The effects of a universal short-term home visiting program: Two-year impact on parenting behavior and parent mental health.

BACKGROUND: At the time of childbirth, families face heightened levels of unmet need. These needs, if left unmet, can lead parents to engage in less positive parenting practices, which in turn, increase the risk of child maltreatment. Family Connects (FC) is a universal postnatal nurse home-visiting program designed to prevent child maltreatment by supporting all families in a community through one to three visits to improve parent mental health and parenting behaviors. A randomized controlled trial of FC demonstrated improving positive parenting and reducing postpartum depression through age 6 months. OBJECTIVE: To determine sustained (2-year) impact of random assignment to FC on parenting behavior and parent mental health and identify heterogeneity of effects. PARTICIPANTS AND SETTING: A representative subsample of 496 families that had been randomized to FC (255 treatment; 241 control) of infants born between July 1, 2009, and December 31, 2010, in Durham County, North Carolina. METHODS: Demographic characteristics were collected through hospital discharge data. Treatment-blinded interviewers collected maternal reports of parenting behavior and mental health at infant age two years. Moderation and subgroup analyses were conducted to estimate heterogeneity in impact of FC. RESULTS: Mothers assigned to FC engaged in more self-reported positive parenting relative to control mothers (B = 0.21; p < 0.05). Hispanic mothers assigned to FC reported greater sense of parenting competence (B = 1.28; p < 0.05). No significant main effect differences were identified for negative parenting, maternal depression, or father involvement. CONCLUSIONS: Assignment to FC was associated with improvements in population-level self-reported scores of positive parenting 2 years post-intervention.

Evaluation of a Family Connects Dissemination to Four High-Poverty Rural Counties.

OBJECTIVES: Home visiting is a popular approach to improving the health and well-being of families with infants and young children in the United States; but, to date, no home visiting program has achieved population impact for families in rural communities. The current report includes evaluation results from the dissemination of a brief, universal postpartum home visiting program to four high-poverty rural counties. METHODS: The study utilized a quasi-experimental design. From Sept. 1, 2014-Dec. 31, 2015, families of all 994 resident births in four rural eastern North Carolina counties were assigned to receive Family Connects (FC; intervention group). A representative subsample of families participated in impact evaluation when the infants were 6 months old: 392 intervention group families and 126 families with infants born between Feb. 1, 2014-July 31, 2014 (natural comparison group). Data were analyzed preliminarily for reporting to funders in 2016 and, more comprehensively, using propensity score matching in 2020. RESULTS: Of FC-eligible families, 78% initiated participation; 83% of participating families completed the program (net completion = 65%). At age 6 months, intervention parents reported more community connections, more frequent use of community services, greater social support, and greater success with infants sleeping on their backs. Intervention infants had fewer total emergency department and urgent care visits. Intervention parents had more total emergency department and urgent care visits and (marginally) fewer overnights in the hospital. CONCLUSIONS FOR PRACTICE: FC can be implemented successfully in high-poverty rural communities with broad reach and positive benefits for infants and families.

Maximizing the return on investment in Early Childhood Home Visiting through enhanced eligibility screening.

