Prenatal and Pediatric Primary Care-Based Child Obesity Prevention: Effects of Adverse Social Determinants of Health on Intervention Attendance and Impact.

Background: Adverse social determinants of health (SDoHs), specifically psychosocial stressors and material hardships, are associated with early childhood obesity. Less is known about whether adverse SDoHs modify the efficacy of early childhood obesity prevention programs. Methods: We conducted a secondary analysis of publicly insured birthing parent-child dyads with Latino backgrounds participating in a randomized controlled trial of the Starting Early Program (StEP), a child obesity prevention program beginning in pregnancy. We measured baseline adverse SDoHs categorized as psychosocial stressors (low social support, single marital status, and maternal depressive symptoms) and material hardships (food insecurity, housing disrepair, and financial difficulties) individually and cumulatively in the third trimester. Logistic regression models tested effects of adverse SDoHs on StEP attendance. We then tested whether adverse SDoHs moderated intervention impacts on weight at age 2 years. Results: We observed heterogeneous effects of adverse SDoHs on outcomes in 358 parent-child dyads. While housing disrepair decreased odds of higher attendance [adjusted odds ratio (aOR) 0.52, 95% confidence interval (CI): 0.29-0.94], high levels of psychosocial stressors doubled odds of higher attendance (aOR 2.36, 95% CI: 1.04-5.34). Similarly, while certain adverse SDoHs diminished StEP impact on weight (e.g., housing disrepair), others (e.g., high psychosocial stress) enhanced StEP impact on weight. Conclusions: Effects of adverse SDoHs on intervention outcomes depend on the specific adverse SDoH. Highest engagement and benefit occurred in those with high psychosocial stress at baseline, suggesting that StEP components may mitigate aspects of psychosocial stressors. Findings also support integration of adverse SDoH assessment into strategies to enhance obesity prevention impacts on families with material hardships. Trial Registration: This study is registered on clinicaltrials.gov: Starting Early Obesity Prevention Program (NCT01541761); https://clinicaltrials.gov/ct2/show/NCT01541761.

Integrating equifinality and multifinality into the of prevention programs in early childhood: The conceptual case for use of tiered models.

Introduced in the context of developmental psychopathology by Cicchetti and Rogosh in the Journal, the current paper incorporates the principles of equifinality and multifinality to support the use of tiered models to prevent the development of emerging child psychopathology and promote school readiness in early childhood. We use the principles of equifinality and multifinality to describe the limitations of applying one intervention model to address all children presenting with different types of risk for early problem behavior. We then describe the potential benefits of applying a tiered model for having impacts at the population level and two initial applications of this approach during early childhood. The first of these tiered models, Smart Beginnings, integrates the use of two evidenced-based preventive interventions, Video Interaction Project, a universal parenting program, and Family Check-Up, a selective parenting program. Building on the strengths of Smart Beginnings, the second trial, The Pittsburgh Study includes Video Interaction Project and Family Check-Up, and other more and less-intensive programs to address the spectrum of challenges facing parents of young children. Findings from these two projects are discussed with their implications for developing tiered models to support children's early development and mental health.

An exploration of the domain specificity of maternal sensitivity among a diverse sample in the infancy period: Unique paths to child outcomes.

Maternal sensitivity during an observed mother-child clean-up task at 18 months and maternal sensitivity during an observed mother-child free-play task at 18 months were tested as independent predictors of child internalizing symptoms, externalizing symptoms, social competence, and language development at 24 months. Participants (n = 292 mothers) were recruited between 2015 and 2017, and were low-income (mean annual income = $19,136) and racially and ethnically diverse (43.8% Black; 44.2% Latinx). Maternal sensitivity during clean-up was a significant predictor of all social-emotional outcomes, and a unique predictor of child internalizing symptoms. Maternal sensitivity during free-play was a unique predictor of child language. Results suggest that context-specific subtypes of maternal sensitivity may differentially relate to early child outcomes.

Stress and Infant Media Exposure During COVID-19: A Study Among Latino Families.

