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Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity (2019)

Chapter: 4 Fostering Caregiver Well-Being Toward Healthy Child Development

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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"4 Fostering Caregiver Well-Being Toward Healthy Child Development." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

4 Fostering Caregiver Well-Being Toward Healthy Child Development INTRODUCTION The focus of this chapter is on how to best foster children’s healthy psychosocial development, emotional adjustment, and physical health using what science has shown about risk and resilience among children and families in high-risk contexts. With the goal of systematically addressing inequities, the broad question to address is, “For those children who are at risk for negative outcomes, what can be done—guided by science-based evidence—to expediently and effectively move them toward positive developmental trajectories?” In other words, how can the playing field be leveled, so that all children have the best possible opportunity to flourish and thrive in terms of their social-emotional, behavioral adjustment? This chapter is structured in the following sections. At the outset is an overview of what developmental theory and research has demonstrated about “universals” in child development, beginning with a definition of core concepts in the phenomenon of resilience, followed by descriptions of risk and protective processes that are pervasive across diverse types of life adversities, with large and long-standing effects. Front and center among these universals are positive, supportive relationships and access to other basic and critical resources, such as good nutrition, health care, and early childhood education; these are all essential for developing children and for those charged with their care, and relevant theory and empirical evidence are provided on each. The primary focus is on fostering caregiver well-being and support, family cohesion, and social connections to promote healthy child development. This is reflected in the most proximal level to the individual child’s development in the report conceptual model (see Figure 1-9). After discussions on these universals, the chapter continues with a consideration of some context-specific pathways to healthy child development: influences that are potent in and unique to particular subgroups of the population. As an example, issues of discrimination and segregation warrant attention for racial, ethnic, and sexual minorities. See Box 4-1 for an overview of this chapter. PREPUBLICATION COPY: UNCORRECTED PROOFS 4-1

4-2 VIBRANT AND HEALTHY KIDS BOX 4-1 Chapter in Brief: Fostering Caregiver Well-being Maximizing the well-being of young children and their primary caregivers within the context of the family, and with a focus on optimizing development in circumstances that place them at risk, is of utmost importance. The committee identified nine principles of psychological and behavioral human development. For example, for all children, the single most important factor in promoting positive psychosocial, emotional, and behavioral well-being is having a strong, secure attachment to their primary caregivers; in most instances, this is their biological mother. This chapter also examines the evidence on interventions that support strong relationships and highlights promising examples. Chapter conclusions in brief: • The primary caretakers of children—usually the mothers—are critical to fostering child well- being, especially in high-risk circumstances. Assuring the well-being of caretakers through ongoing support, extending beyond meeting basic needs, is necessary for child well-being. • The most urgent parenting concern for families experiencing chronic stress and adversity is the potential for children’s exposure to maltreatment. • There is an urgent need to develop interventions well suited for fathers and other male caregivers; existing approaches that are developed for and tested with women cannot be assumed to generalize to other caregivers. • Specific subgroups of children have unique needs and challenges when adjusting to adversity. Careful attention to potent subculture-specific processes be considered when working with subgroups well known to face serious inequities in relation to mental health. • A tiered approach is needed for families known to be at risk due to their life adversities, with appropriate investment of resources to expand delivery of promising cost-effective programs and assessments via scientifically sound measures of critical constructs. Chapter recommendations in brief: • Implement programs that ensure mothers and families have access to high-quality, cost- effective community programs, including interventions to foster strong attachments and group- based supports in communities. • Strengthen and expand evidence-based home visiting programs. • Support research on: o the development of preventive interventions that target fathers and other male caregivers (with an emphasis on those that can be scaled up in the future); and o the development of culturally sensitive interventions