BACKGROUND: The MIECHV (Maternal, Infant, and Early Childhood Home Visiting) program invests substantial federal resources to prevent child maltreatment and emergency medical costs. Eligibility is based on screening of demographic or clinical risk factors, but because screening accuracy in predicting poor outcomes is unknown, assignment to home-visiting might miss high-risk families or waste resources on low-risk families. OBJECTIVES: To guide eligibility decisions, this study tested accuracy of demographic and clinical screening in predicting child maltreatment and emergency medical care. PARTICIPANTS AND SETTING: A population-representative sample of 201 birthing mothers (39.8% Black, 33.8% Latina) in Durham, NC, was enrolled between July 2009, and December 2010, and followed through December 2015. METHODS: Participants were screened demographically (i.e., Medicaid, first-born, teenage, no high school diploma) and clinically (i.e., health/health care, parenting readiness, home safety, and parent mental health) at birth and followed through age 60 months, when Child Protective Services and hospital records were reviewed. Cox hazard models tested accuracy of prediction from screening variables. RESULTS: Demographic factors did not significantly predict outcomes, except having Medicaid/uninsured predicted more emergency medical care and being first-born was a (surprising) protective factor against a child maltreatment investigation. In contrast, clinical factors strongly predicted both maltreatment investigations (Hazard Ratio = 4.01 [95% CI = 1.97, 8.15], sensitivity = 0.70, specificity = 0.64, accuracy = 0.65) and emergency medical care (Hazard Ratio = 2.14 [95% CI = 1.03, 2.14], sensitivity = 0.50, specificity = 0.69, accuracy = 0.58). CONCLUSIONS: Even with added costs for clinical screening, selecting families for home visiting based on assessed clinical risk will improve accuracy and may yield a higher return on investment. The authors recommend a universal system of screening and care to support birthing families.

Effect of a Universal Postpartum Nurse Home Visiting Program on Child Maltreatment and Emergency Medical Care at 5 Years of Age: A Randomized Clinical Trial.

Importance: The Family Connects (FC) program, a community-wide nurse home visiting program for newborns, has been shown to provide benefits for children and families through the first 2 years of life. Potential longer-term outcomes for child well-being remain unknown. Objective: To determine the effect of randomization to FC on child maltreatment investigations and emergency medical care through 5 years of age. Design, Setting, and Participants: In this randomized clinical trial, families of all 4777 resident births in Durham County, North Carolina, from July 1, 2009, to December 31, 2010, were randomly assigned to receive the FC program or treatment as usual. Impact evaluation was on an intent-to-treat basis and focused on a subsample of 549 families randomly selected from the full population and included review of hospital and Child Protective Services (CPS) administrative records. Statistical analysis was conducted from November 6, 2020, to April 25, 2021. Interventions: The FC programs includes 1 to 3 nurse home visits beginning at the infant age of 3 weeks designed to identify family-specific needs, deliver education and intervention, and connect families with community resources matched to their needs. Ongoing program engagement with service professionals and an electronic resource directory facilitate effective family connections to the community. Main Outcomes and Measures: Two primary trial outcomes were CPS-recorded child maltreatment investigations and emergency medical care use based on hospital records. Results: Of the 4777 randomized families, 2327 were allocated to the intervention, and 2440 were allocated to services as usual. Among the children in the full study population, 2380 (49.8%) were female, 2397 (50.2%) were male, and 3359 (70.3%) were from racial/ethnic minority groups; of the 531 children included in the impact evaluation follow-up, 284 (53.5%) were female, 247 (46.5%) were male, and 390 (73.4%) were from racial/ethnic minority groups. Negative binomial models indicated that families assigned to FC had 39% fewer CPS investigations for suspected child maltreatment through 5 years of age (95% CI, -0.80 to 0.06; 90% CI, -0.73 to -0.01; control = 44 total investigations per 100 children and intervention = 27 total investigations per 100 children); intervention effects did not differ across subgroups. Families assigned to FC also had 33% less total child emergency medical care use (95% CI, -0.59 to -0.14; 90% CI, -0.55 to -0.18; control = 338 visits and overnight hospital stays per 100 children and intervention = 227 visits and overnight hospital stays per 100 children). Positive effects held across birth risk, child health insurance, child sex, single-parent status, and racial/ethnic groups. Effects were larger for nonminority families compared with minority families. Conclusions and Relevance: The findings of this randomized clinical trial suggest that, when implemented with high quality and broad reach, a brief postpartum nurse home visiting program can reduce population rates of child maltreatment and emergency medical care use in early childhood. Trial Registration: ClinicalTrials.gov Identifier: NCT01406184.

Treatment Outcomes for Adolescents Versus Adults Receiving Cognitive Processing Therapy for Posttraumatic Stress Disorder During Community Training.

