Interventions that take a generational approach are designed to provide supports to parents and other caregivers that strengthen both their understanding of what children and youth need and their capacity to provide it. Such interventions may influence more than one generation by improving outcomes for children and thereby improving outcomes for the children they will care for in the future. These interventions often target opportunities to reach parents and caregivers at critical junctures, such as before and just after a child is born, as well as reduce known risk factors for children’s healthy mental, emotional, and behavioral (MEB) development, including negative parenting practices and parental mental health problems or substance use disorders. They also increase protective factors such as parent–child attachment or bonding.
Our focus on these interventions is an acknowledgment that caregivers need assistance to promote MEB health across generations; fostering their healthy MEB development now can pay off for future generations. As noted in Chapter 2, community- and society-level factors contribute significantly to the challenges that all parents encounter as their infants grow into young adults, an issue to which we return at the end of the report. Thus, providing support at the community level for parents and caregivers is an obvious and productive way to promote healthy MEB development.
Researchers have developed numerous interventions to strengthen parenting skills. Many parenting interventions target early developmental stages for two reasons: first, parents generally have the most extensive contact and exert the greatest influence while their offspring are infants, toddlers, and young children; second, early brain development is critical for MEB health outcomes. Prevention programs for parents of young infants or children include universal approaches designed to promote parents’ knowledge of child development and positive parenting (e.g., prenatal care, well-child visits); selective approaches aimed at providing support for low-income families (e.g., home visiting, Early Head Start, Head Start); and indicated approaches that teach behavioral management
techniques for improving child behaviors (e.g., Parent–Child Interaction Therapy, Child Adult Relationship Enhancement, the Incredible Years).
Programs for parents of adolescents have focused primarily on prevention of the child’s substance use or risky sexual behavior through parent education to improve parent–child communication (see Sandler et al., 2011). Fewer parent-focused interventions have addressed parents of college-age children, but those that have done so have produced promising results despite the fact that many of these emerging adults are living away from home, and their parents tend to have less contact and influence at this life stage than at earlier ones.
The literature in this area is substantial, and parenting is considered in depth in a recent National Academies of Sciences, Engineering, and Medicine (NASEM, 2016) report. That report identifies knowledge, attitudes, and practices of parents that are associated with positive developmental outcomes in children ages 0–8, and also examines universal/preventive and targeted interventions designed to support parents and caregivers in developing those attributes. Although the authors do not confine their attention to MEB outcomes, the report identifies features of parenting interventions that “appear to influence success in engaging parents and increasing their use of effective parenting practices” (p. 8):
- viewing parents as equal partners in determining the types of services that would most benefit them and their children;
- tailoring interventions to meet the specific needs of families;
- integrating and collaborating in services for families with multiple service needs;
- creating opportunities for parents to receive support from peers to encourage engagement, reduce stigma, and increase the sense of connection to other parents with similar circumstances;
- addressing trauma, which affects a high percentage of individuals in some communities and can interfere with parenting and healthy child development;
- making programs culturally relevant to improve their effectiveness and participation across diverse families; and
- enhancing efforts to involve fathers, who are underrepresented in parenting research.
Recent work in this area includes studies of links between low birthweight and the probability of later development of mental health disorders such as depression and attention deficit-hyperactivity disorder (Nigg and Song, 2018; Pettersson, Larsson, and D’Onofrio, 2019). Other research includes studies of programs for parents of older children and adolescents. Two examples illustrate ways that interventions can support positive parenting for older children: Triple P (Positive Parenting Program) and Parent–Child Interaction Therapy (see Boxes 3-1 and 3-2, respectively). These two programs have been studied in randomized controlled trials (RCTs), which demonstrated effects including improved
parenting practices and competence, parent–child interactions, and child behavior (NASEM, 2016).
Researchers have also studied interventions designed to support parents in preventing anxiety and depressive symptoms and disorders (i.e., internalizing problems) in children and youth. For example, a meta-analysis of RCTs of such parent-focused interventions showed small but significant effects on internalizing symptoms and on prevention of anxiety disorders (Yap et al., 2016). There is also evidence that parent-focused programs can reduce short- and long-term alcohol, tobacco, and illicit drug use among adolescents (Allen et al., 2016). Examples of programs with this focus include the Strengthening Families Program (see Box 3-3), Guiding Good Choices, and Familias Unidas; they emphasize family skills training and can be delivered to both high- and low-risk families.1
Although fewer interventions have targeted parents of college-age youth, there has been some promising work in this area. For instance, Turrisi and colleagues (2009) developed a handbook to guide parents in communicating effectively with their children regarding the harms of alcohol use; use of this handbook reduced the likelihood that nondrinking students would use alcohol in their first year of college (Ichiyama et al., 2009). More recently, FITSTART, an interactive online intervention that corrects parents’ alcohol-related misperceptions and provides strategies for effective communication about alcohol with their college-age children, was tested in an RCT and found to reduce college students’ heavy episodic drinking (LaBrie et al., 2016). Conversely, an RCT of an intervention that provided parents of college students with online normative feedback, but not with strategies for discussing alcohol with their children, showed no such effects on student drinking (Napper, LaBrie, and Earle, 2016).