that are tailored to meet the needs of subgroups of children known to be vulnerable. • Routinely track levels of risk among mothers and children over time using periodic assessments. The majority of this chapter is devoted to describing intervention programs that carry great promise in promoting positive outcomes among children in high-risk contexts. The focus is interventions that are well grounded in developmental theory and research; have demonstrated significant improvements with replications; have moderate or substantial effect sizes with a meaningful impact for the population; and, importantly, can feasibly be taken to large scale. Methods used to deliver the interventions, to ensure fidelity (to intervention strategies), and to assess outcomes are described in detail, to provide “blueprints” of science-based programs most likely to promote positive outcomes among young children and their caregivers who negotiate challenging life circumstances. For parameters and operational definitions used in this chapter, see Box 4-2. PREPUBLICATION COPY: UNCORRECTED PROOFS

FOSTERING CAREGIVER WELL-BEING 4-3 BOX 4-2 Maximizing the Well-being of Young Children and Their Primary Caregivers: Parameters and Operational Definitions As described in Chapter 1, “inequities” are operationally defined for the purpose of this report, in part, as the unequal likelihood of thriving or attaining positive adjustment outcomes over time because of differences in opportunity leading to unfair and avoidable differences in health outcomes (NASEM, 2017). The focus in this chapter is on behavioral/psychological/socio-emotional outcomes, rather than physical health or education; there are obviously some common “protective processes” involved in affecting all of these outcomes, but there are unique important issues for health (such as immunizations, primary care, and access to safe housing) or education (such as early Head Start and high-quality child care for early education) that are addressed in the following chapters. The focus of this chapter is on discussing how to best maximize well-being among young children and families that are vulnerable at the outset. These are individuals whose life circumstances have rendered them statistically more likely—compared to national normative samples—to be on negative adjustment trajectories from early in life onward. In the field of risk and resilience, any group demonstrated to be at significantly higher odds for negative outcomes is described as being “at risk.” For the purpose of this report, the term “children in high-risk contexts” will be used, as it is the contexts in which children live, grow, and play that puts them at risk. The goal of this chapter is to describe how best to intervene to optimize developmental trajectories across diverse groups of young children and their families in life circumstances that place them at risk for poor health outcomes. Resilience Under the definition of inequities (see Box 4-2) as unequal likelihood of thriving or attaining positive adjustment outcomes over time, the construct of resilience from developmental science is directly relevant to discussions here, as it implies correcting what otherwise might have been negative trajectories, given major life stressors. Resilience can be defined as a dynamic process encompassing positive adaptation within the context of significant adversity (Cicchetti, 2010; Luthar et al., 2015; Masten, 2014). By this definition, there are two essential conditions that make up resilience: “a) exposure to significant threat, severe adversity, or trauma; and b) the achievement of positive adaptation despite major assaults on the developmental process” (Cicchetti, 2010, p. 145). With respect to a child’s health, resilience is evident when physical, behavioral, and emotional well-being and development tip toward positive outcomes, even when a heavy accumulation of negative influences or risk factors exists. Reviewing the body of accumulated scientific literature on resilience and socio-emotional functioning, Luthar et al. (2015) summarize the following core findings: ● Resilience happens; across risk and age groups; there will be a subset of individuals who show some positive adaptation. ● Resilience relies fundamentally on relationships, and this is true for children and adults. ● Children’s resilience is shaped by multiple transactional systems (i.e., proximal and distal processes and environments affect the child, and the developing child in turn affects each of these). ● Resilience is not fixed over time but is dynamic; periods of positive adaptation can be interrupted by times of struggles. PREPUBLICATION COPY: UNCORRECTED PROOFS

