Moving toward precision in prenatal evidence-based home visiting to achieve good birth outcomes: assessing the alignment of local programs with their national models.

BACKGROUND: Low birthweight and preterm birth rates are higher in the United States than in other developed countries and exhibit pronounced racial inequities. Home visiting is a strategy to promote equity in birth outcomes. Research points to precision home visiting as the path to equity. The purpose of this study is to describe local programs' risk reduction priorities, intended behavioral pathways, and expectations of home visitors; compare these local program features with those of their national model; and assess the strength of implementation systems to support staff in meeting job expectations. METHODS: We surveyed local programs implementing one of four evidence-based home visiting models that aim to promote good birth outcomes: Family Spirit, Healthy Families America, Nurse-Family Partnership, and Parents as Teachers. RESULTS: Representatives from 169 local programs completed the survey. Overall, 59% endorsed all their model's high priority risks, 16% endorsed all its required behavioral pathways, and 11% endorsed all its required techniques. Local programs went beyond their national model's explicit intentions. Overall, 91% of local programs prioritized risks beyond those of their model, 85% endorsed behavioral pathways beyond those of their model, 95% endorsed visitors' use of techniques not explicitly endorsed by their model but compatible with it, and 19% endorsed use of techniques judged incompatible by their model. Implementation system strength was positively associated with local program and model expectations. CONCLUSIONS: Precision home visiting to achieve health equity requires shared learning of what works best for whom. This observational study showed the Precision Paradigm's usefulness for cross-model research to advance precision.

Does Child Likeability Mediate the Link Between Academic Competence and Depressive Symptoms in Early Elementary School?

The present study investigated the role of teacher-rated likeability as a mediator of the relation between low academic competence and depressive symptoms in elementary-aged children. Analyses focused on a sample of children at risk for child maltreatment living in Hawaii (n = 380). Structural equation modeling supported the hypothesized negative relations between academic competence in first grade and depressive symptoms in third grade controlling for correlated constructs (e.g., baseline social avoidance, parenting stress, externalizing problems, and internalizing symptoms). Teacher-rated likeability in second grade negatively mediated the effect of academic competence on depressive symptoms. Implications for understanding the role of early academic skill deficits and social judgments on risk for depressive symptoms as well as recommendations for interventions and prevention strategies are discussed.

Impact of a Child Abuse Primary Prevention Strategy for New Mothers.

First Steps (FS) is a brief obstetrics-based primary prevention strategy that aims to strengthen protective factors to prevent child maltreatment. This randomized controlled trial assessed how well FS services aligned with family interests and needs, how FS providers used communication strategies to build partnership with mothers, and the impact of FS on mothers' parenting knowledge in core content areas and access to services. Mothers completed a baseline survey and were randomly assigned to FS and control conditions (n = 374 and 375, respectively). The parenting education services provided to mothers were assessed by independent participant report immediately postintervention for the full FS group and by analysis of audio-recordings of the FS encounter for a subsample (n = 150). Outcomes were measured at 4 months via maternal survey. Compared to controls at follow-up, FS mothers had significantly higher knowledge scores in some areas but similar access to needed services. Few mothers lacked access to most services at baseline, and FS content was similar to that provided by other hospital personnel. FS providers' communication style promoted rapport, but providers did not tailor content to mothers' educational and service access needs. Implications of the findings for similar services are discussed.

Using latent profile and transition analyses to understand patterns of informant ratings of child depressive symptoms.

The present study examined the latent profiles of child, parent, and teacher ratings of child depressive symptoms in a developmental sample of children from Hawaii at two time points (2nd and 3rd grade). The study attempted to identify patterns of agreement and discrepancy among raters and correlates of these patterns to test a new theory for understanding rating disagreements as Divergent Operations. Three profiles best described the ratings at both time points: Child-Only High Depression, Child-Only Mild Depression, and Normative (non-depressed). Second and third grade measures of child social skills, externalizing symptoms, attention problems, and language and academic competence confirmed the distinctiveness of these classes which provides support for a Divergent Operations perspective. Latent transition analyses suggested that depressive symptoms were relatively transient for each class. Implications regarding the measurement and identification of child depressive symptoms across development and the meaning and use of discrepant ratings are discussed.