Researchers have examined parenting interventions spanning different child ages and including both promotion and prevention approaches. Overall, the large and growing literature on family-focused programs suggests that they have benefits for children and adolescents, particularly in reducing internalizing problems, behavior issues, and substance use. Research on such programs is building the case for making these interventions available to families and communities, and more can be learned as they are disseminated more widely. The intervention mechanisms that produce long-term program impacts are not well understood (Sandler et al., 2011; Yap et al., 2016). Further work could also explore questions about optimal parenting skills to foster at different critical stages of developmental challenge, such as entry into primary school or the transition to middle or high school, and biological transitions, such as puberty, as well as ways to optimize the use of primary care and other access points to reach parents and caregivers.
1 See U.S. Department of Health and Human Services (2016) for a list of substance abuse prevention programs and policies.
Another set of interventions addresses mental health and substance use disorders in parents, which have been clearly linked to negative outcomes for infants as well as impacts on older children and adolescents, including an increased likelihood that they will develop substance use problems and other mental health disorders (see Chapter 2). The link between depression in mothers and negative outcomes for their children, as well as the benefits of intervention in this area, have been particularly well documented, but work has also shed light on ways of addressing substance use and other disorders.
As discussed in Chapter 2, a mother’s depression during pregnancy is associated with a number of negative outcomes. Shorter-term effects include increased health problems for mothers; lower birthweight and preterm deliveries for babies; and negative child outcomes, including slower cognitive development, less secure attachment, and greater behavioral difficulties (Gelaye and Koenen, 2018; Goodman et al., 2011). When a mother’s depression persists or is present when her children are older, effects can include poor school performance, depression, anxiety, substance abuse, and suicidal behavior (Netsi et al., 2018; Santavirta, Santavirta, and Gilman, 2018; Stein et al., 2018; Weissman et al.,
Because the evidence of harm caused to children by depression in parents, and particularly in pregnant women and new mothers, is so well established, prevention researchers have long held that waiting for the onset of clinical depression before intervening is not enough and that preventing major depressive episodes at any time, but particularly during pregnancy and the postpartum period, is critical (Le et al., 2003). It is also important to note that depression is a chronic illness in which remission and relapse are common, so treatment needs to be available over the life course.
Treatment and Prevention
There are two ways of preventing the sequelae of maternal depression in infants and children: (1) treatment during pregnancy or postpartum for women already suffering from clinical depression and (2) prevention interventions to forestall clinical episodes of depression. Treating and preventing prenatal and postnatal depression in mothers are developing areas of research, but several points are well established. Clinical trials have demonstrated the efficacy of psychological treatments during pregnancy and the postpartum period in reducing the mother’s depressive symptoms. A review of 50 clinical trials of different approaches, adapted for women immediately before and after giving birth, showed that interpersonal therapy (IPT) and cognitive-behavioral therapy (CBT) both have the capacity to reduce depression by approximately 50 percent (Burns et al., 2013). In addition, the U.S. Preventive Services Task Force determined in 2019 that there is no need to wait until a person is suffering from a clinical depression episode to intervene (O’Connor et al., 2019; U.S. Preventive Services Task Force, 2019). It is possible to identify women at risk for the onset of a major depressive episode and offer preventive interventions (Le et al., 2003). The evidence that counseling interventions based on IPT (Grote et al., 2009; Lenze and Potts, 2017; Spinelli et al., 2016; Weissman, Markowitz, and Klerman, 2018; Zlotnick, Capezza, and Parker, 2011) or CBT, such as the Mothers and Babies Course (Muñoz et al., 2007; Sockol, Epperson, and Barber, 2011; Tandon et al., 2011), are effective in preventing perinatal depression is sufficiently strong to recommend that clinicians provide or refer patients to receive such interventions (O’Connor et al., 2019; U.S. Preventive Services Task Force, 2019).