4-4 VIBRANT AND HEALTHY KIDS ● Resilience is not a unidimensional construct; among those at risk, successful adaptation in some areas (such as overt behaviors) can co-occur with difficulties in others (e.g., covert anxiety or depression). For information on physiologic resilience and variability in susceptibility, see Chapter 2. As noted above, there are important considerations for the context within which a child exists and how that environment affects resilience. As is true for all children—facing adversities or not—the developing child’s lived experience is shaped by the family, caregivers, community, and systems that the child interacts with on a daily basis. Reis et al. (2000) identify four propositions to describe this phenomenon: 1) from conception forward, individuals exist within the context of their social relationships; 2) each relationship is nested in a social and physical environment system; 3) each relationship is embedded in larger societal and cultural systems; and 4) all of these systems are continuously changing and interacting with each other over time. For these reasons, taking a multilevel, transactional, and relationship-centered approach to understanding resilience and its determinants for children is important (Luthar et al., 2015; Reis et al., 2000). Of particular salience and proximity are family-level influences of relationships on resilience in childhood, as will be described in detail within discussions that follow. While risk factors such as exposure to significant adversity often unfold within the context of the family, so too do the protective factors that have been shown to foster resilience, such as parental warmth, responsiveness, and sensitivity (Hamoudi et al., 2015). Therefore, the parent or primary caregiver is a major target for interventions to promote resilience in children. Across socioeconomic strata and in most parts of the United States (and the world), the primary caregiver is generally the mother or a mother figure. It is certainly true that in general, it is better for children to have two parents in the home, to share the responsibilities of child care and running the household. At the same time, even when there are two co-residing parents, one typically shoulders most of the child care, and this is generally the mother (e.g., see Ramey and Ramey, 2010). However, it should be clarified that in the discussions that follow, the term “mother” is used as a proxy for the primary caregiver who is a woman—whether that is the biological mother, grandmother, older sister, or other female relative. Considerations around men and fathers as primary caregivers are discussed separately later in this chapter, as the literature clearly indicates that there are distinct needs and issues that warrant specific, careful attention in interventions for men. The critical importance of the parent–child relationship, specifically, is underscored in a 2017 special section published in Child Development, which highlights evidence-based interventions to maximize resilience in children and families. In their overview article, Luthar and Eisenberg (2017) outlined the key findings and recommendations that emerged from the collection of papers. Across these 11 papers, the single theme that most consistently recurred was the need to support the well-being of the primary caregiver—typically the mother. Contributing authors emphasized the importance of psychological and emotional support for mothers, particularly for single mothers (Taylor and Conger, 2017), those struggling with depression (Goodman and Garber, 2017), those at risk for maltreating their children (Valentino, 2017), and those living in poverty (Morris et al., 2017). Another, second, important target for intervention identified from this set of articles was specific types of parenting behaviors that most urgently warranted attention among at-risk families. It was particularly important to minimize harsh, rejecting, or neglectful parenting behaviors (e.g., Goodman and Garber, 2017; Harold et al., PREPUBLICATION COPY: UNCORRECTED PROOFS

FOSTERING CAREGIVER WELL-BEING 4-5 2017; Reynolds et al., 2017), because the ill effects of maltreatment on children can be profound, pervasive across areas of adjustment, and long-standing, especially when it starts early in development and is prolonged. A third target area identified as beneficial for interventions was self-regulation and coping skills among adults—parents and teachers—as well as children (e.g., (Domitrovich et al., 2017; Modecki et al., 2017; Morris et al., 2017; Smith et al., 2017). Promoting self-regulation and coping for both the parent and child is essential because parents are likely to adjust their parenting behavior based on their children’s behavior. Of course, for all parents living in challenging circumstances, there needs to be attention to not only their personal well-being and parenting but also the social and economic conditions that provoke the toxic stress response (discussed later in this chapter in the section on group difference). HUMAN DEVELOPMENT IN THE CONTEXT OF RELATIONSHIPS This chapter, and the associated conclusions and recommendations, are based on what is known from extant scientific literature about the major, critical building blocks to optimize the child’s development from pregnancy through puberty (approximately 8–10 years of age). Sections that follow begin with a synthesis of this literature providing the basis for what are considered the universal principles of human child development; that is, principles that are largely generalizable to most children and families in the United States. Following this is a discussion of instances where children and families in discrete subcultural groups