OBJECTIVE: The COVID-19 pandemic disproportionately harmed Latino families; however, its effects on their stress and media routines remain understudied. We examined economic and parenting stress patterns during the COVID-19 pandemic and estimated associations between these forms of stress and nonadherence to American Academy of Pediatrics (AAP) infant media exposure recommendations among Latino families. We also explored how nonadherence with AAP recommendations varied with COVID-19 cases. METHODS: We analyzed baseline data from an ongoing clinical trial recruiting low-income Latino parent-infant dyads. Nonadherence with AAP media exposure recommendations (ScreenQ) and economic and parent stress were measured using parent reports. Additional variables included epidemiological data on COVID-19 cases. Linear models examined associations between the pandemic and both stress variables as well as between stress and ScreenQ. Using locally weighted scatterplot smoothing curve fitting, the rise and fall of NJ COVID-19 cases were overlayed with ScreenQ scores over time to visualize and explore trends. RESULTS: All parents identified as Latino (62.6% unemployed, 91.5% limited English proficiency). Mean infant age was 8.2 months. Parent stress increased over time during the COVID-19 pandemic (r = 0.13, p = 0.0369). After covariate adjustment, economic and parent stress were associated with increased nonadherence with AAP recommendations (standardized beta = 0.16, 95% confidence interval [CI], 0.03-0.29; standardized beta = 0.18, 95% CI, 0.04-0.31, respectively). Nonadherence to media exposure recommendations seemed to track with rises in the number of COVID-19 cases with a lag of 7 days. CONCLUSION: Parent and economic stress were associated with nonadherence to infant media exposure recommendations among Latino families. These findings highlight the need for practitioners to support families from under-resourced communities and to promote healthy media routines.

Maximizing the impact of reach out and read literacy promotion:anticipatory guidance and modeling.

BACKGROUND: Reach Out and Read (ROR) is a multi-component pediatric literacy promotion intervention. However, few studies link ROR components to outcomes. We examine associations between receipt of (1) multiple ROR components and (2) clinician modeling, a potential best practice, with enhanced home literacy environments (EHLEs) among Latino families. METHODS: We conducted secondary analyses of cross-sectional enrollment data from a randomized clinical trial at three urban community health centers between November 2020 and June 2023. Latino parents with infants 6-<9 months old were surveyed about ROR component receipt (children's book, anticipatory guidance, modeling) and EHLE (StimQ2- Infant Read Scale). We used mixed models with clinician as a random effect, adjusting for covariates. RESULTS: 440 Latino parent-infant dyads were included. With no components as the reference category, receipt of 1 component was not associated with EHLE. Receipt of 2 components (standardized beta = 0.27; 95%CI: 0.12-0.42) and 3 components (standardized beta = 0.33; 95% CI: 0.19-0.47) were associated with EHLE. In separate analyses, modeling was associated with EHLE (standardized beta = 0.16; 95%CI: 0.06-0.26). CONCLUSION: Findings support modeling as a core ROR component. Programs seeking to enhance equity by promoting EHLE should utilize such strategies as anticipatory guidance and clinician modeling in addition to book distribution. IMPACT: Reach Out and Read, a multi-component literacy promotion intervention, leverages primary care to promote equity in children's early language experiences. However, few studies link Reach Out and Read components to outcomes. Among Latino parent-infant dyads, we found that implementation of two and three components, compared to none, was associated with enhanced home literacy environments, following a dose response pattern. Parent report of clinician modeling was associated with enhanced home literacy environments. Literacy promotion programs seeking to enhance equity by promoting enhanced home literacy environments should utilize strategies in addition to book distribution, including anticipatory guidance and modeling, to maximize impact.

Impacts of a tiered intervention on child internalizing and externalizing behavior in the context of maternal depression.