Pregnant women with depression that is severe or is not responding to psychotherapy also may benefit from the use of antidepressant medications. Emerging evidence, however, indicates that such medications may have deleterious effects on the developing fetus (see, e.g., Gingrich et al., 2017). Research to understand the effects of selective serotonin reuptake inhibitors, the most common type of antidepressant medication, on the developing fetus is ongoing. However, maternal depression during pregnancy poses a considerable risk for negative child outcomes, and some women require medication for
depression during pregnancy. The current advice is that women’s treatment options be assessed individually by their clinicians and discussed with them.
Other psychological and psychosocial approaches for treating maternal depression, such as postpartum home visits by professional staff and postpartum telephone support, physical exercise, and dietary supplements, have been less well studied, but several of them offer intriguing ideas for further study (Brugha et al., 2011; Dennis and Dowswell, 2013; Lavender et al., 2013; Morrell et al., 2016; Tandon et al., 2011). For example, mindfulness-based perinatal interventions show preliminary promise for both treatment and prevention, although the quality of studies in this area is variable (Shi and MacBeth, 2017). A prenatal program to promote parenting skills in couples has also shown improvements for outcomes associated with mother–child attachment (Feinberg et al., 2015).
The treatment of depression is complex, and numerous therapies, both medical and psychotherapeutic, are available. The relationships among the factors relevant to maternal depression and children’s MEB development are also complex, and it has been suggested that interdisciplinary research including the fields of epidemiology, genomics, neuroscience, and child development is needed to build understanding of the underlying mechanisms (Gelaye and Koenen, 2018). It will also be important to learn more about when and how to intervene with different subpopulations of women. The 2019 recommendations of the U.S. Preventive Services Task Force are highlighting the need for new research to explore the impact of averting the onset of depression in the mother altogether and thereby possibly preventing the development of MEB disorders in her child and fostering healthy lifelong development. This is a major advance in the field of prevention science that needs to be underscored and built upon in the next decades.
Benefits for Infants and Older Children
Because the evidence of harm from maternal depression is so strong, it is logical to expect that effectively preventing or treating it would have identifiable benefits for both infants and older children. Researchers are still exploring questions about specific benefits, but the number of studies in this area remains small, and the available studies vary in the nature, duration, and timing of intervention approaches examined; the offspring outcomes measured; and the developmental stages assessed. Additional work is needed to develop a more detailed picture.
For example, both providing IPT to mothers and a home visiting program have been associated with greater improvements in toddler attachment, maternal perceptions of toddler temperament, and parenting efficacy than were found with enhanced community care (Handley et al., 2017; Sierau et al., 2016). Other studies, however, were unable to document impacts of such interventions on infant outcomes. Two studies of postpartum psychotherapy found that even when treatment reduced maternal depression, effects on parenting or early child
adjustment (Ammerman et al., 2015) and child development at age 7 (Maselko et al., 2015) could not be established. A pilot RCT study of an individual mother–infant dyad approach (in which the pair are treated as a unit whose relationship is critical) to reducing maternal depression and improving parent–child interaction found no significant differences in maternal outcomes or mother–infant interaction (Goodman et al., 2015).
However, while this work points to questions for further research, the authors of a meta-analysis of studies of the effects of treating depression during and after pregnancy concluded that there are promising findings for psychological interventions delivered during pregnancy and postpartum on a range of indicators relevant to parenting and child development (Letourneau et al., 2017). Furthermore, investigators working with mothers and infants have suggested that focusing solely on the mother fails to engage the unique mother–infant experience of the postpartum period. Learning to deal with infant fussing, crying, and sleeping and feeding patterns can reduce maternal depression, and positive interaction between mother and infant or child can be therapeutic in itself (Werner et al., 2016). A 2017 review of evidence-based interventions for depressed mothers and their young children presents evidence for interventions to reduce maternal depression and describes the mechanisms underlying its relationship to the child’s development (Goodman and Garber, 2017). The authors of this review and others (Stein et al., 2018) recommend testing interventions that both treat maternal depression and enhance parenting skills with infants and young children.
There is also evidence that treating a parent’s depression using medications and evidence-based psychotherapy, alone or in combination, can reduce adverse effects on older children (Cuijpers et al., 2015). One example is the Sequenced Treatment Alternatives to Relieve Depression study, which was designed to test how best to treat depression and included an add-on study to determine the effect of remission of maternal depression on offspring (Weissman et al., 2006). This study showed that remission decreased the symptoms of adverse effects in a woman’s children, whereas when a mother remained depressed, her children showed either no change or an increase in their symptoms; the positive effects on children were sustained 1 year after the mother’s remission (Wickramaratne et al., 2011). Comparable effects were found by Garber and colleagues (2009), and a similar study in which mothers were treated successfully with medication showed positive effects on children of the participants (ages 7–17) (Weissman et al., 2015). A separate clinical trial found positive effects on children when their depressed mothers were treated with IPT (Swartz, 2015), suggesting that the important factor for the child was the successful treatment of the mother’s depression by reducing her depressive symptoms, whether by medication or by psychotherapy.
