Page 1
Parenting Enhancement Boosts In-Home Interpersonal Psychotherapy
for Low-Income Mothers with Depressive Symptoms
Linda S. Beeber, PhD, RN, CNS,BC, FAAN School of Nursing, University of North Carolina at Chapel Hill
Diane Holditch-Davis, PhD, RN, FAAN Duke University School of Nursing
Todd Schwartz DrPH Regina Canuso, MSN, RN, CNS, BC
Virginia Lewis, B. A. School of Nursing, University of North Carolina at Chapel Hill
Page 2
Acknowledgements
• The National Institute of Mental Health (Beeber, PI: RO1 MH065524)
• Staff of the “HILDA” Project and the participating Early Head Start programs (North Carolina & New York)
• The mothers who taught us how to help.
Page 3
Depressive Symptoms are Prevalent
• 40-59% of low-income mothers Mayberry, Horowitz, & Declercq, 2007
• Limit coping with stressors• Reduce benefit of education & work programs Feder et al., 2009; Mickelson, 2008
• Add to reproduction of multigenerational poverty• Compromise parenting Lovejoy, Graczyk, O'Hare, & Neuman, 2000
Page 4
• Shorter, less child-centered interactions Rosenblum, 1997; Zeanah, 1997; Zlochower, 1996
• Less sensitive, responsive interactions Cohn & Tronick, 1989; Weinberg, et al,1998; Hammen, 1991
• Less frequent touch, play, joy Rosenblum, 1997; Bettes, 1988; Stepakoff, 2000
• Negative judgments of child’s behavior Koschanska, 1987; Murray, 1996; Radke-Yarrow, 1990
• Highly stimulating, “rough touch” Cohn, 1989; Weinberg, 1998
At Moderate Levels Depressive Symptoms Compromise Parenting
Page 5
Negative Outcomes in the Infant and Toddler (> 6 mos duration)
• Smaller fetal body & head growth El Marroun, et. al., 2012
• Delayed language & developmental milestones Lyons-Ruth,1986; Murray, 1996; Zeanah, 1997
• Negative affect & severe tantrums Goodman, 1993; Needlman, 1991
• Less positive affect toward self Cicchetti, 1997
• Lowered resilience to environmental risks Barnard, 1985
• Less confidence in social situations Hart, 1999; Gross, 1994 & 1995
Page 6
Beyond the 0-3 Era
• School-aged children of symptomatic mothers:– conduct disorders– social difficulties– learning/language problems that persist– limited achievement (Campbell, Morgan-Lopez, Cox, & McLoyd, 2009
• Require remedial services • At risk for depression and suicide in adolescence/adulthood
Page 7
Interventions
• Barriers: Transportation difficulties, childcare needs, stigma, competition with meeting basic needs
• Problems with acceptability, fidelity, adequate retention Appleby, Warner, Whitton, & Faragher, 1997; Cooper, Murray, Wilson,
& Romaniuk, 2003; Spinelli & Endicott, 2003; Miranda et al., 2006;
van Doesum, Riksen-Walraven, Hosman, & Hoefnagels, 2008
• Psychotherapy offered in the home - a solution• Miranda (2006) suggested embedding mental health
intervention into existing, trusted community entity
Page 8
Intervention: Adapted Interpersonal Psychotherapy (IPT)
• Specific for depression Klerman & Weissman, 1984
• Evidence-supported & effective • Tested with middle- & low-income postpartum mothers in
traditional clinic model Weissman, Markowitz, & Klerman, 2007; Forman, et. al. , 2008;
Grote et al., 2009)
• Forman, et al, (2008): reduction of depressive symptoms alone did not change critical views of mother toward child or parenting behaviors
• Beeber, et al. (2010) found that critical views of child could be reduced along with depressive symptoms
Page 9
Intervention: Adapted Interpersonal Psychotherapy (IPT)
• Our team: – Adapted IPT to low-income, limited literacy mothers &
added depression-specific parenting guidance Beeber, Perreira & Schwartz, 2008
– Designed delivery to fit into Early Head Start (EHS) programming
– Two RCT’s showed adapted IPT effective in reducing symptoms & changing perceptions
Beeber, et al., 2004 & 2010
– Had not yet shown impact on parenting behaviors after symptoms reduced
Page 10
Purpose: Primary Aim
Deliver the adapted IPT and parenting enhancement guidance (IPT + PE) to low-income, mothers
Test effect on mothers’:
• Depressive symptom severity• Responsiveness while interacting with child
Page 11
Hypotheses
• Compared to mothers who received an attention control condition, mothers receiving IPT+PE would demonstrate:
• less depressive symptom severity at 14 weeks, 22 weeks, and 1 month following completion of treatment (26 weeks)
• more positive involvement & developmental stimulation and less negative control at 26 weeks
Page 12
Design• Randomized, two-group, repeated
measures design• Four measurement points:
– Baseline (T1)– Mid-intervention - 14 weeks (T2)– Termination - 22 weeks (T3)– 1-month post-termination – 26
weeks (T4)• IPT+PE: Psychiatric Mental Health
APRNs • Attention-control condition: RNs with
no mental health preparation
Page 13
Sample:
• 226 low-income mothers • Child 6 weeks – 30 months old enrolled in EHS• Northeast & southeast US; Urban, rural & suburban• ≥ 16 Center Epidemiological Studies-Depression scale
(CES-D) Radloff, 1977
