Linda S. Beeber

Patterns of distress in African-American mothers of preterm infants.

Objective: To examine inter-relationships among stress due to infant appearance and behavior in the neonatal intensive care unit (NICU), parental role alteration stress in the NICU, depressive symptoms, state anxiety, posttraumatic stress symptoms, and daily hassles exhibited by African-American mothers of preterm infants and to determine whether there were subgroups of mothers based on patterns of psychological distress. Method: One hundred seventy-seven African-American mothers completed questionnaires on their psychological distress at enrollment during infant hospitalization and 2, 6, 12, 18, and 24 months after term. Results: Psychological distress measures were intercorrelated. There were four latent classes of mothers: the low distress class with low scores on all measures; the high NICU-related stress class with high infant appearance and parental role stress and moderate scores on other measures; the high depressive symptoms class with high depressive symptoms and state anxiety and moderately elevated scores on NICU-related stress and posttraumatic stress symptoms; the extreme distress class with the highest means on all measures. Infants in the high stress class were sicker than infants in the other classes. The extreme distress class mothers averaged the lowest educational level. The classes differed on distress measures, worry about the child, and parenting stress through 24 months with the extreme distress class having the highest values. Conclusion: Although different types of maternal psychological distress were substantially related, there were distinct subgroups of mothers that were identifiable in the NICU. Moreover, these subgroups continued to differ on trajectories of distress and on their perceptions of the infants and parenting through 24 months after term.

Challenges and Strategies to Maintaining Emotional Health: Qualitative Perspectives of Mexican Immigrant Mothers

Mexican immigrant mothers face many challenges that put them at increased risk for poor mental health. To understand the factors that lead to the development of depressive symptoms among Mexican immigrant mothers, we analyzed data from 20 qualitative, semistructured interviews. Participants included low-income, Mexican-born mothers of young children living in North Carolina. Most of the mothers in our study reported experiencing depressive symptoms after becoming parents. They expressed their symptoms as feelings of sadness, depression, loneliness, shame, and anxiety. Economic stressors contributing to their emotional health included financial obligations, work, and child care. Social stressors included family separation, social isolation, and discrimination. To cope with these stressors, mothers relied heavily on social networks and community resources. Our results suggest that a combination of both risk and resiliency factors shape the emotional health of Mexican immigrant mothers.

Risk for maternal depression and child aggression in Early Head Start families: A test of ecological models

Current literature indicates that risk for maternal depression is substantial in low-income families. A large body of research also indicates that when mothers are depressed, children are at risk for a number of developmental difficulties. While mutual influence between child and parental difficulties has been noted, few studies examine risk factors for both depression and child aggression within ecological models. The present cross-site study examined the unique and additive contributions of contextual factors, including SES and family functioning, on maternal depression and child aggression in Early Head Start families. A multiethnic sample of parents and their children, between the ages of 12 and 43 months, participated in this study. Families came from five Early Head Start programs across the United States, representing both urban and rural areas. Structural equation models (SEM) demonstrate mutual links between depression and aggression, mediated at least in part by ecological factors. SEM indicated that 36.4% of the variance in child aggression is accounted for in a model linking aggressive behavior to parent depression, stress, and couple-level functioning, as well as other family interaction variables. A second model focusing on maternal depression revealed that 44.5% of the variance in maternal depression was accounted for through family factors, including couple-related support and satisfaction and parenting stress. In this second model, child aggression was indirectly linked to maternal depression. These data have important implications for programs serving at-risk families.

IN-HOME INTERVENTION FOR DEPRESSIVE SYMPTOMS WITH LOW-INCOME MOTHERS OF INFANTS AND TODDLERS IN THE UNITED STATES

Depressive symptoms in low-income mothers negatively affect infant–toddler development. This pilot study tested a short-term, home-based depressive symptom intervention with 16 African American and White, Non-Hispanic mothers in Early Head Start (EHS) programs who were randomly assigned to intervention and usual care/waiting list conditions. Mothers met in their homes with masters-prepared psychiatric mental health nurses who worked with them to improve their management of depressive symptoms and life issues, use of social support, and parenting. The intervention group showed a significantly greater decrease from baseline in depressive symptom severity at 8 and 16 weeks in contrast to the mothers receiving usual care. Observations of maternal interactions showed improvement in the intervention mothers. The results support testing on a larger scale.

