Preventing Child in High-Risk Mothers

A multi-site longitudinal intervention project of the University of Notre Dame, University of Kansas, Georgetown University and University of Texas Health Sciences

Too often, outreach and intervention programs have addressed child neglect only when it is at an extremely advanced point, and harm has already been inflicted upon the child and/or mother. In such situations, children suffer and mothers slip back into the cycle of neglect and delinquency as well. There have been many unsuccessful efforts to enhance the developmental outcome of children with adolescent mothers (and at-risk mothers) through early intervention. The lessons learned from these efforts, as well as interventions that have achieved a significant impact, form the basis for this comprehensive, highly-focused model of early intervention that includes a combination of elements likely to alter the trajectories of child and maternal development, and set the stage for the child's successful entry into kindergarten. It is the first parenting intervention project to use a randomized design, with a carefully selected control group and an intense measuring scheme of relevant predictor and outcome variables. The intervention program we have developed includes a number of unique elements combined with a number of elements that research has indicated are crucial to generating positive outcomes for the children of high-risk adolescent mothers and adult mothers with low education (and other risk factors). The innovative aspects include:

• The ongoing, explicit use of a clear positive model of parenting that is practical, evidence based and context sensitive.
• Specific parenting strategies and actions that will be taught in one-one home visits at a level that is developmentally appropriate for each young mother who participates in this project
• The Integration of interventions for which there is strongest evidence of effectiveness.

The project also includes a number of elements identified in earlier research critical to ensuring a positive impact. These include:

• Basing intervention on strong relationship with a home visitor but focusing on specific skills known to enhance parenting and child development outcomes
• Enrolling mothers prior to the birth of the child
• Continuing the intervention for three years with home visitation
• Referring depressed mothers for treatment
• Providing an intensive intervention by well-trained professionals
• Carefully monitoring and ensuring treatment fidelity
• Including both proximal and distal measures of treatment effects on both mother and child

The combination of "unique" elements with "tried and true" intervention components should result in the most effective parenting program yet devised for high-risk teenage mothers and their children. The benefits of this approach should produce important changes in the lives of both mothers and children over both the short- and long-term: Mothers should be better adjusted, more successful, and happier. Children's early self-regulation will be supported, thereby helping them to be "ready for school" on their first day of kindergarten.

Design

The project uses a treatment-control design. Pregnant teen and adult mothers without a high school degree will be randomly assigned to one of two groups: A Low Intensity Group that will provide referral to community support services based on assessed needs and High-Intensity Group that provides referrals to social support plus training at least bi-weekly on a wide range of skills related to parenting.

Participants. The enrollment of 400 dyads (100/site) will begin before the birth of the child, with data gathered until each child is 3 years of age. Mothers will be recruited from prenatal clinics during pregnancy. All participants will be between 15-18 years of age at the time of birth of their first child, or over 21 and without a high school degree or will fit a "risk profile" reflecting an elevated likelihood that they will neglect their child (history of depression or substance abuse). Extensive efforts will be made to ensure that the samples recruited at each site (South Bend, Kansas City, Washington, D.C., and Houston) are similar on key variables at the outset of the study (e.g. education level). Extensive efforts will be made to minimize attrition through frequent contacts and incentives related to project participation.

Higher Intensity Direct Intervention Strategies

The high intensity intervention will occur primarily on a one-to-one basis in the home. Specific intervention components include the following:

• Problem-Solving and Decision-Making: Adapted from the work of Barbara Wasik with the Infant Health and Development Project, this intervention will be provided during pregnancy and then occasionally throughout the project to the parent on "making good choices" and building a positive future for themselves and their child. This component of the intervention introduces parents to a simple and concrete approach to stimulate reflective thinking and planning ahead (e.g., things to do to prepare for the birth of their baby, determining who will care for the baby while mother is in school or working etc., how to finish school with a baby etc.). The goals of this effort are to help the mother's achieve a greater degree of self-sufficiency and self-efficacy.
• Teaching Specific Parent-Child Interaction Strategies: Specific interaction strategies will be taught in correspondence with the child's development throughout the intervention. Mothers will be taught to embed these strategies in the course of their ongoing routine interactions with the child. For example, mothers will be taught to recognize their infants' cues or bids for attention and to respond in a warm and sensitive manner. As the child matures, the mother will be taught methods of enhancing vocabulary development. In short, our goals are to develop sensitive and responsive parents, who are aware of the importance of language, cognitive, and social interactions. This intervention component is based on the Play and Language Strategies developed by Susan Landry at the University of Texas Health Science Center in Houston.
• Early Routines: Parents will be taught very practical strategies for providing care to their children during routines such as feeding, bathing, dressing/diapering and soothing. These behaviors will be taught through a combination of discussion, modeling, practice and reflective feedback.
• Health: Based on the work of Lutzker & Bigelow (2002), this module teaches parents basic home health care skills. Parents learn what to do when their child develops symptoms or when various health concerns arise. Parents learn to recognize when a situation needs immediate attention in an emergency room, or when to call a nurse/doctor for more information and how to do this effectively.
• Home Safety: Based on the work of Lutzker & Bigelow (2002), this module helps parents learn how to make their homes safer for their child. Parents learn what items in the home pose risks to their developing child and how to problem solve about how to arrange their environments to remove these risks. Parents learn how to examine their own environments and determine which items may be dangerous to their child. This module is being used by child welfare workers throughout the state of Oklahoma.
• Loving Touch Module: These strategies focus on teaching parents how to provide gentle touch to their infants through daily routines such as diapering/dressing, bedtime, play, feeding and soothing.
• Healthy Start, Grow Smart: This module focuses on helping parents to know about typical developmental milestones and how to tune in and support their child during specific developmental age periods. This module is being implemented by interventionists throughout the state of Texas.

Assessment Measures

A number of specific outcome and treatment fidelity measures will be utilized. Treatment fidelity measures will include: a) number, distribution, and length of contact with each mother; Outcomes will be evaluated using both distal and proximal measures. Many of these measures will be collected throughout the first three years of life. They include the widest array of theoretically driven measures ever collected in intervention research on responsive parenting.

• The HOME
• Size of children's vocabulary
• Complexity of children's language
• Standardized child language and cognitive measures
• Attachment
• A variety of psycho-social measures of neglect (obtained via cell phones)
• Health indicators for both the mother and child
• Mother-child interactive communication measures (e.g., responsivity, feedback tone, etc.)
• Mother's perception of her relationship with her child, and beliefs about parenting
• Mother and child involvement in the community (e.g. church attendance, child-care, etc.)
• Maternal cognitive competence
• Maternal depression
• Maternal substance abuse

Expected Outcomes

We expect that mothers who receive appropriate levels of high quality intensive intervention will be less likely to engage in child maltreatment and demonstrate better personal parental decision-making. This will result in improved child development outcomes and a reduction in costs from social service and educational systems.

We expect that those modules that are most promising will be translated in print and video materials that can be used by a wide variety of personnel working to prevent the incidence of child neglect.

Researchers leading these projects include:

John Borkowski, Ph.D. Christine Noria, Ph.D. Steve Warren, Ph.D. Judith Carta, Ph.D. Kathleen Baggett, Ph.D. Sharon Ramey, Ph.D. Craig Ramey, Ph.D. Bette Keltner, Ph.D. Robin Lanzi, Ph.D. Susan Landry, Ph.D. Cathy Guttentag, Ph.D.	University of Notre Dame University of Notre Dame University of Kansas University of Kansas University of Kansas Georgetown University Georgetown University Georgetown University Georgetown University University of Texas Health Sciences University of Texas Health Sciences

For more information in Kansas City, contact: Judith Carta, Ph.D. (carta@ku.edu) or Kathleen Baggett, Ph.D. (kbaggett@ku.edu)