Since nurses who delivered the NFP trial interventions were also expected to deliver the program in the communities to which it would be disseminated, the trials had elements of effectiveness studies. However, the cost of training and the limited pool of nursing professionals in some communities may impede community-wide implementation.

A randomized controlled study by DuMont, Mitchell-Herzfeld, et al. (2008) of the Healthy Families New York (HFNY) program suggests that the use of paraprofessionals can achieve prevention benefits when targeting women during their first pregnancy. The results of this study are consistent with those for NFP in at least two ways. First, like NFP, HFNY worked with young mothers enrolled during their pregnancy (DuMont, Mitchell-Herzfeld, et al., 2008). Second, HFNY had a greater impact on psychologically vulnerable mothers, results that parallel findings for NFP (Olds, Robinson, et al., 2004).

Important differences were also reported. DuMont, Mitchell-Herzfeld, et al. (2008) found greater benefit from delivery of HFNY by paraprofessionals than was found in the NFP trial in Colorado (Olds, Robinson, et al., 2002, 2004). This result may be attributable to the larger number of cases in the HFNY study and the limited statistical power of the Colorado NFP trial (Olds, Robinson, et al., 2002). However, further research is needed to determine conclusively whether paraprofessional home visitors can achieve results comparable to those of nurse visitors.

Early Childhood and Childhood

Aggressive social behavior, which typically begins to emerge during childhood, is a key risk factor for progression of externalizing disorders (see Brook, Cohen, et al., 1992; Kellam, Ling, et al., 1998; Lipsey and Derzon, 1998; Robins and McEvoy, 1990; Tremblay and Schaal, 1996; Woodward and Fergusson, 1999) and also is a predictor of internalizing disorders (Kaltiala-Heino, Rimpela, et al., 2000; Keenan, Shaw, et al., 1998; Kellam, Brown, et al., 2008). There is now extensive evidence on interventions designed to help families develop practices that prevent the development of aggressive and antisocial behavior and its associated problems. These interventions focus on providing training in parenting skills.

Seminal research on family interactions by Patterson and colleagues over the past 40 years has shown that harsh and inconsistent parenting practices contribute to aggressive and uncooperative behavior and that positive involvement with children and positive reinforcement of desirable behavior contribute to cooperative and prosocial behavior (e.g., Patterson and Cobb, 1971; Patterson, 1976, 1982). Building on the early parenting interventions by Patterson’s group (e.g., Patterson and Gullion, 1968;

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