have important, unique needs, given the presence of potent risk or protective processes in their particular contexts. The remainder of this chapter is focused on a review of interventions that have been proven to be effective to promote relational supports and well-being of caregivers toward maximizing resilient adaptation. Universals of Human Development Universals: The interplay of biology and environment in human development As described in Chapter 2, during prenatal development, genetic and environmental factors work together to build organ systems that promote the ability of the individual and species to thrive and survive (Center on the Developing Child at Harvard University, 2010; National Scientific Council on the Developing Child, 2010). It is an evolutionary conserved core principle that prenatal through early childhood development is both experience dependent and experience expectant.1 Thus, the adaptability of the organism to future challenges is influenced substantially by genetic and epigenetic factors that contribute to homeostatic boundaries within which the brain and other organ systems operate over the life course and the experiences that occur during development that the organism anticipates as the “future” contexts in which it will need to operate to survive and thrive. This core principle relates to both physical survival, which Maslow’s (1943) hierarchy of needs indicates is the most basic need for all humans (children and 1 “Experience-dependent” describes the aspects of development that depend on the quality of the environmental input (for example, while babies are born with a capacity for language development, their ability to communicate verbally will depend on their exposure to language during early development). “Experience-expectant” describes the normal, generalized development when the environment provides infants with the needed input to develop neural connections that enable function in certain domains (such as vision and hearing). If input during these critical periods of development is not received, these functions will be lost permanently (Gallagher et al., 2003). PREPUBLICATION COPY: UNCORRECTED PROOFS

4-6 VIBRANT AND HEALTHY KIDS their caregivers), and relationships that contribute to physical and behavioral well-being. See Figure 4-1 for Maslow’s hierarchy pyramid. All human circuits are built from the bottom up, with simple skills forming the foundation for the emergence of more complex skills (Center on the Developing Child at Harvard University, 2011). For sociability, the interaction between humans starts after birth, but the initial circuits needed to direct interactions that are fundamental to early development, such as caregiver–infant attachment, are established prenatally. Infants are ready to use their senses to attend to environmental stimuli—what they hear, see, smell, feel and taste—to receive the most important information that supports their immediate internal needs, such as hunger, thirst, and arousal (Hammock and Levitt, 2006). In essence, early experiences drive a process in which the motivation and attention circuits focus more and more on those stimuli that are most meaningful—a process known as contingent learning. Building these circuits occurs in a social context with the primary caregiver and others, providing key opportunities for the infant to associate stimuli with social meaning. Over time, as social context becomes more and more complex, the developing child engages cognitive and emotional regulatory processes to infer social meaning and ultimately, social responsiveness to cues—back and forth or “serve and return” interactions (National Scientific Council on the Developing Child, 2004). These skills develop over an extended period, through adolescence (Casey et al., 2016; Dahl, 2004). There are extended discussions pertaining to the importance of all children having their basic needs met and the existing problems that place children and families at risk, including those related to access to adequate housing, good nutrition, and health care (along with the associated barriers, ranging from parents’ inability to take time off of work and lack of transportation to logistical problems deriving from the spread of critical services across physical locations and delivery systems). These issues are discussed extensively in Chapters 3 and 6. FIGURE 4-1: Maslow’s hierarchy SOURCE: McLeod, 2018 NOTE: Concepts from Maslow, 1943. Universals: Development in the Context of Proximal Family Relationships The focus of this chapter is the next most basic need in Maslow’s (1943) hierarchy: belongingness and love. To set the foundation for the committee’s discussions on this topic, the PREPUBLICATION COPY: UNCORRECTED PROOFS