Improving the Nurse–Family Partnership in Community Practice

BACKGROUND: Evidence-based preventive interventions are rarely final products. They have reached a stage of development that warrant public investment but require additional research and development to strengthen their effects. The Nurse-Family Partnership (NFP), a program of nurse home visiting, is grounded in findings from replicated randomized controlled trials. OBJECTIVE: Evidence-based programs require replication in accordance with the models tested in the original randomized controlled trials in order to achieve impacts comparable to those found in those trials, and yet they must be changed in order to improve their impacts, given that interventions require continuous improvement. This article provides a framework and illustrations of work our team members have developed to address this tension. METHODS: Because the NFP is delivered in communities outside of research contexts, we used quantitative and qualitative research to identify challenges with the NFP program model and its implementation, as well as promising approaches for addressing them. RESULTS: We describe a framework used to address these issues and illustrate its use in improving nurses’ skills in retaining participants, reducing closely spaced subsequent pregnancies, responding to intimate partner violence, observing and promoting caregivers’ care of their children, addressing parents’ mental health problems, classifying families’ risks and strengths as a guide for program implementation, and collaborating with indigenous health organizations to adapt and evaluate the program for their populations. We identify common challenges encountered in conducting research in practice settings and translating findings from these studies into ongoing program implementation. CONCLUSIONS: The conduct of research focused on quality improvement, model improvement, and implementation in NFP practice settings is challenging, but feasible, and holds promise for improving the impact of the NFP.

Testing an explanatory model of the development of depressive symptoms in young women during a life transition.

Factors to explain the rising incidence of depressive symptoms among young women making the transition from home to university life were investigated. A path analysis of data from 213 18- and 19-year-old women entering a large university indicated that negative life events, interpersonally derived social support, self-esteem, and depressive symptoms were significantly related. Negative life events that affected the womens self-esteem (drawn from the womens performance in interpersonal relationships) were most strongly associated with depressive symptoms, and self-esteem derived through efficacy (i.e., taking control and acting assertively) was not associated with negative events. The women in the sample appeared to derive efficacy self-esteem from relationships. An analysis of the data supported developing interventions to improve interpersonal relationships rather than focusing on competence in gaining access to resources.

The early promotion and intervention research consortium (E‐PIRC): Five approaches to improving infant/toddler mental health in Early Head Start

One planned consequence of the national Infant Mental Health Forum held in the United States in 2000 was the funding of five research projects conducted in Early Head Start (EHS) programs. Each project strengthened existing programs by integrating infant/toddler mental health approaches and testing the outcomes on infant/toddler development, behavior, and parent-child interactions. In two of the projects, the effect of offering enrichment for EHS staff was tested. The other three projects tested the effect of services offered directly to parents and children. This article describes the five projects and the theories, methods, and outcome measures used. In order to understand more fully the elevated risk factors in these families and the consequences for mental health in their infants and toddlers, a common set of measures was developed. Data have been used to explore the common threats to mental health and the factors that moderate the impact on infants and toddlers.

Public health nursing case management for women receiving temporary assistance for needy families: a randomized controlled trial using community-based participatory research.

OBJECTIVES We evaluated the effectiveness of a community-based participatory research-grounded intervention among women receiving Temporary Assistance for Needy Families (TANF) with chronic health conditions in increasing (1) health care visits, (2) Medicaid knowledge and skills, and (3) health and functional status. METHODS We used a randomized controlled trial design to assign 432 women to a public health nurse case management plus Medicaid intervention or a wait-control group. We assessed Medicaid outcomes pre- and posttraining; other outcomes were assessed at 3, 6, and 9 months. RESULTS Medicaid knowledge and skills improved (P < .001 for both). Intervention group participants were more likely to have a new mental health visit (odds ratio [OR] = 1.92; P = .007), and this likelihood increased in higher-risk subgroups (OR = 2.03 and 2.83; P = .04 and .006, respectively). Depression and functional status improved in the intervention group over time (P = .016 for both). No differences were found in routine or preventive care, or general health. CONCLUSIONS Health outcomes among women receiving TANF can be improved with public health interventions. Additional strategies are needed to further reduce health disparities in this population.

Flying under the radar: engagement and retention of depressed low-income mothers in a mental health intervention.

A randomized trial of in-home psychotherapy for depressive symptoms that targeted low-income mothers of infants and toddlers used innovative design features to reduce stigma and enhance acceptability. Despite these features, advanced practice psychiatric mental health nurses used specialized, relationship-based strategies to engage and retain these high-risk mothers in the intervention. Data revealed that the nurses needed to diligently maintain contact, provide encouragement, use empathy for rapid assessment and response, and control the intensity of the relationship-based contacts in order to retain mothers.

Supporting the Mental Health of Mothers Raising Children in Poverty : How Do We Target Them for Intervention Studies?

Poverty increases maternal stress by heightening exposure to negative life events, job loss, chronic strains, poor housing, dangerous neighborhoods, and conflict with partners, culminating in crippling depressive symptoms, the most prevalent mental health threat. Depressive symptoms interfere with the provision of the strong maternal support needed to counter the hardships of poverty, thus placing infants and toddlers at risk for delayed language, social, and emotional development. Initial clinical trials in high‐risk mothers have shown promise, and successive tests of interventions will be strengthened if mothers who have mental health risks can be accurately targeted for inclusion. This article reports on a sequential, data‐driven process by which high‐risk mothers were targeted for intervention in two trials currently in progress to reduce depressive symptoms. An iterative process of using data to identify at‐risk mothers and validate the presence of risk factors helped hone the recruitment and design of the intervention trials. This report also offers guidance for further study.