Cognitive processing therapy (CPT) is a gold-standard treatment for adults with posttraumatic stress disorder (PTSD). However, adolescents may also benefit from CPT, particularly when existing evidence-based treatments for adolescents are unavailable or not a good fit. In this program evaluation study, community-based therapists participating in training delivered a modular version of CPT to 32 adolescents (age range: 14-17 years) and 174 adults recruited at their sites (overall sample: 81.1% female, 59.7% White, 31.6% Black, 21.6% Hispanic, 2.9% American Indian/Alaskan Native, 1.9% Asian, and 9.7% other race). The same protocol was used for adolescents as adults. Treatment outcomes, including treatment completion status, number of sessions needed, and PTSD and depression symptom change, were compared between groups. In total, 47.1% of adults versus 71.9% of adolescents completed treatment. Among completers, there was no between-group difference in the number of attended sessions, RR = 1.04, 95% CI [0.88, 1.23], p = .576. Overall, in the full intent-to-treat sample (i.e., completers and noncompleters), large symptom reductions were observed for PTSD, b = -3.27, SE = 0.17, p < .001, d = 1.22; and depression, b = -0.82, SE = 0.07, p < .001, d = 0.84. There were no differences in the rate of change for adolescents versus adults regarding PTSD, b = -0.15, SE = 0.48, p = .759; or depression, b = -0.20, SE = 0.14, p = .181. These findings suggest that CPT is a viable treatment option for adolescents, who benefited from treatment and completed treatment at a high rate.

Military Life Stressors, Family Communication and Satisfaction: Associations with Children's Psychosocial Outcomes.

Families experience multiple stressors as a result of military service. The purpose of this study was to examine facets of military life and family factors that may impact child psychosocial and mental health functioning. Using baseline data from the Millennium Cohort Family Study, this study examined family demographics and composition (age, number of children), military life stressors (injury, family, and deployment stressors), family communication and satisfaction as assessed by the Family Adaptability and Cohesion Evaluation Scale-IV, parental social functioning assessed via the Short Form Health Survey-36, and child mental health and behavioral functioning (parental reports of clinician-diagnosed mental health conditions such as depression) and an adapted version of the Strengths and Difficulties Questionnaire. Injury- and family-related military stressors were significant indicators of heightened risk for child mental health conditions, whereas greater levels of parental social functioning and family satisfaction were associated with lower risk of child mental health conditions. Differential associations were found in child functioning when military-related variables (e.g., service component), sociodemographic, and family composition factors (number and age of the children in the home) were examined. These findings underscore the importance of examining the "whole child" within the broader ecological and military family context to understand factors associated with children's mental and behavioral health. The results from the present study highlight the complex relationships that may be at play, which, in turn, have considerable implications for the development of policies to support children and families encountering multiple stressors related to a parent's military service.

Effect of a Community Agency-Administered Nurse Home Visitation Program on Program Use and Maternal and Infant Health Outcomes: A Randomized Clinical Trial.