FOSTERING CAREGIVER WELL-BEING 4-7 following section outlines nine committee-generated, universal principles of human development that are derived from the scientific literature on child development in the context of relationships. To reiterate, these principles all pertain to the broad domain encompassing children’s psychological and behavioral adjustment. See Box 4-3 for a list of the nine universal principles of human development. BOX 4-3 Nine Universal Principles of Psychological and Behavioral Human Development 1. For all children, the single most important factor in promoting positive psychosocial, emotional, and behavioral well-being is having a strong, secure attachment to their primary caregivers; in most instances, this is their biological mother. 2. This strong attachment presupposes effective parenting behaviors in everyday life, and “effective parenting” changes in nature and complexity and with development over time. 3. Effective parenting presupposes the caregivers’ own well-being. 4. It is critical to ensure that children’s mothers have the necessary supports for maintaining good mental health and psychological well-being. 5. If there is any concern about a parent “faltering,” the single most important dimension of parenting in which parents need to be helped is maltreatment (by parent figures or others). 6. The early childhood years are critical in shaping subsequent child development—but at the same time, there remains much room to change course and impact these trajectories in a positive fashion. 7. The ill effects of toxic early environments (e.g., unhealthy relationships) can manifest in physical health problems in childhood and throughout life. 8. The ill effects of early childhood adversities (e.g., abuse or neglect by caregivers) can become most visibly apparent later in life (i.e., there can be latent or “sleeper” effects that are seen at later points in development). 9. Biology is not “destiny”; rather, while indicating relative risk rates, it sets “confidence limits” within which environmental influence can lead to relatively positive versus negative adaptation. The first principle, deriving from over eight decades of research on resilience, is the following, mentioned earlier: For all children, the single most important factor in promoting positive psychosocial, emotional, and behavioral well-being is having a strong, secure attachment to their primary caregivers; in most instances, this is their biological mother. This conclusion makes good sense intuitively, as it is the primary caregiver who is the most constant and proximal person who has everyday contact with the young child and long-standing influence on the developing child from conception through late childhood. In most settings, this is typically the mother (relationships with fathers are obviously also extremely important, and are discussed below). Even in families where they are employed outside the home, across socioeconomic contexts, it is typically mothers who have the earliest, most constant, and most prolonged everyday contact with the child. However, it should be noted that even when the primary caregiver is another adult, the universals that are described here would largely generalize to these PREPUBLICATION COPY: UNCORRECTED PROOFS

4-8 VIBRANT AND HEALTHY KIDS other main caregivers (with a few exceptions that are discussed explicitly). See Box 4-4 for discussion of gender specificity. BOX 4-4 The Need for Gender Specificity in Referring to Parents Developmental scientists have increasingly emphasized the need to avoid using gender-neutral terms in referring to parents in at-risk circumstances, and, instead, to describe patterns specific to fathers and mothers (see Cabrera et al., 2014; Luthar and Eisenberg, 2017; Phares et al., 2005; Rotheram-Borus et al., 2001; Yogman et al., 2016). By far, most of the existing developmental studies on parenting have focused on mothers, as it is mothers who are typically primary caregivers of young children and who usually enroll and participate in intervention programs (Pruett et al., 2017). Yet, there are many instances where fathers are primarily responsible for raising their children, and their unique needs require attention: It cannot be presumed that what helps fathers do well as parents is the same as what most benefits mothers (Cabrera et al., 2014; Luthar and Eisenberg, 2017). To that end, differences between mothers and fathers render it critical to better understand the unique factors that shape fatherhood and child development to inform interventions. To illustrate, fathering is more affected by the quality of the marital relationship (levels of satisfaction and support) than is mothering (Lamb, 2004; Lewis and Lamb, 2003). Similarly, programs based in supportive, close relationships among women (service providers and community-based “mentor mothers”) can effectively recruit mothers (Luthar, 2015; Valentino, 2017) but are unlikely to attract men as strongly. For fathers, recruitment efforts in community settings where they are commonly found, including soccer games, employment centers, and shopping malls, are more effective (Pruett et al., 2017). Following this first universal—that a strong attachment to primary caregivers is critical for the child’s well-being—the second major universal is that this strong attachment presupposes effective parenting behaviors in everyday life, and “effective parenting” changes in nature and complexity and with development over time. In infancy, parenting is extremely demanding on physical energy, and, of course, on sleep; at a psychological level, it calls for sensitivity to the child’s needs and appropriate responsiveness (e.g., soothing/comforting when the child is in discomfort or pain). Often, parents are physically exhausted and not sure about how to soothe a baby who might cry inconsolably for hours. As children grow into the toddler years, in addition to providing love and comfort, effective parenting calls for constant vigilance and appropriate limit-setting. During the toddler years, children are physically very mobile, oblivious to physical dangers (e.g., sharp objects or electrical outlets), increasingly and energetically willing to explore the world around them, rarely responsive to a simple “no” from adults, and prone to tantrums. The use of language as mediator of appropriate parent–child interactions becomes increasingly complex and important. In early childhood through the onset of kindergarten and formal schooling, in addition to the primary caregiver providing love and comfort and appropriate, consistent limit-setting at home, a new developmental task for the child—and thus for that caregiver—is adjustment to external influences. This subsumes the transition to child care and then to kindergarten with separation from the primary caregiver and learning to handle routines and a new set of socializing influences, including other adults plus children. During the elementary school years, failures and successes in various areas—academics, peer relations, sports or other specialized arenas—need to be processed at the socio-emotional level. Peers and others adults can provide support to children and parents as they navigate increasingly diverse and demanding contexts. The third universal is that effective parenting presupposes the caregivers’ own well- being. Being able to deal with the various tasks/demands of parenting is difficult at the best of PREPUBLICATION COPY: UNCORRECTED PROOFS

FOSTERING CAREGIVER WELL-BEING 4-9 times, and this becomes particularly challenging in the presence of high levels of life stress. Chronic exposure to poverty or prolonged periods of limited resources, as well as life events involving high levels of trauma, can lead to maternal depression, anxiety, and other mental health problems, which in turn can greatly compromise the quality of parenting. There are multiple studies showing that when mothers struggle with mental illness, this can significantly affect all their parenting behaviors (Knitzer, 2000; Luthar and Sexton, 2007; Rahman et al., 2013). In particular, maternal depression and high stress have been linked consistently with tendencies to neglectful or harsh parenting, increasing the likelihood of the child’s exposure to ACES (Goodman and Garber, 2017; Plant et al., 2013; Toth et al., 2013; Valentino, 2017). Another important psychological element of effective parenting is parent agency or self-efficacy (i.e., the parent’s perceived ability to influence the development of the child) (Jones and Prinz, 2005). The report Parenting Matters: Supporting Parents of Children Ages 0–8 highlights parent self-efficacy as a contributing factor in shaping parenting competence and child self-regulation, social, and cognitive skills (NASEM, 2016). The report identifies one possible mechanism for this association as increased competence-promoting parenting practices (e.g., family routines or involvement with children in schools). And as the current report’s conceptual model in Chapter 1 suggests (see Figure 1-9), caregivers and families live in the context of their social circumstances and living conditions; therefore, they need support in coping with related stressors or eliminating such sources of stress, in addition to efficacy-promoting supports. The first three universals have been long cited in the developmental literature; the next has been more recently emphasized explicitly: from as early in a child’s life as possible, it is critical to ensure that the mother has the necessary supports for maintaining good mental health and psychological well-being. Resilience researchers have clearly articulated that in order to achieve positive mental health and functioning, the same principles that apply for children apply to their mothers. Just as children need ongoing unconditional love from their mothers, so do the mothers need ongoing love and support from other adults to function well across their life roles (Luthar et al., 2015). In developmental science, for too many years, the tendency in studying families has been to discuss what parents should do and should not do, with little attention to what it is that allows parents themselves to function well and develop resilience at this daunting, decades long-task. In other words, what has been missing is mothers’ well-being as the dependent variable. In the last few years, this has changed (see, Balaji et al., 2007; Jolly et al., 2014; Luthar and Ciciolla, 2015; Taylor and Conger, 2017). There is now much more explicit emphasis on the need to understand what helps mothers do well over time, especially in highly stressful life circumstances. With accumulating evidence from both basic research and intervention trials, the answer is clear: the single most important need is dependable supports in their role as parents— emotional/intangible and tangible—from a dependable, reliable network of others in their lives (for a review on this topic, see Luthar and Eisenberg, 2017). The nature of these supports, furthermore, are both perceived (e.g., the expectation that comfort will be available when distressed or help will be forthcoming if needed for parenting/running the household) and instrumental (e.g., actual receipt of help with child care or aspects of running the home; see Balaji et al., 2007; Goodman and Garber, 2017 for more information). See Box 4-5 for more on supporting caregivers. PREPUBLICATION COPY: UNCORRECTED PROOFS

