Judith B. Van Ginkel

Predictors of Early Engagement in Home Visitation

Predictors of engagement in mothers receiving home visitation in the first year of service was examined. Early engagement was studied in three ways: (1) length of time active in the program during the first year of service (duration), (2) number of visits received (quantity), and (3) gaps in service between visits (consistency). Examined visits received in 515 first-time mothers in a Healthy Families America (HFA) program. Parameters of engagement were investigated, and predictors of engagement were identified using demographics and the Kempe Family Stress Inventory. Inclusive of the Assessment Visit, 31.8% of mothers disengaged prior to the first month of service. Remaining active in the program was associated with being Caucasian, and increased parenting risk (mental health/substance abuse history, low social support, increased stress). Most mothers had fewer home visits than prescribed. Gaps in prescribed service were common, with 89.4% of mothers experiencing gaps between visits of 1 month, and dropping to 16.4% having gaps of 2 months. In contrast to findings from clinic-based interventions, early engagement in home visitation is associated with lower levels of functioning and acute needs. These findings add to a growing body of literature suggesting that increased adversity promotes engagement in prevention programs in general, and home visitation programs in particular. To the extent that mothers who are actively engaged in home visitation are likely to have increased psychosocial needs, curricula may require modification and augmentation to address these needs and optimize program effectiveness.

Changes in depressive symptoms in first time mothers in home visitation

OBJECTIVE The expansion of Home Visitation Programs for at-risk, first-time mothers and their young children has drawn attention to the potential impact of depression on program outcomes, yet little research has examined depression in the context of home visitation. The purpose of this study was to determine the prevalence of and changes in depressive symptoms in mothers enrolled in home visitation and identify predictors of change in symptoms over the first 9 months of service. METHODS Subjects consisted of 806 at-risk, first-time mothers enrolled in a Home Visitation Program. Self-reported depression was measured at enrollment and again 9 months later. Established clinical cutoffs were used to identify clinically elevated levels of depression. Additional measures were taken of interpersonal trauma history, concurrent intimate partner violence, and social support. RESULTS Results indicated that: (1) 45.3% of mothers had clinically elevated symptoms of depression at some point during the first 9 months of service, (2) 25.9% of mothers had elevated symptoms at both time points or at the 9-month assessment, and (3) 74.1% experienced an interpersonal trauma prior to enrollment. Lack of improvement or worsening of depressive symptoms from enrollment to 9 months was best predicted by pre-enrollment interpersonal trauma history, young maternal age, being African American, and symptoms severe enough to have led to mental health treatment. CONCLUSIONS Findings suggest that maternal depressive symptoms are a significant problem in home visitation. The role of interpersonal trauma in depressive symptoms, and how to best address these clinical issues in home visitation, warrants further examination. PRACTICE IMPLICATIONS Maternal depression is prevalent in Home Visitation Programs, and many mothers exhibit elevated symptoms at multiple time points over the first year of service. Interpersonal trauma history is also prevalent, and is predictive of increased depressive symptoms over time. Home Visitation Programs should note that mothers with interpersonal trauma history, young maternal age, and being African American have an increased likelihood of persistent depressive symptoms, which may in turn pose significant challenges to providing services.

A Clinical Trial of In-Home CBT for Depressed Mothers in Home Visitation

Despite negative outcomes for depressed mothers and their children, no treatment specifically designed to address maternal depression in the context of home visitation has emerged. In-Home Cognitive Behavioral Therapy (IH-CBT) is an adapted treatment that is delivered in the home, focuses on the needs of new mothers, and leverages ongoing home visiting to optimize engagement and outcomes. This study examined the efficacy of IH-CBT using a randomized clinical trial. Subjects were 93 new mothers in a home visiting program. Mothers with major depressive disorder identified at 3months postpartum were randomized into IH-CBT and ongoing home visitation (n=47) or standard home visitation (SHV; n=46) in which they received home visitation alone and could obtain treatment in the community. Depression was measured at pre- and posttreatment, and 3-month follow-up using interviews, clinician ratings, and self-report. Mothers receiving IH-CBT showed improvements in all indicators of depression relative to the SHV condition and these gains were maintained at follow-up. For example, 70.7% of mothers receiving IH-CBT were no longer depressed at posttreatment in terms of meeting criteria for major depressive disorder compared to 30.2% in the SHV group. These findings suggest that IH-CBT is an efficacious treatment for depressed mothers in home visitation programs.