Importance: Postnatal home visitation to support parenting and infant healthy development is becoming increasingly common based on university efficacy studies, but effectiveness when disseminated by communities is not clear. Objective: To test implementation and impact of the Family Connects (FC) program when administered by a community agency. Design, Setting, and Participants: In this randomized clinical trial, births were randomly assigned to receive FC or treatment as usual. Independent evaluation was conducted through parent interviews and review of health and child protective services records. Interviewers were blind to the experimental condition of participants, and participants were blind about the purpose of the interview as an intervention evaluation. A total of 936 consecutive residential births at Duke University Hospital from January 1, 2014, through June 30, 2014, were included. Data were analyzed preliminarily for reporting to funders in early 2015 before all birth-record covariates were scored and were analyzed more comprehensively in mid-2019 after administrative birth and child protective service records became available. Interventions: The goals of the FC brief universal program were to assess family-specific needs, complete brief interventions, and connect families with community resources. Community agencies and families were aligned through an electronic data system. Main Outcomes and Measures: Case records documented program penetration and quality. The primary outcome was child protective services investigations for maltreatment. Secondary outcomes were the number of sustained community connections, maternal mental health, parenting behavior, infant well-child care visits and maternal postpartum care compliance, and emergency health care utilization. Results: Of 936 births, 451 infants (48.2%) were female and 433 (46.3%) were from racial/ethnic minority groups. In all, 456 births (46.5%) were randomized to the intervention and 480 (53.5%) were randomized to the control. All analyses were based on intention to treat. The impact analysis included 158 intervention families and 158 control families. Intervention penetration was 76%, adherence to the protocol was 90%, and independent agreement in scoring (κ) was 0.75. Nurses identified and addressed minor problems for 52% of families and connected an additional 42% to community resources. Analysis of the primary outcome of child abuse investigations revealed a mean (SD) of 0.10 (0.30) investigations for the intervention group vs 0.18 (0.56) investigations for the control group (b = -0.09; 90% CI, -0.01 to -0.12; 95% CI, -0.18 to 0.01; P = .07). The intervention group's rate of possible maternal anxiety or depression was 18.2% vs 25.9% for the control group (b = -7.70; 90% CI, -15.2 to -0.1; 95% CI, -16.6 to 1.3; P = .09). Conclusions and Relevance: This study indicates that a nurse home visitation program for families of newborns can be implemented by a community agency with high penetration and quality. Other communities could benefit from wider dissemination of the program provided that quality remains strong and evaluation continues. Trial Registration: ClinicalTrials.gov identifier: NCT01843036.

Randomized controlled trial of Family Connects: Effects on child emergency medical care from birth to 24 months.

One of Tom Dishion's most significant contributions to prevention science was the development of affordable, ecologically valid interventions, such as the Family Check-Up, that screen for child and family risk factors broadly, but concentrate family-specific interventions on those with greatest potential for population impact. In the spirit of this approach, investigators examined effects of a brief, universal postnatal home visiting program on child emergency medical care and billing costs from birth to age 24 months. Family Connects is a community-wide public health intervention that combines identification and alignment of community services and resources with brief, postpartum nurse home visits designed to assess risk, provide supportive guidance, and connect families with identified risk to community resources. Over 18 months, families of all 4,777 resident Durham County, North Carolina, births were randomly assigned based on even or odd birth date to receive a postnatal nurse home visiting intervention or services as usual (control). Independently, 549 of these families were randomly selected and participated in an impact evaluation study. Families, blind to study goals, provided written consent to access hospital administrative records. Results indicate that children randomly assigned to Family Connects had significantly less total emergency medical care (by 37%) through age 24 months, with results observed across almost all subgroups. Examination of billing records indicate a $3.17 decrease in total billing costs for each $1 in program costs. Overall, results suggest that community-wide postpartum support program can significantly reduce population rates of child emergency medical care through age 24 months while being cost-beneficial to communities.

The Impact of Military Status on Cognitive Processing Therapy Outcomes in the Community.

