Optimizing Social-Emotional-Communication Development in Infants of Mothers With Depression: Protocol for a Randomized Controlled Trial of a Mobile Intervention Targeting Depression and Responsive Parenting.

BACKGROUND: Postpartum depression interferes with maternal engagement in interventions that are effective in improving infant social-emotional and social-communication outcomes. There is an absence of integrated interventions with demonstrated effectiveness in both reducing maternal depression and promoting parent-mediated practices that optimize infant social-emotional and social-communication competencies. Interventions targeting maternal depression are often separate from parent-mediated interventions. To address the life course needs of depressed mothers and their infants, we need brief, accessible, and integrated interventions that target both maternal depression and specific parent practices shown to improve infant social-emotional and social-communication trajectories. OBJECTIVE: The aim of this study is to evaluate the efficacy of a mobile internet intervention, Mom and Baby Net, with remote coaching to improve maternal mood and promote parent practices that optimize infant social-emotional and social-communication development. METHODS: This is a two-arm, randomized controlled intent-to-treat trial. Primary outcomes include maternal depression symptoms and observed parent and infant behaviors. Outcomes are measured via direct observational assessments and standardized questionnaires. The sample is being recruited from the urban core of a large southern city in the United States. Study enrollment was initiated in 2017 and concluded in 2020. Participants are biological mothers with elevated depression symptoms, aged 18 years or older, and who have custody of an infant less than 12 months of age. Exclusion criteria at the time of screening include maternal homelessness or shelter residence, inpatient mental health or substance abuse treatment, or maternal or infant treatment of a major mental or physical illness that would hinder meaningful study participation. RESULTS: The start date of this grant-funded randomized controlled trial (RCT) was September 1, 2016. Data collection is ongoing. Following the institutional review board (IRB)-approved pilot work, the RCT was approved by the IRB on November 17, 2017. Recruitment was initiated immediately following IRB approval. Between February 15, 2018, and March 11, 2021, we successfully recruited a sample of 184 women and their infants into the RCT. The sample is predominantly African American and socioeconomically disadvantaged. CONCLUSIONS: Data collection is scheduled to be concluded in March 2022. We anticipate that relative to the attention control condition, which is focused on education around maternal depression and infant developmental milestones with matching technology and coaching structure, mothers in the Mom and Baby Net intervention will experience greater reductions in depression and gains in sensitive and responsive parent practices and that their infants will demonstrate greater gains in social-emotional and social-communication behavior. TRIAL REGISTRATION: ClinicalTrials.gov NCT03464630; https://clinicaltrials.gov/ct2/show/NCT03464630. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/31072.

Understanding the Steps Toward Mobile Early Intervention for Mothers and Their Infants Exiting the Neonatal Intensive Care Unit: Descriptive Examination.

BACKGROUND: Neonatal intensive care unit (NICU) history, combined with systemic inequities for mothers of nondominant cultures and mothers who are socioeconomically disadvantaged, places infants at an extraordinary risk for poor developmental outcomes throughout life. Although receipt of early intervention (EI) is the best single predictor of developmental outcomes among children with and at risk for early developmental delays, mothers and infants with the greatest needs are least likely to receive EI. Mobile internet-based interventions afford substantial advantages for overcoming logistical challenges that often prevent mothers who are economically disadvantaged from accessing EI. However, the bridge from the NICU to a mobile internet intervention has been virtually unexplored. OBJECTIVE: This study aims to examine progression flow from NICU exit referral to an early mobile internet intervention to increase EI access and promote parent mediation of infant social-emotional and communication development. METHODS: Three NICUs serving the urban poor in a Midwestern city were provided support in establishing an electronic NICU exit referral mechanism into a randomized controlled trial of a mobile internet intervention for mothers and their infants. Measurement domains to reflect the bridge to service included each crucial gateway required for navigating the path into Part C EI, including referral, screening, assessment, and intervention access. An iterative process was used and documented to facilitate each NICU in establishing an individualized accountability plan for sharing referral materials with mothers before their NICU exit. Subsequent to the referral, progression flow was documented on the basis of a real-time electronic recording of service receipt and contact records. Mother and infant risk characteristics were also assessed. Descriptive analyses were conducted to summarize and characterize each measurement domain. RESULTS: NICU referral rates for EI were 3 to 4 times higher for open-shared versus closed-single gatekeeper referral processes. Of 86 referred dyads, 67 (78%) were screened, and of those screened, 51 (76%) were eligible for assessment. Of the 51 assessment-eligible mothers and infants, 35 dyads (69%) completed the assessment and 31 (89%) went on to complete at least one remote coaching intervention session. The dyads who accessed and engaged in intervention were racially and ethnically diverse and experiencing substantial adversity. CONCLUSIONS: The transition from the NICU to home was fraught with missed opportunities for an EI referral. Beyond the referral, the most prominent reason for not participating in screening was that mothers could not be located after exiting the NICU. Stronger NICU referral mechanisms for EI are needed. It may be essential to initiate mobile interventions before exiting the NICU for maintaining post-NICU contact with some mothers. In contrast to a closed, single point of referral gatekeeper systems in NICUs, open, shared referral gating systems may be less stymied by individual service provider biases and disruptions.