Intensive home visiting is associated with decreased risk of infant death

OBJECTIVE. The goal was to test the hypothesis that participation in a community-based home-visiting program is associated with a decreased risk of infant death. METHODS. A retrospective, case-control design was used to compare the risk of infant death among participants in Cincinnatis Every Child Succeeds program and control subjects matched for gestational age at birth, previous pregnancy loss, marital status, and maternal age. The likelihood of infant death, adjusted for level of prenatal care, maternal smoking, maternal education, race, and age, was determined with multivariate logistic regression. The interaction between race and program participation and the effect of home visiting on the risk of preterm birth were explored. RESULTS. Infants whose families did not receive home visiting (n = 4995) were 2.5 times more likely to die in infancy compared with infants whose families received home visiting (n = 1665). Black infants were at least as likely to benefit from home visiting as were nonblack infants. No effect of program participation on the risk of preterm birth was observed. CONCLUSION. The current study is consistent with the hypothesis that intensive home visiting reduces the risk of infant death.

Development and Implementation of a Quality Assurance Infrastructure in a Multisite Home Visitation Program in Ohio and Kentucky

SUMMARY As home visitation programs go to scale, numerous challenges are faced in implementation and quality assurance. This article describes the origins and implementation of Every Child Succeeds, a multisite home visitation program in southwestern Ohio and Northern Kentucky. In order to optimize quality assurance and generate new learning for the field, a Web-based system (eECS) was designed to systematically collect and use data. Continuous quality assurance procedures derived from business and industry have been established. Findings from data collection have documented outcomes, and have identified clinical needs that potentially undermine the impact of home visitation. An augmented module approach has been used to address these needs, and a program to treat maternal depression is described as an example of this approach. Challenges encountered are also discussed.

An open trial of in-home CBT for depressed mothers in home visitation.

Research has demonstrated that low income mothers participating in home visitation programs have high rates of depression. This study used an open trial design to evaluate In-Home Cognitive Behavioral Therapy (IH-CBT), an evidence-based treatment for depression that is delivered in the home setting and has been adapted to address the needs of low income mothers participating in home visitation. 64 depressed mothers recruited from a home visitation program and who had completed IH-CBT were compared to 241 mothers from the same setting who met identical screening criteria at enrollment but did not receive the treatment. In addition, pre- and post-treatment measures of depression and related clinical features were contrasted in the 64 mothers receiving IH-CBT. There was a significantly greater reduction in depressive symptoms in the IH-CBT group relative to their counterparts who did not receive the treatment. Results from pre-post comparisons showed that treated mothers had decreased diagnosis of major depression, lower reported stress, increased coping and social support, and increased positive views of motherhood at post-treatment. Findings suggest that IH-CBT is a promising approach to addressing maternal depression in the context of home visitation and warrants further study. Public health implications for home visiting programs are discussed.

PTSD in Depressed Mothers in Home Visitation.

Recent research has suggested that mothers participating in home visitation programs have a high incidence of mental health problems, particularly depression. Posttraumatic stress disorder (PTSD) is a common comorbidity with depression, yet its prevalence among home visiting populations and implications for parenting and maternal functioning have not been examined. This study contrasted depressed mothers with (n = 35) and without PTSD (n = 55) who were enrolled in a home visitation program. Results indicated that depressed mothers with comorbid PTSD were more likely to have experienced childhood sexual abuse, had greater severity of depressive symptoms, increased social isolation, and lower overall functioning than their counterparts without PTSD. Among PTSD mothers, greater severity of PTSD symptoms, in particular avoidance and emotional numbness, were associated with increased maternal psychopathology and parenting deficits even after controlling for depression severity. These findings add to the literature documenting the negative impacts of PTSD on maternal functioning and parenting. Implications for screening and treatment in the context of home visitation are discussed.