Greater maternal depressive symptoms are consistently associated with higher levels of behavioral difficulties in children, emerging in early childhood and with long-lasting consequences for children's development. Interventions promoting early relational health have been shown to have benefits for children's behavior; however, these impacts are not always realized in the context of maternal depression. This study examined whether tiered programs could address this limitation by focusing on both parenting, through universal primary prevention, and psychosocial stressors and parent mental health, through tailored secondary prevention. Analysis of a randomized controlled trial (RCT) of the Smart Beginnings (SB) intervention was conducted to determine whether SB attenuated the association between maternal depression and early childhood internalizing and externalizing behaviors. Maternal depression significantly predicted both internalizing and externalizing behaviors in linear regression models. Further, there was a significant interaction between maternal depression and treatment group, such that among mothers with higher depressive symptoms, the SB treatment attenuated the magnitude of the association between depression and child behavior. Findings suggest that while parenting support is important for all families, it may be particularly critical for those with higher levels of depression and underscores the need to consider multidimensional family processes in both research and clinical practice.

Supporting responsive parenting in real-world implementation: minimal effective dose of the Video Interaction Project.

BACKGROUND: The Video Interaction Project (VIP) is a healthcare-based intervention that provides real-time video-feedback of parent-child play and reading interactions to families with children aged 0 to 36 months. Although evidence from randomized controlled trials demonstrates improved early relational health, including responsive parenting, after three to five VIP visits, the minimal effective dose in real-world implementations is unknown. This study aimed to determine the minimal effective dose of VIP during a real-world implementation for changing responsive parenting behaviors. METHODS: We performed a longitudinal prospective study of 183 dyads at a public hospital pediatric clinic. Responsive parenting behaviors were assessed with an observational checklist utilized as part of standard VIP practice at baseline and two follow-up VIP visits. RESULTS: Multilevel models adjusted for baseline sociodemographics (child's sex and age, and maternal education) and time between visits showed that responsive parenting behaviors during parent-child reading and play significantly increased after a single VIP visit (Cohen's d = 0.52, p < 0.05) with additional impact following completion of a second visit (cumulative for 2 visits: d = 0.76, p < 0.05). CONCLUSIONS: A single VIP visit is associated with increased responsive parenting behaviors. Findings support offering VIP widely, regardless of capacity to ensure attendance at multiple visits. IMPACT: This is the first study showing the minimal effective dose of the Video Interaction Project (VIP) for increasing responsive parenting behaviors. Responsive parenting behaviors increased by over 22% following a single VIP visit, with a cumulative increase of 37% following the second visit compared to baseline. Findings have important implications for implementation and scalability of pediatric-based preventive programs that support early relational health through activities such as reading and play.

Enhancing early language and literacy skills for racial/ethnic minority children with low incomes through a randomized clinical trial: The mediating role of cognitively stimulating parent-child interactions.

Parenting is a critical mediator of children's school readiness. In line with this theory of change, data from the randomized clinical trial of Smart Beginnings (tiered Video Interaction Project and Family Check-Up; N = 403, treatment arm n = 201) were used to examine treatment impacts on early language and literacy skills at child age 4 years (nLatinx = 168, nBlack = 198, nMale = 203), as well as indirect impacts through parental support of cognitive stimulation at child age 2 years. Although results did not reveal direct effects on children's early skills, there were significant indirect effects for early literacy (ß = .03, p = .05) and early language (ß = .04, p = .04) via improvements in parental cognitive stimulation. Implications for interventions targeting parenting to improve children's school readiness beginning at birth are discussed.

Pediatric Resident Communication of Hospital Discharge Instructions.