A related issue is the possibility that treating parental depression may be beneficial for adolescents who are at risk for or experiencing depression, based on the growing evidence that, whether because of genes, environment, or some combination of the two, the children of depressed parents are more likely to become depressed than are children of parents who have not been depressed (e.g.,
Overall, while important questions about long-term outcomes and other issues require further study, it is clear that successfully controlling parental depression is a critically important component of any effort to promote healthy MEB development and prevent MEB disorders.
While the effects of parental substance disorder on children have received attention over the years (U.S. Department of Health and Human Services, 2016), relatively little is known about the impact of substance use treatment for parents that is integrated with programs aimed at improving parenting. For example, a systematic review of studies of this approach found very few studies of child outcomes with either quasi-experimental or experimental comparison group designs, though it concluded that the available evidence does suggest that this approach is associated with improvements in parenting skills (Niccols et al., 2012).
A number of RCTs have examined the impact of adding parent or couples training programs to standard drug treatment. One such program is Parents Under Pressure, in which parent training by clinic staff is offered along with methadone treatment. Researchers documented reductions in child abuse and other improvements, although the study did not address effects on parents’ addiction (Barlow et al., 2019). These findings reinforced findings from earlier work on the program (Dawe and Harnett, 2007). Other older research showed comparable benefits for parenting interventions delivered in the context of substance use treatment (Catalano et al., 1999; Fals-Stewart, O’Farrell, and Birchler, 2004; Haggerty et al., 2008) and similar approaches using couples-based treatment (Lam, Fals-Stewart, and Kelley, 2008). More recently, an RCT showed benefits from providing recovery coaches to substance-abusing mothers whose children had been in foster care and reunited with their parents (Douglas-Siegel and Ryan, 2013).
Overall, the existing research provides some indication that integrating parent training or couples therapy with drug treatment has positive effects on children’s behavior and emotional well-being. With the exception of a single long-term follow-up study spanning 12 years (Haggerty et al., 2008), most of the evidence is based on small samples and short-term follow-up of 1 year or less, but the evidence is promising and merits investment in larger studies and longer-term follow-up.
Child maltreatment—including exposure to sexual, physical, and emotional abuse, physical and emotional neglect, and domestic violence or other trauma—is a global public health problem affecting millions of children (Stoltenborgh et
al., 2014), with well-established adverse effects on emotional, behavioral, and physical functioning over the life course (Devries et al., 2014; Gilbert et al., 2009; Jonson-Reid, Kohl, and Drake, 2012; Lindert et al., 2014). Preventing child maltreatment is critical, and a variety of approaches for intervening with children and youth at risk for abuse and maltreatment have been developed. Research conducted over the past 10 years confirms and extends the evidence base for the effectiveness of home visitation and parenting skills training in preventing child maltreatment (van der Put et al., 2018). While some universal approaches show promise, most preventive interventions in the United States have targeted families at greater risk of child maltreatment based on such risk factors as low income, parental history of maltreatment or other adverse experiences in childhood, or child behavioral problems. One promising example is the Child–Parent Psychotherapy model, which targets children ages 0–5 who have experienced traumatic events, including domestic violence (Lieberman and Van Horn, 2009).
Home visitation has proven to be an effective intervention for preventing child physical abuse and neglect. A meta-analytic review of research on nine different home visiting models identified improved positive parenting and reduced risk for maltreatment as the most robust outcomes across programs; supervision and program fidelity monitoring were found to be significant moderators increasing these effects (Casillas et al., 2016).
One example of this approach that has been extensively evaluated is the Nurse–Family Partnership (NFP) model, in which nurses make home visits to low-income first-time mothers (Macmillan et al., 2009). An RCT with longitudinal follow-up found that firstborn children of mothers with low to moderate levels of exposure to domestic violence who received home visitation through the NFP model had fewer substantiated maltreatment reports through age 15 compared with firstborn children of comparable mothers who did not receive home visitation (Eckenrode et al., 2017). The impact of home visitation in reducing time on public assistance and number of subsequent children explained almost half the variance in this effect (Eckenrode et al., 2017). These findings suggest that reducing poverty and supporting family planning options may be key pathways toward prevention of child maltreatment (Eckenrode et al., 2017), hypotheses that merit further testing.
