Preventing Alcohol and Tobacco Exposed Pregnancies: CHOICES Plus in Primary Care.

INTRODUCTION: Alcohol and tobacco use are common among U.S. women, yet if used during pregnancy these substances present significant preventable risks to prenatal and perinatal health. Because use of alcohol and tobacco often continue into the first trimester and beyond, especially among women with unintended pregnancies, effective evidence-based approaches are needed to decrease these risk behaviors. This study was designed to test the efficacy of CHOICES Plus, a preconception intervention for reducing the risk of alcohol- and tobacco-exposed pregnancies (AEPs and TEPs). STUDY DESIGN: RCT with two intervention groups: CHOICES Plus (n=131) versus Brief Advice (n=130). Data collected April 2011 to October 2013. Data analysis finalized February 2016. SETTING/PARTICIPANTS: Settings were 12 primary care clinics in a large Texas public healthcare system. Participants were women who were non-sterile, non-pregnant, aged 18-44 years, drinking more than three drinks per day or more than seven drinks per week, sexually active, and not using effective contraception (N=261). Forty-five percent were smokers. INTERVENTION: Interventions were two CHOICES Plus sessions and a contraceptive visit or Brief Advice and referral to community resources. MAIN OUTCOME MEASURES: Primary outcomes were reduced risk of AEP and TEP through 9-month follow-up. RESULTS: In intention-to-treat analyses across 9 months, the CHOICES Plus group was more likely than the Brief Advice group to reduce risk of AEP with an incidence rate ratio of 0.620 (95% CI=0.511, 0.757) and absolute risk reduction of -0.233 (95% CI=-0.239, -0.226). CHOICES Plus group members at risk for both exposures were more likely to reduce TEP risk (incidence rate ratio, 0.597; 95% CI=0.424, 0.840 and absolute risk reduction, -0.233; 95% CI=-0.019, -0.521). CONCLUSIONS: CHOICES Plus significantly reduced AEP and TEP risk. Addressing these commonly co-occurring risk factors in a single preconception program proved both feasible and efficacious in a low-income primary care population. Intervening with women before they become pregnant could shift the focus in clinical practice from treatment of substance-exposed pregnancies to prevention of a costly public health concern. TRIAL REGISTRATION: This study is registered at clinicaltrials.gov NCT01032772.

Improving parenting in families referred for child maltreatment: a randomized controlled trial examining effects of Project Support.

Project Support is an intervention designed to decrease coercive patterns of aggressive discipline and increase positive parenting. This research evaluates Project Support in a sample of families reported to Children's Protective Services (CPS) for allegations of physical abuse or neglect; 35 families with a child between 3- and 8-years-old participated. In all families, CPS allowed the children to remain in the family home while the family received services. Families were randomly assigned to receive either Project Support or services as usual, which were provided by CPS or CPS-contracted service providers. To evaluate intervention effects, a multimethod, multi-informant assessment strategy was used that included data from mothers' reports, direct observation of parents' behavior, and review of CPS records for re-referrals for child maltreatment. Families who received Project Support services showed greater decreases than families who received services as usual in the following areas: mothers' perceived inability to manage childrearing responsibilities, mothers' reports of harsh parenting, and observations of ineffective parenting practices. Only 5.9% of families in the Project Support condition had a subsequent referral to CPS for child maltreatment, compared with 27.7% of families in the comparison condition. The results suggest that Project Support may be a promising intervention for reducing child maltreatment among families in which it has occurred.

Reducing conduct problems among children exposed to intimate partner violence: a randomized clinical trial examining effects of Project Support.

This study was a randomized clinical trial of Project Support, an intervention designed to reduce conduct problems among children exposed to intimate partner violence. Participants were 66 families (mothers and children) with at least 1 child exhibiting clinical levels of conduct problems. Families were recruited from domestic violence shelters. The Project Support intervention involves (a) teaching mothers child management skills and (b) providing instrumental and emotional support to mothers. Families were randomly assigned to the Project Support intervention condition or to an existing services comparison condition. They were assessed on 6 occasions over 20 months, following their departure from the shelter. Children in families in the Project Support condition, compared with those in the comparison condition, exhibited greater reductions in conduct problems. Mothers in the Project Support condition, compared with those in the comparison condition, displayed greater reductions in inconsistent and harsh parenting behaviors and psychiatric symptoms. Changes in mothers' parenting and psychiatric symptoms accounted for a sizable proportion of Project Support's effects on child conduct problems at the end of treatment. Clinical and policy implications are discussed.