OBJECTIVE: Suboptimal provider-parent communication contributes to poor parent comprehension of pediatric discharge instructions, which can lead to adverse outcomes. Residency is a critical window to acquire and learn to utilize key communication skills, potentially supported by formal training programs or visual reminders. Few studies have examined resident counseling practices or predictors of counseling quality. Our objectives were to (1) examine pediatric resident counseling practices and (2) determine how formal training and presence of discharge templates with domain-specific prompts are associated with counseling. METHODS: We conducted a cross-sectional survey of a convenience sample of residents in the American Academy of Pediatrics Section on Pediatric Trainees. Outcomes included resident self-report of frequency of (1) counseling in domains of care and (2) use of health literacy-informed counseling strategies (pictures, demonstration, Teach Back, Show Back) (6-point scales; frequent = often/usually/always). Predictor variables were (1) formal discharge-related training (e.g., lectures) and (2) hospital discharge instruction template with space for individual domains. Logistic regression analyses, utilizing generalized estimating equations when appropriate to account for multiple domains (adjusting for resident gender, postgraduate year), were performed. KEY RESULTS: Few residents (N = 317) (13.9%) reported formal training. Over 25% of residents infrequently counsel on side effects, diagnosis, and restrictions. Resident reported use of communication strategies was infrequent: drawing pictures (24.1%), demonstration (15.8%), Teach Back (36.8%), Show Back (11.4%). Designated spaces in instruction templates for individual domains were associated with frequent domain-specific counseling (adjusted odds ratio [aOR] 4.1 [95% confidence interval: 3.5-4.8]). Formal training was associated with frequent Teach Back (aOR 2.6 [1.4-5.1]) and Show Back (aOR 2.7 [1.2-6.2]). CONCLUSIONS: Lack of formal training and designated space for domain-specific instructions are associated with suboptimal counseling at discharge by pediatric residents. Future research should focus on determining the best mechanisms for teaching trainees communication skills and optimizing written instruction templates to support verbal counseling. [HLRP: Health Literacy Research and Practice. 2023;7(4):e178-e186.].

PLAIN LANGUAGE SUMMARY: Pediatric residents infrequently counsel about several important domains of care or use health literacy-informed counseling strategies. Resident receipt of formal training in communication practices and presence of written instruction templates are associated with higher quality counseling. Future research is needed to determine how to better support trainees in learning how to provide high quality and effective communication with parents.

Prenatal Risks to Healthy Food Access and High Birthweight Outcomes.

OBJECTIVE: Infants with high birthweight have increased risk for adverse outcomes at birth and across childhood. Prenatal risks to healthy food access may increase odds of high birthweight. We tested whether having a poor neighborhood food environment and/or food insecurity had associations with high birthweight. METHODS: We analyzed cross-sectional baseline data in Greenlight Plus, an obesity prevention trial across six US cities (n = 787), which included newborns with a gestational age greater than 34 weeks and a birthweight greater than 2500 g. We assessed neighborhood food environment using the Place-Based Survey and food insecurity using the US Household Food Security Module. We performed logistic regression analyses to assess the individual and additive effects of risk factors on high birthweight. We adjusted for potential confounders: infant sex, race, ethnicity, gestational age, birthing parent age, education, income, and study site. RESULTS: Thirty-four percent of birthing parents reported poor neighborhood food environment and/or food insecurity. Compared to those without food insecurity, food insecure families had greater odds of delivering an infant with high birthweight (adjusted odds ratios [aOR] 1.96, 95% confidence intervals [CI]: 1.01, 3.82) after adjusting for poor neighborhood food environment, which was not associated with high birthweight (aOR 1.35, 95% CI: 0.78, 2.34). Each additional risk to healthy food access was associated with a 56% (95% CI: 4%-132%) increase in high birthweight odds. CONCLUSIONS: Prenatal risks to healthy food access may increase high infant birthweight odds. Future studies designed to measure neighborhood factors should examine infant birthweight outcomes in the context of prenatal social determinants of health.

Validation of the StimQ2: A parent-report measure of cognitive stimulation in the home.

Considerable evidence demonstrates the importance of the cognitive home environment in supporting children's language, cognition, and school readiness more broadly. This is particularly important for children from low-income backgrounds, as cognitive stimulation is a key area of resilience that mediates the impact of poverty on child development. Researchers and clinicians have therefore highlighted the need to quantify cognitive stimulation; however existing methodological approaches frequently utilize home visits and/or labor-intensive observations and coding. Here, we examined the reliability and validity of the StimQ2, a parent-report measure of the cognitive home environment that can be delivered efficiently and at low cost. StimQ2 improves upon earlier versions of the instrument by removing outdated items, assessing additional domains of cognitive stimulation and providing new scoring systems. Findings suggest that the StimQ2 is a reliable and valid measure of the cognitive home environment for children from infancy through the preschool period.