Military-affiliated individuals (i.e., active duty personnel and veterans) exhibit high rates of posttraumatic stress disorder (PTSD). Although existing evidence-based treatments for PTSD, such as cognitive processing therapy (CPT), have demonstrated effectiveness with military-affiliated patients, there is evidence to suggest these individuals do not benefit as much as civilians. However, few studies have directly compared the effects of PTSD treatment between civilian and military-affiliated participants. The current study compared treatment outcomes of military-affiliated and civilian patients receiving CPT. Participants with PTSD who were either civilians (n = 136) or military-affiliated (n = 63) received CPT from community-based providers in training for CPT. Results indicated that military-affiliated participants were equally likely to complete treatment, Log odds ratio (OR) = 0.14, p = .648. Although military-affiliated participants exhibited reductions in PTSD, B = -2.53, p < .001; and depression symptoms, B = -0.65, p < .001, they experienced smaller reductions in symptoms relative to civilians: B = 1.15, p = .015 for PTSD symptoms and B = 0.29, p = .029 for depression symptoms. Furthermore, variability estimates indicated there was more variability in providers' treatment of military-affiliated versus civilian participants (i.e., completion rates and symptom reduction). These findings suggest that military-affiliated patients can be successfully retained in trauma-focused treatment in the community at the same rate as civilian patients, and they significantly improve in PTSD and depression symptoms although not as much as civilians. These findings also highlight community providers' variability in treatment of military-affiliated patients, providing support for more military-cultural training.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) El impacto del estatus militar en los resultados de la terapia de procesamiento cognitivo en la comunidad TERAPIA DE PROCESAMIENTO COGNITIVO Y ESTATUS MILITAR Los individuos afiliados a los militares (es decir, personal en servicio activo y veteranos) exhiben altas tasas de trastorno de estrés postraumático (TEPT). Si bien los tratamientos basados ​​en la evidencia existentes para el TEPT, como la terapia de procesamiento cognitivo (CPT en sus siglas en inglés), han demostrado ser efectivos con los pacientes afiliados a las fuerzas armadas, existen evidencias que sugieren que estas personas no se benefician tanto como los civiles. Sin embargo, pocos estudios han comparado directamente los efectos del tratamiento de TEPT entre participantes civiles y afiliados a los militares. El presente estudio comparó los resultados del tratamiento de los pacientes civiles y afiliados a los militares que recibieron CPT. Participantes con TEPT que eran civiles (n = 136) o afiliados a los militares (n = 63) recibieron CPT de proveedores comunitarios en entrenamiento de CPT. Los resultados indicaron que los participantes afiliados a las fuerzas armadas tenían la misma probabilidad de completar el tratamiento, razón de probabilidades de registro (OR) = 0.14, p = .648. Aunque los participantes afiliados a los militares mostraron reducciones en el TEPT, B = -2.53, p <.001; y los síntomas de depresión, B = - 0.65, p <.001, experimentaron reducciones más pequeñas en los síntomas en relación con los civiles: B = 1.15, p = .015 para los síntomas de TEPT y B = 0.29, p = .029 para los síntomas de depresión. Además, las estimaciones de variabilidad indicaron que había una mayor variabilidad en proveedores de tratamiento de los participantes afiliados a los militares en comparación con los civiles (es decir, las tasas de finalización y la reducción de los síntomas). Estos hallazgos sugieren que los pacientes afiliados a las fuerzas armadas pueden ser retenidos con éxito en el tratamiento centrado en el trauma en la comunidad al mismo ritmo que los pacientes civiles, y mejoran significativamente en los síntomas de TEPT y depresión, aunque no tanto como los civiles. Estos hallazgos también resaltan la variabilidad de los proveedores comunitarios en el tratamiento de los pacientes afiliados a las fuerzas armadas, brindando apoyo para una mayor capacitación de la cultura militar.

Moving Beyond Program to Population Impact: Toward a Universal Early Childhood System of Care.

Families have clearly benefited from increased availability of evidence-based intervention, including home-visiting models and increased federal funding for programs benefiting parents and children. The goal of population-level impact on the health and well-being of infants and young children across entire communities, however, remains elusive. New approaches are needed to move beyond scaling of individual programs toward an integrated system of care in early childhood. To advance this goal, the current article provides a framework for developing an early childhood system of care that pairs a top-down goal for the alignment of services with a bottom-up goal of identifying and addressing needs of all families throughout early childhood. Further, we describe how universal newborn home visiting can be utilized to both support alignment of and family entry into an early childhood system of care with broad reach, high quality, and evidence of population impact for families and children.

Using a Learning Collaborative Model to Disseminate Cognitive Processing Therapy to Community-Based Agencies.