4-10 VIBRANT AND HEALTHY KIDS BOX 4-5 Providing Supports for Caregivers Recognizing the critical importance of supports for caregivers by no means implies parent- blaming or minimizing parents’ agency. Rather, it is intended to draw much needed-attention to the great challenges of this life role and what even the most well-meaning caregiver needs, on an ongoing basis, to do this job well. As an analogy, consider the role of a surgeon. Ultimately, the physical manipulation of nerves, arteries, etc. is in his or her hands. Yet, it is common knowledge that for any surgery to go well, there needs to be high-level, ongoing supportive conditions—ranging from the assistants in the room to sterile operating room and appropriate medications. It would be illogical to turn to any “surgeon- blaming” if a procedure failed in the absence of these various essential supports. In the same way, the first order of business, in ensuring optimal child development, is to ensure that all primary caregivers have the necessary supports on an ongoing basis, if they are to sustain optimal parenting. Providing supports (e.g., in the form of services) does not assume any weakness on the part of the caregiver; instead, it promotes parents’ agency to care for their children in the face of increasing demands as parents (e.g., work, child care) (Lino et al., 2017; NASEM, 2016; National Partnership for Women & Families, 2018). A fifth universal, and also one more recently emphasized specifically in the literature, is that if there is any concern about a parent “faltering,” the single most important dimension of parenting in which parents need to be helped is maltreatment (by parent figures or others).2 In general, psychologists have shown that “bad is stronger than good” (Baumeister et al., 2001); that is, the ill effects of harsh behaviors are much stronger than the positive effects of praise (see also Fredrickson and Losada, 2005; Sparks and Baumeister, 2008). Additionally, the accumulated literature on resilience has shown that early and chronic maltreatment is the one category of adversity in which it is rare to find children who “do well” over time, showing little to no trouble across major adjustment domains; in fact, this has many serious long-term effects across salient aspects of child development (see Bolger and Patterson, 2003; Cicchetti, 2013). Therefore, as a society, prevention of maltreatment needs to be a top priority in promoting the well-being of children in high-risk contexts. This again implies attentiveness when primary caregivers are stretched too thin, because they are at the most risk for maltreatment. As noted earlier, living with chronically high stress or mental illnesses, such as untreated depression, can lead the most well-meaning and loving parent to become angry and slip into neglectful or harsh parenting behaviors. If caregivers are believed to be at risk for abusing or neglecting their children—or of not being able to protect them from maltreatment by other adults—the situation needs to be treated as urgent and the appropriate help identified. Most importantly, the best help would be providing supports and/or mental treatment for the primary caregiver to address the root cause of maltreatment or neglect (Cicchetti, 2013; Cicchetti et al., 2006; Lieberman et al., 2005; Luthar et al., 2007; Toth et al., 2013). In the most extreme cases, continued high risk for maltreatment or actual maltreatment could entail removing the child from the home; however, there is evidence that suggests that this is not always the best course of action for the child (Toth et al., 2016). Implicit within the above universals that the well-being of the young child inherently involves the well-being of the primary caregiver; in fact, Seifer (2003) explicitly pointed out that it does not make sense to think about resilience of infants; rather, we should consider the positive 2 The Centers for Disease Control and Prevention (CDC) define child maltreatment as any type of abuse (e.g., physical, sexual, or emotional) and neglect of a child under 18 years of age by a parent, caregiver, or another person in a custodial role (CDC, 2014). PREPUBLICATION COPY: UNCORRECTED PROOFS

