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.

Virtual interviewing with marginalized young adult mothers: appreciating the New Norm.

BACKGROUND AND OBJECTIVE: Virtual interviewing in qualitative research may promote inclusion, diversify samples, and maximize participation, but there is limited research regarding methodological best practices for marginalized study populations. Emerging adult (ages 18-29) and young adult (through age 40) mothers have ongoing stressors and competing responsibilities that may preclude participation with in-person interviews. The purpose of this article is to describe the processes and experiences of virtual interviewing among young adult mothers living in under-resourced communities, based on their responses to specific interview questions. DESIGN AND SAMPLE: As part of an explanatory sequential mixed methods study, qualitative interviews were conducted with a sample of young adult mothers who had previously participated in randomized controlled trials testing an intensive early home visiting intervention. Thirty-one participants (M = 29.7 years, SD = 2.5) who identified as Black (39%), Hispanic (55%), and White (7%), were interviewed using Zoom. RESULTS: The overarching theme was Zoom: Appreciating the New Norm. Identified categories were Practical Benefits of Virtual Interviewing, Sharing Stories, and Drawbacks of Virtual Interviewing. CONCLUSION: Findings support virtual interviewing as a feasible and potentially ideal method for qualitative studies with emerging/young adults. Further research to examine this approach with other marginalized populations may lead to more inclusive representation in qualitative research.

"Here I Don't Feel Like a Stranger": Adolescents' Perspectives on School-Based Health Centers.

This study explored adolescent perspectives on school-based health center (SBHC) services and how services differed from school nurses and community agencies. Six focus groups were conducted with adolescents, 13-19 years old, as part of a larger mixed-methods study. Data were analyzed for themes using content analysis. Adolescents (N = 30) described the accessibility, positive attitude of staff, competence of the nurse practitioner, confidentiality/privacy, and trusted relationships with staff as important aspects of SBHC care. SBHC services allowed adolescents to stay in school, provided confidentiality/privacy, were comfortable and convenient, fostered their independence, and adolescents felt SBHC staff knew them and they did not feel like strangers. SBHCs are adolescent-friendly resources that maximize school time and an important source for contraception, sexually transmitted infection testing, and mental health care. Additionally, SBHC services help support adolescents' transition from pediatric to adolescent-focused care and foster their growing self-awareness and empowerment related to their engagement in health care services.

Something Has to Give: An Urban Community-Engaged Focus Group Study of Teen Sleep.

Sleep is critical to teen physical and mental health, daily function, and school performance. Yet, sleep deficiency is prevalent among ethnoracially diverse teens. The purpose of this community-engaged focus group study was to explore multilevel influences on teen sleep from teen and community stakeholder perspectives and to use this information to develop a tailored sleep health intervention. We conducted seven focus groups (N = 46) and analyzed data via content analysis. Five themes, each with subthemes, described sleep knowledge/attitudes, sleep habits, the multilevel causes and consequences of decreased nighttime sleep and suggestions for improving teen sleep. Teen health, mood, and school engagement were all impacted by inadequate nighttime sleep. Exhaustion emerged as an overarching theme and coincided with the transition to high school. The data from this study provide insight into important areas of focus for a sleep intervention tailored to the needs of ethnoracially diverse teens living in an urban community.

School age effects of Minding the Baby-An attachment-based home-visiting intervention-On parenting and child behaviors.

Multiple interventions have been developed to improve the caregiver-child relationship as a buffer to the effects of early life adversity and toxic stress. However, relatively few studies have evaluated the long-term effects of these early childhood interventions, particularly on parenting and childhood behaviors. Here we describe the early school-age follow-up results of a randomized controlled trial of Minding the Baby ® (MTB), a reflective, attachment-based, trauma-informed, preventive home-visiting intervention for first-time mothers and their infants. Results indicate that mothers who participated in MTB are less likely to show impaired mentalizing compared to control mothers two to eight years after the intervention ended. Additionally, MTB mothers have lower levels of hostile and coercive parenting, and their children have lower total and externalizing problem behavior scores when compared to controls at follow-up. We discuss our findings in terms of their contribution to understanding the long-term parenting and childhood socio-emotional developmental effects of early preventive interventions for stressed populations.

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.

Structural violence: An evolutionary concept analysis.