Although effective treatments for posttraumatic stress disorder exist, their use in community settings is disappointingly low. Training alone does not necessarily lead to adoption. To address this problem, we trained community clinicians in cognitive processing therapy, an evidence-based treatment for posttraumatic stress disorder, using a Learning Collaborative, an intensive training methodology focused on both clinical training and developing sustainability. Sixty clinicians within 18 agencies began the year-long, team-based Learning Collaborative. Clinicians attended three in-person Learning Sessions, received weekly consultation, and submitted audio-recorded sessions to be rated for fidelity. Clinicians were rostered as approved treatment providers if they completed all training requirements. Additionally, we engaged leadership from each agency to build a sustainable practice. Clinicians trained through the Learning Collaborative demonstrated a high degree of fidelity to the treatment (average competence ratings "satisfactory" to "good"), and most (68%) were rostered as approved treatment providers. Patients treated by clinician trainees exhibited significant symptom reductions (d = 1.68 and 1.28 for posttraumatic stress and depression symptoms, respectively, among treatment completers). At a 6-month follow-up, 95% of rostered clinicians and 100% of agencies with rostered clinicians were still providing the treatment. These results suggest that the Learning Collaborative model is a promising approach for the dissemination and implementation of evidence-based treatments for adult posttraumatic stress disorder.

Mental Health of Children of Deployed and Nondeployed US Military Service Members: The Millennium Cohort Family Study.

OBJECTIVE: Families experience multiple stressors as a result of military service. The purpose of this study was to investigate the associations among service member deployment experiences, family and military factors, and children's mental health using baseline data from the Millennium Cohort Family Study, a study designed to evaluate the health and mental health effects of military service on families, including children. METHOD: This study examined administrative data on deployment status (combat, noncombat, and no deployments), as well as service member- and spouse-reported data on deployment experiences and family functioning in relation to the mental health of children in the family who were aged 9 to 17 years. RESULTS: Most children were not reported to have mental health, emotional, or behavioral difficulties regardless of parental deployment status. For an important minority of children, however, parental deployments with combat, compared with those with no deployment, were associated with a parental report of attention-deficit disorder/attention-deficit hyperactivity disorder and depression as diagnosed by a clinical provider, after accounting for demographics, psychosocial context, and military factors. Children's odds of a parental report of depression were significantly higher in both the combat and the noncombat deployment groups than in the no deployment group. CONCLUSION: These findings extend our understanding of the association between parental deployments and children's mental health, with implications for services and training mental health providers serving military families.

Pilot to policy: statewide dissemination and implementation of evidence-based treatment for traumatized youth.

BACKGROUND: A model for statewide dissemination of evidence-based treatment (EBT) for traumatized youth was piloted and taken to scale across North Carolina (NC). This article describes the implementation platform developed, piloted, and evaluated by the NC Child Treatment Program to train agency providers in Trauma-Focused Cognitive Behavioral Therapy using the National Center for Child Traumatic Stress Learning Collaborative (LC) Model on Adoption & Implementation of EBTs. This type of LC incorporates adult learning principles to enhance clinical skills development as part of training and many key implementation science strategies while working with agencies and clinicians to implement and sustain the new practice. METHODS: Clinicians (n = 124) from northeastern NC were enrolled in one of two TF-CBT LCs that lasted 12 months each. During the LC clinicians were expected to take at least two clients through TF-CBT treatment with fidelity and outcomes monitoring by trainers who offered consultation by phone and during trainings. Participating clinicians initiated treatment with 281 clients. The relationship of clinician and client characteristics to treatment fidelity and outcomes was examined using hierarchical linear regression. RESULTS: One hundred eleven clinicians completed general training on trauma assessment batteries and TF-CBT. Sixty-five clinicians met all mastery and fidelity requirements to meet roster criteria. One hundred fifty-six (55%) clients had fidelity-monitored assessment and TF-CBT. Child externalizing, internalizing, and post-traumatic stress symptoms, as well as parent distress levels, decreased significantly with treatment fidelity moderating child PTSD outcomes. Since this pilot, 11 additional cohorts of TF-CBT providers have been trained to these roster criteria. CONCLUSION: Scaling up or outcomes-oriented implementation appears best accomplished when training incorporates: 1) practice-based learning, 2) fidelity coaching, 3) clinical assessment and outcomes-oriented treatment, 4) organizational skill-building to address barriers for agencies, and 5) linking clients to trained clinicians via an online provider roster. Demonstrating clinician performance and client outcomes in this pilot and subsequent cohorts led to legislative support for dissemination of a service array of EBTs by the NC Child Treatment Program.