• 15 years of age or older• No regular counseling or psychotherapy• No psychotropic medications• Able to consent or have a guardian consent
Page 14
Intervention• Engagement via nurse-client relationship Peplau, 1952 & 1988
• IPT+ PE (Interpersonal Psychotherapy + Parenting Guidance) Weissman, M. M., Markowitz, J. C., & Klerman, G. L., 2007
• 10 in-person in-home visits, 4-5 telephone booster sessions, 1 termination session
• Content:– Depression linked to transition, dispute, loss, interpersonal
deficit– Focus on depressive symptoms that compromise parenting– Specific strategies to enact and evaluate– Relapse prevention strategies
Page 15
Intervention
• Assessed for depression, suicide/infanticide risk and parenting interactions
• Distressing depressive symptoms addressed immediately
• Parenting guidance offered as symptoms diminished• Interactive, personalized skill sheets kept work focused• PMH APRN Nurses:
– Manualized training– Weekly audit of notes & periodic training for fidelity– Weekly conference call for supervision & support
Page 16
Attention-Control Condition
• Health education in format identical to intervention
• Relationship strategies to engage mothers• RNs followed a strict content protocol• Assessed for crisis; no discussion of
personal matters• Weekly conference supervision to detect
drift from protocol
Page 17
Depressive Symptoms & Depression
• Depressive symptoms: Hamilton Rating Scale for Depression (HRSD)
Hamilton, 1960
• Depression: Structured Clinical Interview for DSM-IV (SCID – Research version) First, Spitzer, Gibbon, & Williams, 2001
–Major Depressive Episode (MDE)–Minor Depression
Page 18
Parenting Outcome Measures
•Maternal Responsiveness : – Maternal Child Observation (behaviors from unstructured, videotaped interactions coded in 10-second epochs) Holditch-Davis, et al, 2007
– Home Observation for Measurement of the Environment (HOME – 6 subscales)
(observer-rated behaviors of mother) Caldwell & Bradley, 1980
Page 19
Additional Measures
•Maternal Self-Efficacy: General Self-efficacy Scale Schwarzer & Born, 1997
•Social Support Seeking: Social Support Seeking Inventory Greenglass, Fiksenbaum & Burke, 1996
•Perceived Stress: Everyday Stressors Index Hall & Farel, 1988
•Maternal demographic characteristics
Page 20
Results: Sample Characteristics
Page 21
827 Mothers Screened
˂ 16 on the CES-DN = 398(48%)
˃ 16 on the CES-DN = 429(52%)
Page 22
Demographics• Sample size: 226 (114 Intervention; 112 attention-control)• Age: 26.0 (sd 5.7)• Education: 11.9 yrs (sd 2.2)• Ethnicity
– Black/African American 61%
– White 27%
– Mixed/Native American/
Hawaiian/Pacific Islander/Asian 8%
– Unreported 4%• Working : 43% • Living without a Partner: 63%• Child age & gender: 24.9 mos. (sd 13.5); 52% female; 56% chronic health problems• Depressive symptom severity: 16.2 (sd 7.7)• Depression: 24% MDE 35% Minor Depression
Page 23
Results: Depressive Symptoms
Page 24
HRSD Reduction at Each Timepoint by Group
Group Baseline Time 2 Time 3 Time 4
Intervention 16.8 (7.8) -4.7 -4.8 -5.0
Attention-Control 15.7 (7.6) -4.5 -4.9 -5.3
P-value Group Difference
n/s n/s n/s n/s
Page 25
Results: Maternal
Responsiveness
Page 26
Maternal Responsiveness Operationalized
Positive Involvement Developmental Stimulation
Negative Control
Near proximity to child Warm touchSmiling at childLooking at childPlaying with child Affectionate gesturesTotal interaction time with child
Child-centered talkingTeaching the child
Shouting at childHostility toward childSlapping or spanking childScolding or derogation of the childRestriction of the child (except for safety)
(HOME sub-scale II)
Page 27
Maternal Responsiveness
• Compared to the ACTAU mothers, mothers receiving IPT + PE showed a significant increase in positive involvement between
Time 1 and Time 4 (26 weeks)
(T4 [26 weeks]: t = 2.22, df = 156, p < .03)
• N/S differences in developmental stimulation and
negative control
Page 28
Additional Analyses
Page 29
Post-hoc Analyses
Perceived Stress
Social Support Seeking
Self-Efficacy
Intervention p<.001 p <.02 p < .01
Attention-Control
p<.001 p <.02 p < .01
Pairwise change from T1 to T4 in both intervention and attention-control groups showed significant within-group reductions
Page 30
Conclusions, Implications, Future Studies
• Reached unserved mothers and vulnerable children• RNs providing health education reduced symptoms as effectively as
adapted IPT+PE• HOWEVER, only mothers receiving IPT+PE showed significant
increase in positive involvement• 75% of mothers in the intervention group completed seven or more
IPT/parenting enhancement sessions (higher than comparison – 36%)
• Further studies: – longer window to observe changes in parenting and child
outcomes– Test hybrid model of RN +APRN model to make it cost-effective
and change enduring behaviors
Page 31
Questions????
Linda S. Beeber [email protected]
The University of North Carolina at Chapel HillSchool of Nursing Tel: (919) 843-2386 FAX: (919) 966-0984
CB #7460, Chapel Hill, NC 27599-7460