Bidirectional Associations Between Parental Responsiveness and Executive Function During Early Childhood.

In this study, we examined bidirectional associations between parental responsiveness and executive function (EF) processes in socioeconomically disadvantaged preschoolers. Participants were 534 3- to 5-year-old children (71% Hispanic/Latino; 28% African American; 1% European American) attending Head Start programs. At Time 1 (T1) and 6.5 months later at Time 2 (T2), parents and children participated in a videotaped free play session and children completed delay inhibition (gift delay-wrap, gift delay-bow) and conflict EF (bear/dragon, dimensional change card sort) tasks. Parental warm acceptance, contingent responsiveness, and verbal scaffolding were coded from the free play videos and aggregated to create a parental responsiveness latent variable. A cross-lagged panel structural equation model indicated that higher T1 parental responsiveness significantly predicted more positive gain in delay inhibition and conflict EF from T1 to T2. Higher T1 delay inhibition, but not T1 conflict EF, significantly predicted more positive change in parental responsiveness from T1 to T2. These associations were not explained by several possible confounding variables, including children's age, gender, race/ethnicity, and verbal ability. Findings suggest that parental responsiveness may support EF development in disadvantaged children, with reciprocal effects of delay inhibition on parental responsiveness.

Parenting Predictors of Delay Inhibition in Socioeconomically Disadvantaged Preschoolers.

This study examined longitudinal associations between specific parenting factors and delay inhibition in socioeconomically disadvantaged preschoolers. At Time 1, parents and 2- to 4-year-old children (mean age = 3.21 years; N = 247) participated in a videotaped parent-child free play session, and children completed delay inhibition tasks (gift delay-wrap, gift delay-bow, and snack delay tasks). Three months later, at Time 2, children completed the same set of tasks. Parental responsiveness was coded from the parent-child free play sessions, and parental directive language was coded from transcripts of a subset of 127 of these sessions. Structural equation modeling was used, and covariates included age, gender, language skills, parental education, and Time 1 delay inhibition. Results indicated that in separate models, Time 1 parental directive language was significantly negatively associated with Time 2 delay inhibition, and Time 1 parental responsiveness was significantly positively associated with Time 2 delay inhibition. When these parenting factors were entered simultaneously, Time 1 parental directive language significantly predicted Time 2 delay inhibition whereas Time 1 parental responsiveness was no longer significant. Findings suggest that parental language that modulates the amount of autonomy allotted the child may be an important predictor of early delay inhibition skills.

Parenting predictors of cognitive skills and emotion knowledge in socioeconomically disadvantaged preschoolers.

This study examined the concurrent and longitudinal associations of parental responsiveness and inferential language input with cognitive skills and emotion knowledge among socioeconomically disadvantaged preschoolers. Parents and 2- to 4-year-old children (mean age=3.21 years, N=284) participated in a parent-child free play session, and children completed cognitive (language, early literacy, early mathematics) and emotion knowledge assessments. Approximately 1 year later, children completed the same assessment battery. Parental responsiveness was coded from the videotaped parent-child free play sessions, and parental inferential language input was coded from transcripts of a subset of 127 of these sessions. All analyses controlled for child age, gender, and parental education, and longitudinal analyses controlled for initial skill level. Parental responsiveness significantly predicted all concurrent cognitive skills as well as literacy, math, and emotion knowledge 1 year later. Parental inferential language input was significantly positively associated with children's concurrent emotion knowledge. In longitudinal analyses, an interaction was found such that for children with stronger initial language skills, higher levels of parental inferential language input facilitated greater vocabulary development, whereas for children with weaker initial language skills, there was no association between parental inferential language input and change in children's vocabulary skills. These findings further our understanding of the roles of parental responsiveness and inferential language input in promoting children's school readiness skills.

Associations Among Parental Education, Home Environment Quality, Effortful Control, and Preacademic Knowledge.

This study used a longitudinal design to examine whether effortful control mediated the associations of parental education and home environment quality with preacademic knowledge in toddlers and young preschoolers. The sample consisted of 226 children (2 to 4 years of age at T1) from socioeconomically disadvantaged backgrounds. Parents provided data on parent education and home environment quality. Children completed effortful control, early literacy, and early math assessments. T2 effortful control partially mediated the associations of T1 parental education and T1 home environment quality with T3 emergent literacy after accounting for child age, gender, race/ethnicity, T1 effortful control, and T2 early literacy. T2 effortful control partially mediated the association between T1 parental education and T3 emergent math after accounting for child age, gender, race/ethnicity, T1 effortful control, and T2 early math. Prior to entry into preschool, parental education and home environment quality may shape effortful control which in turn influences preacademic knowledge.