How Medicaid and Managed Care Can Support Evidence-Based Treatment in North Carolina That is Informed by Adverse Childhood Experiences.

North Carolina has increased the percentage of its clinical workforce that is proficient in evidence-based treatment and adverse childhood experiences-informed care. Medicaid and managed care have contributed through standards and reimbursement that are consistent with treatment costs. Further progress requires a concerted response from payers, policymakers, providers, and families receiving evidence-based treatment.

Can typical US home visits affect infant attachment? Preliminary findings from a randomized trial of Healthy Families Durham.

US government-funded early home visiting services are expanding significantly. The most widely implemented home visiting models target at-risk new mothers and their infants. Such home visiting programs typically aim to support infant-parent relationships; yet, such programs' effects on infant attachment quality per se are as yet untested. Given these programs' aims, and the crucial role of early attachments in human development, it is important to understand attachment processes in home visited families. The current, preliminary study examined 94 high-risk mother-infant dyads participating in a randomized evaluation of the Healthy Families Durham (HFD) home visiting program. We tested (a) infant attachment security and disorganization as predictors of toddler behavior problems and (b) program effects on attachment security and disorganization. We found that (a) infant attachment disorganization (but not security) predicted toddler behavior problems and (b) participation in HFD did not significantly affect infant attachment security or disorganization. Findings are discussed in terms of the potential for attachment-specific interventions to enhance the typical array of home visiting services.

A statewide nurse training program for a hospital based infant abusive head trauma prevention program.

Successful implementation of universal patient education programs requires training large numbers of nursing staff in new content and procedures and maintaining fidelity to program standards. In preparation for statewide adoption of a hospital based universal education program, nursing staff at 85 hospitals and 1 birthing center in North Carolina received standardized training. This article describes the training program and reports findings from the process, outcome and impact evaluations of this training. Evaluation strategies were designed to query nurse satisfaction with training and course content; determine if training conveyed new information, and assess if nurses applied lessons from the training sessions to deliver the program as designed. Trainings were conducted during April 2008-February 2010. Evaluations were received from 4358 attendees. Information was obtained about training type, participants' perceptions of newness and usefulness of information and how the program compared to other education materials. Program fidelity data were collected using telephone surveys about compliance to delivery of teaching points and teaching behaviors. Results demonstrate high levels of satisfaction and perceptions of program utility as well as adherence to program model. These findings support the feasibility of implementing a universal patient education programs with strong uptake utilizing large scale systematic training programs.

Predictors of treatment completion in a sample of youth who have experienced physical or sexual trauma.

Despite significant advances in knowledge and availability of evidence-based models for child traumatic stress, many children simply do not complete treatment. There remain notable gaps in the services research literature about treatment completion among youth, particularly those who have experienced trauma and related sequelae. This study investigated the linkages among child physical and sexual trauma, posttraumatic stress disorder (PTSD) symptomatology, and treatment completion utilizing a clinical sample drawn from a large database from community treatment centers across the United States specializing in childhood trauma. Results from regression analyses indicated that neither the experience of sexual nor physical trauma directly predicted successful treatment completion. The links between sexual trauma and treatment completion, however, were mediated by PTSD avoidance symptoms. Children and youth experiencing sexual trauma reported higher levels of avoidance symptoms that were, in turn, significantly associated with a lower likelihood of completing trauma-focused mental health treatment. Practice implications are discussed and include strategies for clinicians to intervene during pivotal points of treatment to improve rates of service utilization and treatment completion.

Implementation and randomized controlled trial evaluation of universal postnatal nurse home visiting.