AIMS: To enhance conceptual clarity and interdisciplinary understanding of structural violence, and to illuminate its implications for contemporary social justice and health equity research, by: (1) synthesizing scholarly literature pertaining to structural violence and health; (2) defining its key attributes, antecedents, consequences and characteristics; (3) contextually situating this phenomenon over time and across disciplines. DESIGN: A comprehensive review of scholarly health literature pertaining to 'structural violence' or its surrogate term 'structural determinants of health' was guided by a Research and Education Librarian. DATA SOURCES: In November 2019 and again in April 2021, CINAHL, Embase, Global Health, Medline, PsycINFO, PubMed and Scopus electronic databases were searched for peer-reviewed articles that described structural violence in the context of health. Of the 238 unique records identified, 32 articles were selected for inclusion and comprise the review sample. REVIEW METHODS: Using Beth Rodgers' evolutionary concept analysis method, articles were comparatively analysed to identify key attributes, antecedents and consequences associated with the concept's use in health research. RESULTS: The five interrelated attributes characterizing structural violence are: power, marginality, oppression, adversity and trauma. Hegemonic social, cultural, economic and political systems serve as antecedents, whilst the consequences of structural violence can be broadly classified as health inequity, injustice and indignity, and social disorganization. CONCLUSION: This analysis contributes to conceptual clarity and mutual understanding of the usage, application and significance of structural violence across health disciplines and provides a strong foundation for continued concept development and operationalization. Further research is needed to substantiate the relationship between structural violence and health inequity.

Using probabilistic record linkage and propensity-score matching to identify a community-based comparison population.

In retrospective cohort studies of interventions disseminated to communities, it is challenging to find comparison groups with high-quality data for evaluation. We present one methodological approach as part of our study of birth outcomes of second-born children in a home visiting (HV) program targeting first-time mothers. We used probabilistic record linkage to link Connecticut's Nurturing Families Network (NFN) HV program and birth-certificate data for children born from 2005 to 2015. We identified two potential comparison groups: a propensity-score-matched group from the remaining birth certificate sample and eligible-but-unenrolled families. An analysis of interpregnancy interval (IPI) is presented to exemplify the approach. We identified the birth certificates of 4822 NFN families. The propensity-score-matched group had 14,219 families (3-to-1 matching) and we identified 1101 eligible-but-unenrolled families. Covariates were well balanced for the propensity-score-matched group, but poorly balanced for the eligible-but-unenrolled group. No program effect on IPI was found. By combining propensity-score matching and probabilistic record linkage, we were able to retrospectively identify relatively large comparison groups for quasi-experimental research. Using birth certificate data, we accessed outcomes for all of these individuals from a single data source. Multiple comparison groups allow us to confirm findings when each method has some limitations. Other researchers seeking community-based comparison groups could consider a similar approach.

An unbelievable ordeal: The experiences of adult survivors treated with extracorporeal membrane oxygenation.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a rescue treatment option for adult patients with severe cardiac dysfunction or respiratory failure. While short-term patient outcomes, such as in-hospital mortality and complications, have been widely described, little is known about the illness or recovery experience from the perspectives of survivors. Subjective reports of health are important indicators of the full, long-term impact of critical illness and treatment with ECMO on survivors' lives. OBJECTIVE: The objective of this study was to describe the experiences and needs of adults treated with ECMO, from onset of illness symptoms through the process of survivorship. METHODS: This study was guided by the qualitative method of interpretive description. We conducted in-depth, semistructured interviews with 16 adult survivors of ECMO who were treated at two participating regional ECMO centres in the northeast United States. Additional data were collected from demographic questionnaires, field notes, memos, and medical record review. Development of interview guides and data analysis were informed by the Family Management Style Framework. Qualitative data were analysed using thematic analysis techniques. RESULTS: The sample (n = 16) included 75% male participants; ages ranged from 23 to 65 years. Duration from hospital discharge to interviews ranged from 11 to 90 (M = 54; standard deviation = 28) months. Survivors progressed through three stages: Trauma and Vulnerability, Resiliency and Recovery, and Survivorship. Participants described short- and long-term impacts of the ECMO experience: all experienced physical challenges, two-thirds had at least one psychological or cognitive difficulty, and 25% were unable to return to work. All were deeply influenced by their own specific contexts, family support, and interactions with healthcare providers. CONCLUSIONS: The ECMO experience is traumatic and complex. Recovery requires considerable time, perseverance, and support. Long-term sequelae include impairments in cognitive, mental, emotional, physical, and social health. Survivors could likely benefit from specialised posthospital health services that include integrated, comprehensive follow-up care.

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.

Encountering Child Abuse and Neglect in Home Visiting: a Qualitative Study of Visitor and Supervisor Experiences.