Exploring Multilevel Factors for Family Engagement in Home Visiting Across Two National Models.

The associations of family, home visitor and site characteristics with family engagement within the first 6 months were examined. The variation in family engagement was also explored. Home visiting program participants were drawn from 21 Healthy Families America sites (1707 families) and 9 Nurse-Family Partnership sites (650 families) in New Jersey. Three-level nested generalized linear mixed models assessed the associations of family, home visitor and site characteristics with family receipt of a high dose of services in the first 6 months of enrollment. A family was considered to have received a high dose of service in the first 6 months of enrollment if they were active at 6 months and had received at least 50% of their expected visits in the first 6 months. In general, both home visiting programs engaged, at a relatively high level (Healthy Families America (HFA) 59%, Nurse-Family Partnership (NFP) 64%), with families demonstrating high-risk characteristics such as lower maternal education, maternal smoking, and maternal mental health need. Home visitor characteristics explained more of the variation (87%) in the receipt of services for HFA, while family characteristics explained more of the variation (75%) in the receipt of services for NFP. At the family level, NFP may improve the consistency with which they engage families by increasing retention efforts among mothers with lower education and smoking mothers. HFA sites seeking to improve engagement consistency should consider increasing the flexible in home visitor job responsibilities and examining the current expected-visit policies followed by home visitors on difficult-to-engage families.

Outcomes of a Randomized Trial of a Cognitive Behavioral Enhancement to Address Maternal Distress in Home Visited Mothers.

Objectives To assess the effectiveness of a 6-week, cognitive behavioral therapy (CBT) group-based enhancement to home visiting to address stress and prevent depression as compared with home visiting as usual in low income mothers of young children. Methods We conducted a randomized controlled trial with 95 low-income mothers of young children to assess the effectiveness of a 6-week, cognitive behavioral group-based enhancement to Healthy Families America and Parents as Teachers home visiting (HV/CBT = 49) to address stress and prevent depression as compared with home visiting as usual (HV = 46). Booster sessions for the HV/CBT group were offered at 3 and 6 months. Participants completed measures of coping, stress and depression at three points: baseline prior to randomization, post-intervention, and 6 months post-intervention. Parent child interaction was also measured at 6 months. Results Intent-to-treat analyses found improved coping and reduced stress and depression post-intervention. While impacts on these outcomes were attenuated at 6 months, positive impacts were observed for selected aspects of mothers' interactions with their children. Maternal characteristics at baseline were associated with participation in the intervention and with post-intervention and 6-month outcomes. Mothers with lower levels of stress and those with fewer children were more likely to attend intervention sessions. Mothers with lower levels of stress had more favorable post intervention outcomes. Conclusions CBT group-based enhancement to home visiting improved maternal coping, reduced stress and depression immediately post intervention but not at 6 months, suggesting more work is needed to sustain positive gains in low-income mothers of young children.

Language Delays and Child Depressive Symptoms: the Role of Early Stimulation in the Home.

The present study investigated the role of early stimulation in the home and child language delays in the emergence of depressive symptoms. Data were from a longitudinal study of at-risk children in Hawaii (n = 587). Low learning stimulation in the home at age 3 and language delays in first grade both significantly increased risk for child depressive symptoms in third grade. Structural equation modeling supported the hypothesized path models from home learning environment at age 3 to depressive symptoms in third grade controlling for a host of correlated constructs (maternal depression, child temperament, and child internalizing symptoms). Total language skills in the first grade mediated the effect of home learning environment on depressive symptoms. The study and findings fit well with a nurturing environment perspective. Implications for understanding the etiology of child depression and for designing interventions and prevention strategies are discussed.

Understanding How Intimate Partner Violence Impacts School Age Children's Internalizing and Externalizing Problem Behaviors: A Secondary Analysis of Hawaii Healthy Start Program Evaluation Data.