OBJECTIVES: We evaluated whether a brief, universal, postnatal nurse home-visiting intervention can be implemented with high penetration and fidelity, prevent emergency health care services, and promote positive parenting by infant age 6 months. METHODS: Durham Connects is a manualized 4- to 7-session program to assess family needs and connect parents with community resources to improve infant health and well-being. All 4777 resident births in Durham, North Carolina, between July 1, 2009, and December 31, 2010, were randomly assigned to intervention and control conditions. A random, representative subset of 549 families received blinded interviews for impact evaluation. RESULTS: Of all families, 80% initiated participation; adherence was 84%. Hospital records indicated that Durham Connects infants had 59% fewer infant emergency medical care episodes than did control infants. Durham Connects mothers reported fewer infant emergency care episodes and more community connections, more positive parenting behaviors, participation in higher quality out-of-home child care, and lower rates of anxiety than control mothers. Blinded observers reported higher quality home environments for Durham Connects than for control families. CONCLUSIONS: A brief universal home-visiting program implemented with high penetration and fidelity can lower costly emergency medical care and improve family outcomes.

Randomized controlled trial of universal postnatal nurse home visiting: impact on emergency care.

BACKGROUND AND OBJECTIVES: Although nurse home visiting has proven efficacious with small samples, scaling up to community populations with diverse families has not yet proven effective. The Durham Connects program was developed in collaboration with community leaders as a brief, universal, postnatal nurse home visiting intervention designed to screen for risk, provide brief intervention, and connect families with more intensive evidence-based services as needed. This study tested program effectiveness in reducing infant emergency medical care between birth and age 12 months. METHODS: All 4777 resident births in Durham, North Carolina across 18 months were randomly assigned, with even birth date families to intervention and odd birth date families to control. Intervention families were offered 3 to 7 contacts between 3 and 12 weeks after birth to assess family needs and connect parents with community resources to improve infant health and well-being. Hospital records were analyzed by using an intent-to-treat design to evaluate impact among a representative subset of 549 families. RESULTS: After demographic factors (ie, birth risk, Medicaid status, ethnicity, and single parenthood) were covaried, relative to control families, families assigned to intervention had 50% less total emergency medical care use (mean [M] emergency department visits and hospital overnights) (M(intervention) = 0.78 and M(control) = 1.57; P < .001, effect size = 0.28) across the first 12 months of life. CONCLUSIONS: This brief, universal, postnatal nurse home visiting program improves population-level infant health care outcomes for the first 12 months of life. Nurse home visiting can be implemented universally at high fidelity with positive impacts on infant emergency health care that are similar to those of longer, more intensive home visiting programs. This approach offers a novel solution to the paradox of targeting by offering individually tailored intervention while achieving population-level impact.

Implementation and dissemination of military informed and evidence-based interventions for community dwelling military families.

Community dwelling military families from the National Guard and Reserve contend with deployment-related stressors in relative isolation, living in communities where mental health providers may have little knowledge of military culture. When they are community residents, active duty service members and families tend to live in close proximity to their military installations. This article will focus primarily on the challenges to quality mental health care for reserve component (RC) families. Where studies of RC families are absent, those of active component (AC) families will be highlighted as relevant. Upon completion of a deployment, reintegration for RC families is complicated by high rates of symptomatology, low service utilization, and greater barriers to care relative to AC families. A paucity of providers skilled in evidence-based treatments (EBTs) limits community mental health capacity to serve RC military families. Several emergent programs illustrate the potential for better serving community dwelling military families. Approaches include behavioral health homes, EBTs and treatment components, structured resiliency and parent training, military informed schools, outreach methods, and technology-based coping, and psychoeducation. Methods from implementation science to improve clinical skill acquisition and spread and sustainability of EBTs may advance access to and quality of mental health treatment and are reviewed herein. Recommendations related to research methods, military knowledge and treatment competencies, and transition to a public health model of service delivery are discussed.