Prevention of child maltreatment is a goal of home visiting (HV) for new mothers. How home visitors and their clinical supervisors manage concerns about child maltreatment may impact both the families' and the home visitors' engagement with the program. We sought to understand how HV personnel encounter and respond to concerns of child maltreatment and how these concerns are related to their work with families. We conducted an interpretive descriptive qualitative study of home visitors and supervisors in a statewide HV program, using the Parents as Teachers curriculum, to describe the experience of HV personnel. Two researchers conducted semi-structured interviews March 2016 to October 2017. Interviews were concurrently transcribed, coded, and analyzed, using thematic analysis. After 13 interviews with home visitors and 13 interviews with supervisors, codes and themes were saturated. We identified three themes: Decision to Call Child Protective Services (CPS), Relationships, and Collaborating with CPS. The decision to call CPS was described as difficult, and there was substantial variation in the details of this decision. The relationship between home visitor and family was consistently the most important. Variations were seen in how home visitors and supervisors collaborated with CPS, ranging from strong connections through liaisons to frustrations due to poor communication and perceived variation in how cases were handled. The decision to report a family to CPS is a challenging clinical issue; additional training and connections with CPS may improve consistency across sites for home visitors.

Hostile/Helpless maternal representations in pregnancy and later child removal: A pilot study.

This article presents the results of a small pilot study examining links between Hostile/Helpless (HH) representations of caregiving in pregnancy and later child removal by child protective services. The sample was drawn from a replication study of the Minding the Baby® attachment-based home-visiting intervention conducted in the United Kingdom, serving young first-time mothers in under resourced communities. The HH classification system (Lyons-Ruth et al.) was adapted for use with the Pregnancy Interview (PI) (Slade); 26 PIs were assessed (coders blinded) in a sample that included 13 mothers whose infants were removed from custody due to anticipated or documented maltreatment within 2 years of childbirth, and 13 mothers who did not have their infants removed. Mothers whose infants were removed from their custody had significantly higher HH scores than mothers of infants who were not removed from their care (F(1, 24) = 14.500, p < .001), and the relation between overall HH classification and infant removal status was also significant (χ2 (1, N = 26) = 12.462, p < .001). Results suggest that prenatal maternal caregiving representations may predict postnatal relationship disruptions, and indicate the need for larger studies further testing this prenatal approach to maltreatment risk assessment in at-risk populations.

Este artículo presenta los resultados de un pequeño estudio piloto que examina las conexiones entre las representaciones Hostiles/Indefensas de la prestación de cuidado durante el embarazo y más tarde cuando los servicios de protección a la niñez han separado al niño. El grupo muestra fue seleccionado de un estudio de replicación de la intervención Cuidando al Bebé (Minding the Baby® -MTB) de visita a casa con base en la afectividad, llevada a cabo en el Reino Unido para servirles a madres jóvenes en comunidades de pocos recursos. El sistema de clasificación Hostil/Indefensa (HH) (Lyons-Ruth et al., 1995-2005) se adaptó para el uso con la Entrevista del Embarazo (PI) (Slade, 2011); se evaluaron 26 entrevistas PI (los codificadores lo hicieron de manera ciega), de un grupo muestra que incluía 13 madres cuyos infantes fueron separados de su custodia debido al anticipado o documentado maltrato dentro de los 2 años anteriores al parto, y 13 madre cuyos infantes no habían sido separados. Las madres cuyos infantes habían sido separado de su custodia presentaron significativamente más altos puntajes HH que las madres de infantes no separados del cuidado materno (F(1, 24) = 14.500, p < .001), y la relación entre la clasificación general HH y la condición de separación del infante fue también significativa (c2(1, N = 26) = 12.462, p < .001). Los resultados sugieren que las representaciones prenatales del cuidado materno pudieran predecir las interrupciones de la relación postnatal, y apuntan a la necesidad de estudios más comprensivos que continúen examinando este acercamiento prenatal a la evaluación del riesgo de maltrato en grupos bajo riesgo.

