods to improve family engagement and retention in child mental health programs published since 1980 (N = 17). Brief, intensive engagement interventions in which providers explicitly addressed families' practical (e.g. schedules, transportation) and psychological (e.g. family members' resistance, beliefs about the treatment process) barriers as they entered treatment were effective in improving engagement in early sessions. The few interventions found to produce long-term impact on engagement and retention integrated motivational interviewing, family systems, and enhanced family stress and coping support strategies at multiple points throughout treatment. Few interventions have been tested in the context of prevention programs. There are promising approaches to increasing engagement and retention; they should be replicated and used as a foundation for future research in this area.