Tiered Universal and Targeted Early Childhood Interventions: Enhancing Attendance Across Families with Varying Needs.

This study examined whether a two-tiered parenting program, which provides universal primary prevention along with targeted secondary prevention only for families with increased needs, would have mutually beneficial impacts on attendance across two program components. A secondary analysis of the Smart Beginnings (SB) randomized controlled trial was conducted. SB takes place from birth to age 3 and combines universal delivery of the Video Interaction Project (VIP) with targeted delivery of the Family Check-Up (FCU) for families identified as having increased risks following yearly screening. The current study analyzed whether attendance in VIP in the first six months was associated with FCU attendance for eligible families at six months, and whether FCU attendance at six and 18 months was associated with subsequent VIP attendance. Analyses included logistic and mixed-effects Poisson regression, as well as group-based trajectory analysis. VIP attendance predicted later FCU attendance (AOR = 5.43, p < .01), and FCU attendance predicted later VIP attendance (IRR = 1.35, p < .01) and a high-stable VIP attendance trajectory (AOR=14.98, p < .01). Findings provide strong support for the ability of tiered models to engage parents, to promote effective and efficient service delivery to reduce disparities in school readiness, and their potential to overcome common barriers to attendance and scaling by addressing the heterogeneity of risk among low-income families.

Pre-pandemic support for shared reading buffers adverse parenting impacts: an RCT in Brazil.

BACKGROUND: To examine whether (1) a parent-child reading program (Universidade do Bebê [UBB]), conducted in Brazil pre-pandemic can support parenting and parent-child reading 6 months into the pandemic, (2) cognitive stimulation at pandemic onset mediates effects of UBB on these outcomes, and (3) UBB pre-pandemic buffers associations between COVID-19-related distress and parenting/parent-child reading 6 months into the pandemic. METHODS: 400 women, either pregnant or with children 0-24 months, were randomized to UBB (n = 200) or control groups. UBB consisted of monthly parent workshops focusing on parent-child reading and a book-lending library. Assessments pre-pandemic (June-2019) and at pandemic onset (April-2020) included cognitive stimulation. Assessments 6 months into the pandemic (October-2020) included COVID-19 exposure/impact/distress, as well as parenting and parent-child reading. RESULTS: 133 families (n = 69 UBB) contributed data 6 months into the pandemic. Participation in UBB pre-pandemic was associated with parent-child reading but not parenting 6 months into the pandemic. Indirect effects of UBB through cognitive stimulation at pandemic onset were observed for both outcomes. Increased COVID-19-related distress was significantly associated with reduced parenting/parent-child reading 6 months into the pandemic in the control group only. CONCLUSION: Promotion of cognitive stimulation pre-pandemic may have reduced risk for effects of the pandemic on parenting/parent-child reading. CLINICAL TRIAL REGISTRATION: The trial has been registered with the Brazilian Clinical Trials Registry RBR-29RZDH on 05/28/2018. IMPACT: This is the first study showing sustained impacts of a reading aloud intervention beginning in pregnancy and early infancy implemented pre-pandemic. Findings suggest that participation in a reading-aloud intervention buffered associations between COVID-19 distress and parenting/parent-child reading 6 months into the pandemic. Novel empirical evidence suggests that promotion of cognitive stimulation prior to the pandemic may buffer its impacts on parenting and parent-child book reading following onset in low- and middle-income countries. Findings provide important new support for implementation of parent-child reading aloud programs and likely have implications for early childhood development beyond the COVID-19 pandemic for disasters generally.

Collateral benefits from a school-readiness intervention on breastfeeding: A cross-domain impact evaluation.