Cet article présente les résultats d'une petite étude pilote examinant les liens entre les représentations Hostile/Impuissant du mode de soin durant la grossesse et plus tard durant le retrait de l'enfant par les services de protection de l'enfance. Cet échantillon a été retiré d'une étude de réplication de l'intervention sur l'attachement et faite à domicile Minding the Baby (MTB), faite au Royaume Unis, servant de jeunes mères n'ayant pas eu d'enfant auparavant dans des communautés n'ayant pas beaucoup de ressources. Le système de classification HI suivant les initiales en français Hostile/Impuissant (Lyons-Ruth et al., 1995-2005) a été adapté pour une utilisation durant l'Entretien de Grossesse (abrégé selon le français EG ici, Slade, 2011). 26 EG ont été évalués (codage à l'aveugle) dans un échantillon qui a inclus 13 mères dont les bébés avaient été retirés de leur garde pour maltraitance documentée ou anticipée dans les deux ans après la naissance, et 13 mères dont les bébés n'avaient pas été retirés. Les mères dont les bébés avaient été retirés de leur garde avaient des scores HI bien plus élevés que les mères de bébés n'avaient pas été retirés de leur garde (F(1, 24) = 14,500, p <,001), et la relation entre la classification générale HI et le statut de retrait du bébé était aussi importante (c2(1, N = 26) = 12,462, p <,001). Les résultats suggèrent que les représentations de mode de soin maternel prénatal peuvent prédire des perturbations de la relation postnatale, et indiquent le besoin d'études plus grandes testant plus profondément cette approche prétanale de l'évaluation de risque de maltraitance chez des populations à risque.

Minding the Baby®: Enhancing parental reflective functioning and infant attachment in an attachment-based, interdisciplinary home visiting program.

In this article, we describe the results of the second phase of a randomized controlled trial of Minding the Baby (MTB), an interdisciplinary reflective parenting intervention for infants and their families. Young first-time mothers living in underserved, poor, urban communities received intensive home visiting services from a nurse and social worker team for 27 months, from pregnancy to the child's second birthday. Results indicate that MTB mothers' levels of reflective functioning was more likely to increase over the course of the intervention than were those of control group mothers. Likewise, infants in the MTB group were significantly more likely to be securely attached, and significantly less likely to be disorganized, than infants in the control group. We discuss our findings in terms of their contribution to understanding the impacts and import of intensive intervention with vulnerable families during the earliest stages of parenthood in preventing the intergenerational transmission of disrupted relationships and insecure attachment.

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.

Sleep health in young children living with socioeconomic adversity.

Racially and ethnically diverse young children who live with socioeconomic adversity are at high risk for sleep deficiency, but few behavioral sleep interventions (BSIs) are tailored to their needs. To support the future development of a feasible, acceptable, and culturally relevant sleep intervention, we conducted a community-engaged, mixed-methods study with 40 low-income, racially, and ethnically diverse parents to describe sleep characteristics, sleep habits, and parental sleep knowledge of their 6-36-month-old children and to examine the associations between children's sleep characteristics and sleep habits. This report presents quantitative data from this mixed-methods study. We measured objective (actigraphy) and parent-reported sleep (Brief Infant Sleep Questionnaire) characteristics, sleep habits at bedtime, sleep onset, and during night awakenings, parental sleep knowledge, psychological function (Brief Symptom Inventory), and parenting stress (Parenting Stress Index). Children had low sleep duration (537.2 ± 54.7 nighttime and 111.2 ± 29.8 nap minutes), late bedtimes (22:36 ± 1.5 hr), and high bedtime variability (mean squared successive difference = 3.68 ± 4.31 hr) based on actigraphy. Parental knowledge about sleep recommendations was limited. Sleep habits before bedtime, at sleep onset, and during night awakenings were varied. Sixty-five percent of parents reported co-sleeping. Feeding near bedtime or during the night was associated with later bedtimes, more fragmented sleep, and increased bedtime variability. These findings suggest the need for BSIs to support earlier bedtimes and improve sleep duration and continuity by addressing modifiable behaviors. Tailored BSIs that consider socioecological influences on the development of sleep habits are needed.

Feasibility and safety of a group physical activity program for youth with type 1 diabetes.