We examined the role of maternal depression and parenting stress in the relationship between intimate partner violence (IPV) and child internalizing and externalizing problems, and explored whether child gender modified these pathways. This secondary analysis used data from the Hawaii Healthy Start Program. Logistic regression models examined the associations between IPV in 1st grade and child internalizing and externalizing behaviors in 1st, 2nd, and 3rd grades. Mediation models used bootstrapping methodology and stratified models examined effect modification. Adjusted models with 214 mothers demonstrated associations between IPV and internalizing (adjusted odds ratios (aOR)=2.62; 95% CI 1.11, 6.21) and externalizing (aOR=4.16; 95% CI 1.55, 11.19) behaviors. The association with externalizing behaviors was mediated by maternal depression and parenting stress, while internalizing behaviors was mediated by depression only. Stratified models found the association between IPV and externalizing behaviors was significant for girls only. Our results support the importance of multicomponent maternal IPV interventions.

Maternal Relationship Insecurity and Depressive Symptoms as Moderators of Home Visiting Impacts on Child Outcomes.

The purpose of this study was to determine the extent to which maternal relationship insecurity and severe depressive symptoms moderate home visiting impacts on developmental and behavioral outcomes in 2-year old children. In an experimental trial of the Healthy Families Alaska home visiting program, families (N = 249) were randomly assigned to home visiting (n = 126) or community services as usual (n = 123). Maternal severe depressive symptoms (CES-D ≥ 24) and relationship insecurity were measured using the Center for Epidemiologic Studies Depression Scale and the Attachment Style Questionnaire at baseline. Child cognitive and psychomotor development and behavior problems were measured with the Bayley Scales of Infant Development and the Child Behavior Checklist at follow-up. The results revealed that home visiting significantly impacted three outcomes- child cognitive development, internalizing behavior, and externalizing behavior. Home visiting impacts were limited to subgroups defined by maternal depressive symptoms and relationship insecurity. Home visiting improved cognitive development (B = 6.02, p < .03), and decreased internalizing behavior (B = -3.83, p = .02) and externalizing behavior problems (B = -3.74, p = .03) in children of mothers with either severe depressive symptoms or high levels of discomfort with trust at baseline, but not both. Family engagement in home visiting seems to play a role in mediating these moderating effects. These findings reflect the importance of screening for maternal relationship insecurity and depressive symptoms to distinguish family subgroups likely to benefit from home visiting from those for whom an enhanced service model might be needed.

Maternal relationship security as a moderator of home visiting impacts on maternal psychosocial functioning.

There is variability in home visiting program impacts on the outcomes achieved by high risk families. An understanding of how effects vary among families is important for refining service targeting and content. The current study assessed whether and how maternal attributes, including relationship security, moderate short- and long-term home visiting impacts on maternal psychosocial functioning. In this multisite RCT of home visiting in a population-based, ethnically-diverse sample of families at risk for maltreatment of their newborns (n = 643), families were randomly assigned to home visited (HV) and control groups. HV families were to receive intensive services by trained paraprofessionals from birth-3 years. Outcome data were collected when children were 1, 2, and 3 years old and 7, 8, and 9 years old. Overall, short- and long-term outcomes for HV and control mothers did not differ significantly. Demographic attributes, a general measure of overall maternal risk, and partner violence did not moderate program impact on psychosocial functioning outcomes. Maternal relationship security did moderate program impact. Mothers who scored high on relationship anxiety but not on relationship avoidance showed the greatest benefits, particularly at the long-term follow-up. Mothers scoring high for both relationship anxiety and avoidance experienced some adverse consequences of home visiting. Further research is needed to determine mediating pathways and to inform and test ways to improve the targeting of home visiting and the tailoring of home visit service models to extend positive home visiting impacts to targeted families not benefiting from current models.

Repeat pregnancy prevention self-efficacy in adolescents: associations with provider communication, provider type, and depression.