Treatment of depressed mothers in home visiting: Impact on psychological distress and social functioning

OBJECTIVES Depression is prevalent in mothers receiving home visiting. Little is known about the impact of treatment on associated features of maternal depression in this population. The purpose of this study was to examine the impact of a novel, adapted treatment for depressed mothers in home visiting on psychological distress and social functioning. METHODS In-Home Cognitive Behavioral Therapy (IH-CBT) was developed to treat depressed mothers in home visiting. A randomized clinical trial design was used in which subjects were 93 new mothers in a home visiting program. Mothers with major depressive disorder identified at 3 months postpartum were randomized into IH-CBT and ongoing home visiting (n = 47) or standard home visiting (SHV; n = 46) in which they received home visitation alone and could obtain treatment in the community. Measures of psychological distress, social support, and social network were measured at pre-treatment, post-treatment, and three-month follow-up. Clinical features of depression and home visiting parameters were examined as potential moderators. RESULTS Subjects receiving IH-CBT reported decreased psychological distress at post-treatment (ES = 0.77) and follow-up (ES = 0.73). Examination of types of psychological distress indicated broad improvements at both time points. Those receiving IH-CBT reported increased social support over time relative to those in the SHV condition. Effect sizes were modest at post-treatment (ES = 0.38) but increased at follow-up (ES = 0.65). Improvements were seen in affiliative and belonginess aspects of social support, in contrast to tangible support which was statistically non-significant. Findings were not moderated by clinical features of depression or home visiting parameters. No group differences were found in size of and involvement with social networks. CONCLUSIONS IH-CBT is effective in reducing psychological distress and improving perceived social support in depressed mothers receiving home visiting. To the extent that mothers are better adjusted and feel socially supported, they are more available to their children and more amenable to home visiting services. IH-CBT is a feasible, readily adopted treatment that is compatible with multiple home visiting models. As a result it is a promising approach to help depressed mothers in home visiting. Additional interventions may be needed to support depressed mothers in building sizable and stable social networks.

Facilitators and Barriers to Engagement in Home Visitation: A Qualitative Analysis of Maternal, Provider, and Supervisor Data

Abstract Given previous findings indicating a positive association between home visitation participation rates and family outcomes, the present study explored reasons for and barriers to engagement in the first six months of these parenting programs. Social support, psychoeducation, and tangible assistance emerged as consistent themes across informants as reasons for participation. Perceived invasiveness of the assessments, maternal concerns about being reported to child protective services, and mismatches between maternal needs and home visitor attributes emerged as recurrent themes regarding barriers to participation. Results of these qualitative analyses converge with previous quantitative research regarding factors associated with home visitation delivery and suggest new areas in need of further inquiry by researchers and practitioners to increase engagement.

In-Home Cognitive Behavior Therapy for a Depressed Mother in a Home Visitation Program

Depression is frequently observed among young mothers who are low income who participate in home visitation programs that are focused on optimizing child development. Maternal depression can undermine such prevention programs, and mothers are faced with significant barriers to obtaining concurrent effective mental health treatment. This case study describes In-Home Cognitive Behavior Therapy (IH-CBT), an adapted treatment for depressed mothers in home visitation. IH-CBT provides an empirically based treatment in the home setting that is tightly integrated with ongoing home visitation. The treated mother presented with major depressive disorder in the postpartum period and poor attachment with her baby. After 15 sessions of IH-CBT, provided in conjunction with home visitation, significant improvement occurred in mood, self-sufficiency, and her relationship with her baby.