This study evaluated the collateral, or unanticipated, impacts of Smart Beginnings (SB), a two-site, tiered intervention designed to promote responsive parenting and school readiness, on breastfeeding intensity in a low-income sample. Impact analyses for the SB intervention were conducted using an intent-to-treat design leveraging a two-arm random assignment structure. Mothers assigned to the SB intervention group were more than three times more likely to give breastmilk as the only milk source at infant age 6 months than mothers assigned to the control group at one site, an effect not evident at the other study site. As development and growth are the two most salient domains of child health, understanding how interventions impact subsequent parenting practices across both domains is critical to address long-term economic and racial/ethnic disparities. Implications of the findings are discussed for improving the efficacy of interventions based on paediatric primary care.

Promoting Cognitive Stimulation in Parents Across Infancy and Toddlerhood: A Randomized Clinical Trial.

OBJECTIVE: To test the impact of the fully integrated Smart Beginnings model on parental support of cognitive stimulation from 6 to 24 months across infancy and toddlerhood. STUDY DESIGN: This was a single-blind, 2-site randomized clinical trial of the Smart Beginnings intervention. Enrollment took place at birth in postpartum units of hospitals in New York City and Pittsburgh, Pennsylvania, with a consecutive sample of 403 mother-infant dyads. Smart Beginnings combines a Video Interaction Project-14-session universal primary prevention program delivered in the pediatric clinic at the time of well-child visits birth-36 months-with potential for Family Check-Up-3-4 sessions targeted secondary prevention home-visiting program. The principal outcome was parental support of cognitive stimulation assessed via parent survey and video-recorded observations of parent-child interactions. Ordinary least squares and mixed effects regressions were conducted. RESULTS: Families were mostly Black/African-American (50%) or Latinx (42%); all were Medicaid eligible (100%). Smart Beginnings significantly promoted cognitive stimulation during infancy and toddlerhood for most survey outcomes across time, including StimQ common total (effect size [ES] = 0.25, P = .01) and READ Quantity (ES = .19, P = .04) and Quality (ES = .30, P = .001). For the observations, the impact of Smart Beginnings varied by time, with significant impacts at 6 (ES = 0.37-.40, P < .001) and 24 (ES = 0.27-.30, P < .001) months, but not 18 months. CONCLUSIONS: Smart Beginnings positively promotes cognitive stimulation from infancy through toddlerhood using the integrated model. This study adds to the body of research showing preventive interventions in pediatric primary care and home visiting can support early relational health including parental support of cognitive stimulation. TRIAL REGISTRATION: NCT02459327.

Protective Effect of Prenatal Social Support on the Intergenerational Transmission of Obesity in Low-Income Hispanic Families.

Background: Prepregnancy overweight/obesity (OW/OB) is a strong risk factor for child obesity. Few studies have identified modifiable factors that mitigate this risk. Objective: The objective of this study was to determine if prenatal social support buffers the effect of prepregnancy OW/OB on child birth weight z-score (BWz) and weight-for-age z-score (WFAz) trajectory. Methods: We performed a longitudinal secondary analysis of 524 mother-infant pairs enrolled in a randomized controlled trial of the Starting Early Program, a child obesity prevention program for Hispanic families with low income. Social support was assessed in the third trimester of pregnancy; maternal prepregnancy OW/OB and child WFAz from birth to age 3 years were obtained from medical records. Linear regression and multilevel modeling tested the effects of maternal prepregnancy OW/OB on child weight outcomes, and whether prenatal social support moderated these effects. Results: Prepregnancy OW/OB was associated with significantly higher child BWz (B = 0.23, p = 0.01) and WFAz trajectories (B = 0.19, 0.01). The interaction between social support and prepregnancy OW/OB was negatively related to child BWz (B = -0.26, p = 0.02) and WFAz trajectory (B = -0.40, p = 0.047). Conclusions: Prenatal social support may be protective against the intergenerational transmission of obesity risk. Interventions for the prevention of child obesity should consider incorporating social support into their design. Clinical Trial Registration Number: NCT01541761.

Effects of maternal trauma and associated psychopathology on atypical maternal behavior and infant social withdrawal six months postpartum.