OBJECTIVES: Among adolescent mothers, pregnancy prevention self-efficacy developed during pregnancy may predict the use of contraception following delivery. Communication between patients and their primary care providers (PCPs) is important for adherence to physician recommendations and may be associated with pregnancy prevention self-efficacy. Depression, which is common among adolescent mothers, has been associated with poor self-efficacy. The associations among pregnancy prevention self-efficacy, provider communication, provider type (PCP vs others), and depression are unclear. The objectives of the study were to determine the association of positive provider communication with pregnancy prevention self-efficacy, whether provider type or depression is associated with positive provider communication, and whether the association between provider communication and pregnancy prevention self-efficacy varies by provider type and depression. METHODS: Cross-sectional study of 164 third trimester Baltimore adolescents measuring pregnancy prevention self-efficacy, perceptions of the quality of provider communication (Ambulatory Care Experiences Survey), provider type, and depressive symptoms. RESULTS: Of 164 pregnant teens, 79% reported pregnancy prevention self-efficacy, 72% had a specific PCP, and 17% scored positive for depression. Positive provider communication was associated with pregnancy prevention self-efficacy (odds ratio 1.25; P = 0.04). Adolescents with PCPs had significantly higher communication scores (ß 0.90; P = 0.001). Depressed adolescents had significantly lower communication scores (ß -0.74; P = 0.03). The association between positive provider communication and self-efficacy was significant only for adolescents who reported having a PCP (P = 0.04) and those who were not depressed (P = 0.05). CONCLUSIONS: Having a PCP and favorable perceptions of provider communication are important for pregnancy prevention self-efficacy among adolescents. Depression negatively affects perceptions of provider communication, which may limit self-efficacy.

Patterns of Intimate Partner Violence in Mothers At-Risk for Child Maltreatment.

Using three interviews spanning 3 years, we identified intimate partner violence (IPV) classes and determined how class membership changed over time amongst a sample of 217 mothers at-risk for child maltreatment that were enrolled in an early childhood home visitation evaluation study. Data on perpetration/victimization, IPV type (verbal, physical, and sexual abuse and injury) and severity were used to conduct latent class analyses at each time point. Latent transition analyses established the proportion of mothers who changed classes over time. A three-class solution (minimal, moderate, and high IPV) was indicated at each time point. All classes included mutual IPV. Partners used minor verbal abuse in the minimal class, minor and severe verbal abuse and minor physical abuse in the moderate class, and all IPV categories in the high class. At each transition, 40% or more moved from minimal to moderate or high IPV. This movement emphasizes the need to screen women frequently and develop interventions recognizing the dynamic nature of IPV.

Relationship between birth spacing, child maltreatment, and child behavior and development outcomes among at-risk families.

Prior research indicates that closely spaced births are associated with poor outcomes for the mother and subsequent child. Limited research has focused on outcomes for the index child (the child born immediately prior to a subsequent child in a birth interval). The objectives are to assess the association of short birth intervals in at-risk families with: (1) indicators of harsh and neglectful parenting behaviors towards the index child, including substantiated maltreatment reports across 6 years; and (2) the index child's behavior and development in first grade. This is a longitudinal study of 658 women screened to be at-risk for child maltreatment. Twenty percent of women had a rapid repeat birth (RRB), defined as the birth of a subsequent child within 24 months of the index child. Generalized estimating equations, survival analyses, and linear and logistic regression models were used to assess the associations between RRB and index child outcomes. Women with an RRB were more likely than those without an RRB to report neglectful parenting of the index child. Children of mothers with an RRB were more likely than children of mothers without an RRB to have more behavioral problems and lower cognitive functioning in first grade. This study is among the first to focus on the associations of birth spacing with maltreatment, behavior and development outcomes in the index child. Future work regarding the effects of birth spacing should include a focus on the index child.

Concurrent and long-term impact of intimate partner violence on employment stability.

Previous research suggests that experiencing intimate partner violence (IPV) may negatively affect employment outcomes. This study explores the relationship between IPV and employment stability both concurrently and longitudinally among a sample of 512 predominantly Asian American and Pacific Islander young women living in Hawaii. Women in this study were identified as being at risk of child maltreatment. About half of women indicated that their current relationship status was married or living together. More than two-thirds of women had graduated from high school and half had worked in the past year. The study explored the concurrent association of IPV and employment by assessing them simultaneously over a 12 month time period. The study examined the longitudinal impact of IPV by analyzing violence at two time points as predictors of unstable employment 6 to 8 years later. The study also explored the mediating effects of depression. Study results demonstrated both concurrent and longitudinal negative associations of IPV with employment stability. Women who experienced violence were more likely to be experiencing unstable employment concurrently. Women who experienced IPV at one point in time had lower levels of employment stability six years later. This decrease was partially mediated by experiencing depressive symptoms. Women who identified their primary ethnicity as Native Hawaiian or Pacific Islander were much more likely to experience unstable employment than Asian American women. More research is needed to explore the roles of mental health, race and ethnicity, and types of violence in the relationship between IPV and employment.