BACKGROUND/OBJECTIVE: Many adolescents with type 1 diabetes do not achieve 60 minutes of daily moderate-to-vigorous intensity physical activity (MVPA). Recognizing the importance of peer influence during adolescence, we evaluated the feasibility and safety of a group MVPA intervention for this population. METHODS: Eighteen adolescents with type 1 diabetes (age 14.1 ± 2 .3 years, female 67%, black or Latino 67%, median body mass index 92%'ile, A1c 79.9 ± 25.1 mmol/mol, 9.5 ± 2.3%). Intervention sessions (35 minutes MVPA and 45 minutes discussion) occurred 1×/week for 12 weeks. Feasibility and safety metrics were enrollment, completion of intervention and assessments, cost, and hypoglycemia rates. Participants completed MVPA (accelerometry), and exploratory nutritional, psychosocial, clinical, and fitness variable assessments at baseline, 3 months, and 7 months. Hedges' effect sizes were calculated. RESULTS: Enrollment was 16%, and intervention completion was 56%. Assessment completion at 7 months was 67% for MVPA, nutrition, and fitness, 83% for psychosocial assessments, and 94% for clinical assessments. Cost was $1241 per completing participant. One episode of mild hypoglycemia occurred during the sessions (0.6%). Self-reported daily fruit/vegetable servings (d = -0.72) and diabetes self-management behaviors decreased over time (d = -0.40). In the 10 completers, endurance run score improved (d = 0.49) from low baseline levels, while systolic blood pressure decreased (d = -0.75) and low-density lipoprotein increased (d = 0.49) but stayed within normal ranges. CONCLUSIONS: The protocol for the group MVPA intervention was safe and had some feasibility metrics meriting further investigation. MVPA levels and glycemic control remained suboptimal, suggesting the need for more intensive interventions for this population.

Maternal Adverse Childhood Experiences, Family Strengths, and Chronic Stress in Children.

BACKGROUND: Researchers have demonstrated that maternal adverse childhood experiences (ACEs), such as abuse and neglect, are associated with prenatal risk factors and poor infant development. However, associations with child physiologic and health outcomes, including biomarkers of chronic or "toxic" stress, have not yet been explored. OBJECTIVES: The purpose of this study was to examine the associations among past maternal experiences, current maternal posttraumatic stress disorder (PTSD) symptoms, and children's indicators of exposure to chronic stress in a multiethnic sample of mothers and children at early school age (4 to 9 years). METHODS: This cross-sectional study included maternal-child dyads (N = 54) recruited from urban community health centers in New Haven, Connecticut. Mothers reported history of ACEs, family strengths, and current PTSD symptoms. Child measures included biomarkers and health and developmental outcomes associated with chronic stress. Correlational and regression analyses were conducted. RESULTS: Childhood trauma in mothers was associated with higher systolic blood pressure percentile (ρ = .29, p = .03) and behavioral problems (ρ = .47, p = .001) in children, while maternal history of family strengths was associated with lower salivary interleukin (IL)-1ß (ρ = -.27, p = .055), salivary IL-6 (ρ = -.27, p = .054), and body mass index z-scores (ρ = -.29, p = .03) in children. Maternal PTSD symptoms were associated with more child behavioral problems (ρ = .57, p < .001) and higher odds of asthma history (ρ = .30, p = .03). DISCUSSION: Results indicate that past maternal experiences may have important influences on a child's health and affect his or her risk for experiencing toxic stress.

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.

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.

The Essential Elements of Adolescent-friendly Care in School-based Health Centers: A Mixed Methods Study of the Perspectives of Nurse Practitioners and Adolescents.

PURPOSE: In this study we identified the essential elements of adolescent-friendly care in school-based health centers (SBHCs) from the perspectives of the nurse practitioners (NPs) providing care to adolescents and the adolescents, as the consumers of these services. DESIGN AND METHODS: Complex adaptive systems provided the philosophical and theoretical foundation for this study. An explanatory sequential mixed methods study was conducted. A Delphi technique (strand one) was conducted with an expert panel of NPs (N = 21) to identify the essential elements of adolescent-friendly care in SBHCs. The second strand, a focus group study with adolescents (N = 30), elaborated on the Delphi results. Data from the two strands were then mixed. RESULTS: This study generated expert opinion regarding the essential elements of adolescent-friendly health care in SBHCs. After four Delphi rounds, consensus was reached on 98-items (49% of the original 200; consensus level of 0.75). The results clustered into 6 essential elements: Confidentiality/Privacy (n = 8; 8.2%), Accessibility, (n = 15; 15.3%), Clinician/Staff (n = 51; 52%), SBHC Clinical Services (n = 12; 12.2%), SBHC Environment (n = 4; 4.1%), and Relationship between the School and SBHC (n = 8; 8.2%). The adolescent focus groups confirmed the essential elements identified in the Delphi and added two overarching themes: Comfortable and Trusted Relationship. CONCLUSIONS: These findings contribute to a greater understanding of essential characteristics needed in adolescent friendly care. PRACTICE IMPLICATIONS: SBHCs, as an important community resource for addressing the health care needs of adolescents, should incorporate these characteristics.