Maternal psychopathology given a history of maltreatment and domestic violence exposure increases the risk for child psychopathology. Infant social withdrawal is one warning sign of adverse developmental outcomes including child anxiety and depression. It remains unclear how maternal trauma-related psychopathology might affect infant social withdrawal six-months postpartum. METHODS: One-hundred ninety-five women and their six-month-old infants were studied in an at-risk community sample. Maternal trauma history, posttraumatic stress (PTSD) and major depressive (MDD) disorders were assessed. Maternal and infant behaviors were coded from videotaped interactions. RESULTS: Maternal trauma was correlated with atypical maternal behavior (AMB) and infant social withdrawal (p ≤ .001). PTSD and MDD, and comorbid PTSD/MDD predicted increased AMB (p ≤ .001) but only maternal MDD was predictive of infant social withdrawal (p ≤ .001). Effects of maternal MDD on infant withdrawal were mediated by AMB. CONCLUSIONS: At six-months postpartum, maternal MDD was associated with infant withdrawal. AMB is an important target for early intervention.

Not built for families: Associations between neighborhood disinvestment and reduced parental cognitive stimulation.

Infants learn and develop within an ecological context that includes family, peers, and broader built and social environments. This development relies on proximal processes-reciprocal interactions between infants and the people and environments around them that help them understand their world. Most research examining predictors of proximal processes like parent-child interaction and parenting has focused on elements within the home and family. However, factors like the neighborhood built environment may also exhibit an influence, and may be particularly critical in infancy, as socioeconomic disparities in cognition and language emerge early in life. Moreover, influence from the built environment could independently exacerbate these disparities, as research indicates that neighborhood impacts may be especially relevant for families living in neighborhoods that have experienced disinvestment and therefore have been under-resourced. The current study examines these questions by determining the association of neighborhood vacancy rate and observed physical disorder-indicators of poverty, residential stability, and long-term structural discrimination-with parental cognitive stimulation among predominantly Black/African-American families in Flint, Michigan. Flint is particularly salient for this study because vacancy rates and disinvestment vary widely across the city, driven by its long-time status as a city struggling economically. Regression analyses controlling for caregiver education, mental health, and social support indicated that vacancy rate and physical disorder negatively predicted parental cognitive stimulation. Moreover, there were significant interactions between the built environment and social support, indicating that, particularly for parent-child shared reading, vacancy rate and physical disorder predicted reduced shared reading only when parents had limited social support. These results have important implications for public policy around vacant property demolition and neighborhood reinvestment programs, as they indicate that the neighborhood built environment is associated with parenting behaviors that have important impacts on infants' learning and development.

Supporting Reading Aloud Beginning Prenatally and in Early Infancy: A Randomized Trial in Brazil.

OBJECTIVE: A previous study of a reading aloud intervention in Brazil, called Universidade do Bebê (UBB), demonstrated impacts on parenting and child outcomes for families with toddlers and preschoolers, even for parents with low literacy, and cognitive stimulation mediated effects on child outcomes. In a new study, we sought to determine whether similar results would be found when UBB was provided beginning in pregnancy through early toddlerhood, including (1) impacts on parenting and child development, (2) variation in impact on parenting and child outcomes by parent literacy level, and (3) indirect impacts on child outcomes through cognitive stimulation. METHOD: Women with low income who were either pregnant or with children aged 0 to 24 months were randomized to UBB or control groups. UBB consisted of monthly workshops focused on reading aloud complemented by a book-lending library. Participants were evaluated at baseline and approximately 11 months later (M = 11.0, SD = 0.4; range 9.9-12.2 months) on parenting (cognitive stimulation, beliefs about early reading, screen time, and discipline) and child development. RESULTS: Four hundred families (n = 200 UBB) were randomized; 286 (71.5%; n = 150 UBB) received 11-month follow-up. UBB families showed increased cognitive stimulation (Cohen's d = 0.92) and awareness about the importance of early reading ( d = 0.90) than controls, with no differences by parent literacy level. UBB was associated with reduced screen time and increased vocabulary, but only for families with low parent literacy. UBB effects on child outcomes were mediated by cognitive stimulation. CONCLUSION: The findings support implementation of reading aloud programs beginning in pregnancy and early childhood.