The importance of early parenting in at-risk families and children's social-emotional adaptation to school.

OBJECTIVE: The aim of this study was to determine the specific aspects of early parenting in psychosocially at-risk families most strongly related to children's social-emotional adaptation to school. METHODS: A cohort study of families (N = 318) identified as at risk for maltreatment of their newborns was conducted. Quality of early parenting was observed in the home when the child was 1 year old. Social-emotional adaptation to school was reported by teachers in first grade. Multivariable models assessed the independent influence of early parenting variables on social-emotional adaptation. RESULTS: Early parenting and social-emotional adaptation to school varied greatly across families. Parental warmth was associated with lower teacher ratings of shyness, concentration problems, and peer rejection. Parental lack of hostility was associated with decreased teacher ratings of concentration problems and peer rejection. Parental encouragement of developmental advance was associated with lower ratings of aggression and peer rejection. Provision of materials to promote learning and literacy was associated with lower ratings of concentration problems. CONCLUSIONS: In this sample of families with multiple psychosocial risks for child maltreatment, specific aspects of early parenting were associated with better social-emotional adaptation to school in the first grade in theoretically predicted ways. Improving parental knowledge about positive parenting via anticipatory guidance should be a focus of well-child visits. Well-child visit-based interventions to improve the quality of early parenting, especially among at-risk families, should be studied for their impact on parenting behavior and on children's successful social-emotional adaptation to school. Primary care providers should reinforce complementary services, such as home visiting, that seek to promote positive parenting.

Reducing maternal intimate partner violence after the birth of a child: a randomized controlled trial of the Hawaii Healthy Start Home Visitation Program.

OBJECTIVES: To estimate whether home visitation beginning after childbirth was associated with changes in average rates of mothers' intimate partner violence (IPV) victimization and perpetration as well as rates of specific IPV types (physical assault, verbal abuse, sexual assault, and injury) during the 3 years of program implementation and during 3 years of long-term follow-up. DESIGN: Randomized controlled trial. SETTING: Oahu, Hawaii. PARTICIPANTS: Six hundred forty-three families with an infant at high risk for child maltreatment born between November 1994 and December 1995. Intervention Home visitors provided direct services and linked families to community resources. Home visits were to initially occur weekly and to continue for at least 3 years. MAIN OUTCOME MEASURES: Women's self-reports of past-year IPV victimization and perpetration using the Conflict Tactics Scale. Blinded research staff conducted maternal interviews following the child's birth and annually when children were aged 1 to 3 years and then 7 to 9 years. RESULTS: During program implementation, intervention mothers as compared with control mothers reported lower rates of IPV victimization (incidence rate ratio [IRR], 0.86; 95% confidence interval [CI], 0.73-1.01) and significantly lower rates of perpetration (IRR, 0.83; 95% CI, 0.72-0.96). Considering specific IPV types, intervention women reported significantly lower rates of physical assault victimization (IRR, 0.85; 95% CI, 0.71-1.00) and perpetration (IRR, 0.82; 95% CI, 0.70-0.96). During long-term follow-up, rates of overall IPV victimization and perpetration decreased, with nonsignificant between-group differences. Verbal abuse victimization rates (IRR, 1.14, 95% CI, 0.97-1.34) may have increased among intervention mothers. CONCLUSION: Early-childhood home visitation may be a promising strategy for reducing IPV.

Association of substance use discussion by pediatric providers with the parent-provider relationship and maternal behavior change.

A cross-sectional study of data from a randomized, controlled trial was conducted to determine (1) provider and parent attributes associated with discussion of maternal substance use, (2) how substance use discussion related to the parent-provider relationship, and (3) whether discussion was associated with maternal attempts at behavior change. Of the 482 mothers, 34% reported discussing all 3 substance use items (smoking, alcohol, and drug use) with their child's provider. Mothers who discussed smoking were more likely to report discussing alcohol and other drug use (P < .001). Parent-provider relationship scores, measured by a modified version of the Primary Care Assessment Survey, were positively associated with discussion of each substance (P < .001). Discussion of smoking and drug use were significantly associated with attempted behavior change. Our findings suggest that discussion of parental substance use by pediatricians is positively associated with the parent-provider relationship and may lead to behavior change.