Another study—a 27-year follow-up of the offspring of mothers who participated in the NFP program—showed that exposure to child abuse and neglect was associated with genome-wide DNA methylation variation at age 27. Changes in DNA methylation patterns are associated with the development of physical and psychological health issues later in life so this is an example of the long-term biological effects of early adversity. Participants in NFP showed a modestly lower DNA methylation than their counterparts who did not participate in the program (Klutstein et al., 2016; O’Donnell et al., 2018; Wajed, Laird, and DeMeester, 2001).
Another program that has been extensively studied is Family Check-Up (FCU), a brief intervention delivered in the context of home visiting in which parents are given feedback to enhance their ability to interact positively with their children through provision of affection and behavioral monitoring (Dishion, Nelson, and Kavanagh, 2003; Shaw et al., 2006). In an RCT of low-income families, FCU was found to increase positive caretaker–child engagement by age 3, which predicted lower levels of child neglect at age 4 (Dishion et al., 2015). The program was particularly effective for families with the highest levels of social, economic, and emotional adversity (Dishion et al., 2015). Participation in these yearly check-ups was associated with improved parent reports of child behavior from ages 2 to 5, and with improved teacher reports when children were 7.5 years of age (Dishion et al., 2014). A similar program based in New Zealand, the Early Start program, also has demonstrated efficacy (Fergusson et al., 2005; Macmillan et al., 2009).
Well-child visits to medical practitioners offer another opportunity to address abuse and neglect. Box 3-4 describes a program implemented in this context to screen mothers for the risk of abusive behaviors.
There has been considerably more study of parent-focused prevention programs that target physical abuse and neglect of children than of those designed to prevent child sexual abuse. Public health responses to child sexual abuse have focused on management of sex offenders through criminal justice policies, including not only incarceration but also registration of offenders and restrictions on their residence and employment. These strategies, however, have generally not been found to significantly reduce rates of abuse (Finkelhor, 2009; Mendelson and Letourneau, 2015). Other approaches to preventing child sexual abuse include advocacy and media campaigns, staff screening and training at youth-serving organizations, and school-based programs that teach children how to avoid sexual abuse. Yet while some of these strategies have been shown to increase knowledge about these offenses, effects on the incidence of abuse are unclear (Finkelhor et al., 2015; Letourneau et al., 2010).
Child sexual abuse is most commonly perpetrated by adults or minors well known to victims and their families, and prevention research suggests that parents may be a crucial target for a public health approach to preventing such abuse. Interventions that support parents in actions such as communicating with their children about rules of sexual behavior; monitoring children for signs of situational discomfort; and consistently monitoring child caretakers and interactions with siblings, peers, and adults have shown promise (Mendelson and Letourneau, 2015). The success of parent-focused interventions in preventing other forms of child maltreatment through enhancement of positive parenting skills (e.g., Triple P, Parent–Child Interaction Therapy) supports the value of this approach.
Parent-focused prevention of sexual abuse may have two kinds of benefits. As a universal prevention approach, it may increase parents’ awareness of situations that pose risks to children and enhance their skills (e.g., communication, monitoring) to reduce the likelihood of their children’s exposure to sexual abuse. As a selective and indicated strategy, it can be used to support families with risk factors for sexual abuse or those that have been reported previously to child protective services on suspicion of such abuse.
Parents play a pivotal role in shaping the MEB health of their children. Evidence has shown that promotive and preventive universal, selective, and indicated parenting interventions can play a role in improving children’s MEB health by improving the MEB health of their parents. Interventions that target both individual children and parent–child dyads also show promise for promoting healthy development and mitigating risks to children’s MEB health. Researchers have compiled evidence for many kinds of interventions, but the picture is not complete. For some interventions, the evidence thus far consists of individual studies covering relatively small populations, but for others, such as teaching some parenting skills and treating depression in pregnant and postpartum women, strong meta-analyses provide a clear indication that these interventions limit potential harms to children and youth. Longer-term studies of the effects on children are needed, particularly to
- improve understanding of the mechanisms that make interventions effective and the specific benefits to children’s MEB health they can yield;
- improve understanding of the needs of fathers and other caregivers and the potential benefits of interventions targeting these groups in addition to what is already understood about the needs of mothers;
- track the long-term impacts of such interventions on MEB development and health; and
- better link efficacious interventions with opportunities to serve the populations who can benefit from them at broad scales.
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