Expanding the reach of preventive interventions: development of an Internet-based training for parents of infants.

There are major obstacles to the effective delivery of mental health services to poor families, particularly for those families in rural areas. The rise of Internet use, however, has created potentially new avenues for service delivery, which, when paired with the many recent advances in computer networking and multimedia technology, is fueling a demand for Internet delivery of mental health services. The authors report on the adaptation of a parenting program for delivery via the Internet, enhanced with participant-created videos of parent-infant interactions and weekly staff contact, which enable distal treatment providers to give feedback and make decisions informed by direct behavioral assessment. This Internet-based, parent-education intervention has the potential to promote healthy and protective parent-infant interactions in families who might not otherwise receive needed mental health services.

The role of early maternal responsiveness in supporting school-aged cognitive development for children who vary in birth status.

OBJECTIVES: To examine the relation between the pattern of maternal responsiveness that children experienced in the infancy, preschool, and school-age periods and growth in cognitive skills across 3-10 years of age and determine whether the relation differs by birth status. METHODS: In 1990-1992, 360 children varying in birth status (very low birthweight [VLBW]; demographically matched controls) were recruited to examine parenting and birth status influences on development. This report includes children with observations of parenting at 6, 12, and 24 months and 3, 4, 6, 8, and 10 years and cognitive skills evaluated at 3, 4, 6, 8, and 10 years of age (71% of original cohort). RESULTS: Four groups of mothers varying in the pattern of responsiveness displayed across the infancy and the preschool period were found. When controlling for school-age parenting and economic status, children parented with higher levels of responsiveness across both developmental periods, irrespective of birth status, showed higher levels in development than those who experienced responsiveness in only 1 development period or minimal responsiveness. Greater benefit was found for consistency in responsiveness for children born VLBW with less, versus more, severe neonatal complications. Inspection of the means showed that higher risk birth status combined with minimal responsiveness resulted in cognitive scores, on average, 14 points lower than when parented with consistently higher responsiveness. CONCLUSIONS: Cognitive development for children born at VLBW, particularly those with less severe complications, are supported by consistently responsive parenting across early childhood in similar ways to those born at term. This effect persisted through 10 years of age even after school-age parenting and economic level. These findings have important implications for the timing (across early childhood) and content (responsive interactive behaviors) of early intervention to enhance the outcomes for children born at VLBW.

The influence of decreased parental resources on the efficacy of a responsive parenting intervention.

To understand whether a responsive parenting intervention for socially disadvantaged mothers was related to preintervention parenting resources, the authors examined both of these conditions as moderators of behavior change in 264 participating families (term, n = 120; very low birth weight, n = 144). Families were randomly assigned to an intervention that targeted responsive behaviors or received developmental information. Limited internal resources, particularly higher levels of anger/hostility, were related to less positive change for the broadest range of responsive behaviors for mothers in the information-only condition but not those in the intervention. Decreased social support moderated less change in provision of rich language input. A systematic session format and parent facilitator may be keys to understanding why a responsive parenting intervention can be effective in spite of limited parental resources.

Environmental effects on language development in normal and high-risk child populations.

This report describes language development from infancy through 8 years of life for a large sample of very low birth weight (VLBW) (high medical risk, n = 94; low medical risk, n = 132) and term (n = 134) children. Children of high and low medical risk status showed lower levels and slower rates of development compared with term children. Although these children also showed nonverbal cognitive deficits, their language difficulties appeared to be independent of these general cognitive problems. Although lower socioeconomic status (SES) showed strong negative effects on rate of language development, this was comparable across the three risk groups. Within this generally lower SES sample of children, the type of interactive behaviors caregivers used in early childhood showed significant relations to skill growth. Children with faster rates of language growth had mothers who maintained their interests more often and were less likely to use highly directive behaviors.

The role of early parenting in children's development of executive processes.

Using structural modeling, we examined the influence of mothers' verbal input that provided information about associations between objects and actions (scaffolding) at 3 and 4 years of age on children's 6-year executive processing skills. Executive processing skills were measured by search retrieval and independent goal-directed play tasks. A set of 4-year basic skills (language, memory, nonverbal problem solving) considered to be prerequisites for executive processing also were included. Patterns of influence across these variables were examined for 253 children who varied in neonatal complications and in their degree of risk for later developmental problems. Results showed that mothers' early verbal scaffolding at 3 years indirectly influenced both types of executive processing skills at 6 years by directly influencing children's language and nonverbal problem-solving skills at 4 years of age. Four-year scaffolding did not show direct influences on later executive processing skills. The provision of this form of maternal verbal input when children are rapidly developing language appears to support a set of basic skills necessary for later executive processing.