Examining maternal depression and attachment insecurity as moderators of the impacts of home visiting for at-risk mothers and infants.

Home visiting programs for at-risk mothers and their infants have proliferated nationally in recent years, yet experimental studies of home visiting have yielded mixed findings. One promising strategy for explicating the effects of early home visiting is to examine moderators of program impacts. This study assessed the roles of maternal depression and attachment insecurity as moderators of the impacts of Healthy Families Alaska home visiting services for at-risk mothers and their infants. At-risk families (N = 325) were randomly assigned to home visiting or community services as usual (n = 162 and 163, respectively). Maternal depression and attachment insecurity (attachment anxiety and discomfort with trust/dependence) were measured at baseline. Maternal psychosocial and parenting outcomes were measured when children were 2 years old via maternal self-report, observation, and review of substantiated reports of child maltreatment. Maternal depression and attachment insecurity interacted in their moderation of program impacts. For several outcomes, home visiting impacts were greatest for nondepressed mothers with moderate-to-high discomfort with trust/dependence and for depressed mothers with low discomfort with trust/dependence. Implications for practice and policy are discussed.

Impact of intimate partner violence on children's well-child care and medical home.

OBJECTIVES: Intimate partner violence has been linked to poor child health. A continuous relationship with a primary care pediatric provider can help to detect intimate partner violence and connect families with needed services. The objectives of this study were to determine the relationship between intimate partner violence and (1) maternal report of a regular site for well-child care, (2) maternal report of a primary pediatric provider, (3) well-child visits in the first year of life, (4) up-to-date immunizations at 2 years of age, (5) maternal report of medical neglect, and (6) maternal report of the pediatric provider-caregiver relationship. METHODS: This retrospective cohort study evaluated data from 209 at-risk families participating in the evaluation of the Healthy Families Alaska program. Research staff interviewed mothers near the time of an index child's birth and again at the child's second birthday. Medical charts were abstracted for information on well-child visits and immunizations. RESULTS: Mothers who disclosed intimate partner violence at the initial interview (n = 62) were significantly less likely to report a regular site for well-child care or a primary pediatric provider. In multivariable models, children of mothers who disclosed intimate partner violence tended to be less likely to have the recommended 5 well-child visits within the first year of life and were significantly less likely to be fully immunized at 2 years of age. Differences in medical neglect were not statistically significant. Of mothers who reported a specific primary pediatric provider, those with intimate partner violence histories trusted this provider less and tended to rate less favorably pediatric provider-caregiver communication and the overall quality of the pediatric provider-caregiver relationship. CONCLUSIONS: Future research should explore effective ways to link intimate partner violence-exposed children with a medical home and a primary pediatric provider and to improve relationships between pediatric providers and caregivers who face violence at home.

Impact of a statewide home visiting program to prevent child abuse.

OBJECTIVES: To assess the impact of a voluntary, paraprofessional home visiting program in preventing child maltreatment and reducing the multiple, malleable psychosocial risks for maltreatment for which families had been targeted. METHODS: This collaborative, experimental study focused on 6 Healthy Families Alaska (HFAK) programs; 325 families were enrolled in 2000-2001, randomized to intervention and control groups, and interviewed to measure baseline attributes. Follow-up data were collected when children were 2 years old (85% follow-up rate). Outcomes included maltreatment reports, measures of potential maltreatment and parental risks, for example, poor mental health, substance use, and partner violence. HFAK records were reviewed to measure home visiting services. Home visitors were surveyed to measure perceived effectiveness and training adequacy. RESULTS: Parental risks were common at baseline, and one-sixth of families had a substantiated child protective services report in the child's first 2 years of life. There was no overall program effect on maltreatment reports, and most measures of potential maltreatment. Home visited mothers reported using mild forms of physical discipline less often than control mothers. The groups were similar in their use of more severe forms of physical discipline. There was no program impact on parental risks. There was no impact on outcomes for families with a 'high dose' of home visiting. Home visitors often failed to address parental risks and seldom linked families with community resources. Contradictions in the model compromised effectiveness. CONCLUSIONS: The program did not prevent child maltreatment, nor reduce the parental risks that had made families eligible for service. Research is needed to develop and test strategies to improve the effectiveness of home visiting.