FOSTERING CAREGIVER WELL-BEING 4-11 functioning of the mother–child dyad. Additionally, in many countries other than the United States, people think about the needs of the child through the needs of the caretaker: if the child is to be helped, that help is most effectively offered if it goes through the caretaker (e.g., see Hrdy, 1999). In many cultural contexts, pregnancy, childbirth, and motherhood are embedded in a system of multiple generations of women who provide support and troubleshooting to the younger generations in all aspects of caretaking. Extended family systems and/or fictive kin are available and ready to help with any problem that arises; they affect the development and well- being of the child and also the mother (see Barlow and Chapin, 2010; Kopp, 2013). To reiterate the caveat noted earlier—that in many instances, it may not be the mother but another family member (or caretaker) who serves as the primary caregiver—the principles described above are still the same; that is, whomever is charged with primary (or salient) responsibility of taking care of the young child needs to receive regular replenishment and support. Child care providers and educators also need ongoing support, including teachers from preschool onward through the K–12 system. These are all jobs that are among the lowest paid and with high levels of burnout and turnover, especially for early childhood educators. Once again, research has shown that these care and education professionals can serve critical protective functions, stepping in to provide the nurturance and support that complement or supplement what mothers, fathers, or other primary caregivers are able to offer. Yet, solutions rarely consider what it is that can and should be done to help replenish these professionals who are the primary adults during significant portions of children’s daily lives. (For a more in-depth discussion of early care and education [ECE] professionals, see Chapter 7.) Sixth, developmental research has clearly shown that relationships in the early childhood years are critical in shaping subsequent child development—but at the same time, there remains much room to change course and impact these trajectories in a positive fashion, with those starting out as negative changing to be more positive as well as the reverse. Without question, early attachments form the lens through which subsequent relationships are viewed (Lieberman et al., 2005; Sroufe et al., 2005; Yates et al., 2003; Zeanah and Zeanah, 1989), so that children with adverse early experiences are less likely to be open to or trusting of other nurturing people in their lives. Yet, there are certainly opportunities for reversals (e.g., at times of transition in life, including moves to new schools for children, and, later in life, marriage or employment changes). Many years ago, Rutter (1987) showed that women who were institutionalized as children were more likely to display positive parenting themselves if they married supportive spouses, and Sampson and Laub (2003) showed that for delinquent children followed over decades, both marriage and entry into the military conferred significant benefits to their well- being and adaptation. In short, even if subjected to early trauma, human beings are capable of recovering and healing. The seventh universal principle is that the ill effects of toxic early environments (e.g., unhealthy relationships) can manifest in physical health problems in childhood as well as throughout life. Common health problems include asthma, headaches and backaches, and even elevated risk for heart disease and compromised immune functioning (e.g., Dong et al., 2004; Dube et al., 2009; Purewal et al., 2016; Wing et al., 2015; Kalmakis and Chandler, 2015). Therefore, once again, preventing exposure to such toxic experiences is of the essence, even if children appear to be adapting well behaviorally or psychologically to these adverse circumstances in their early years of childhood. In a related vein is universal number eight: The ill- effects of early childhood adversities (e.g., abuse or neglect by caregivers) can become most visibly apparent later in life (i.e., there PREPUBLICATION COPY: UNCORRECTED PROOFS

4-12 VIBRANT AND HEALTHY KIDS can be latent or “sleeper” effects that are seen at later points in development). (See Chapter 2 for more information on sleeper effects.) For example, attachment insecurities developed in infancy could manifest in severe separation anxiety from the parent on starting kindergarten or significant difficulties in relating well with peers (Cicchetti and Toth, 2015, 2016). Other examples include behaviors that become relevant or salient closer to puberty or adolescence, such as delinquent behaviors or abuse of drug and alcohol as a function of early relationship disturbances (Cicchetti and Toth, 2015, 2016). Perhaps the most obvious example is impaired parenting as adults; in general, there tends to be some intergenerational continuity of maltreatment (Adams et al., 2019; Cicchetti and Rizley, 1981; Kaufman and Ziegler, 1987; Pears and Capaldi, 2001; Rutter, 1987). Universal nine—biology is not “destiny”; rather, while indicating relative risk rates, it sets “confidence limits” within which environmental influence can lead to relatively positive versus negative adaptation. Genetic factors, for example, can heighten children’s vulnerability to disorders (physical and psychological) that afflict their parents. At the same time, intergenerational transmission of disorders is far from inevitable. As noted earlier, the notion of resilience encompasses the phenomenon wherein children who are at risk for psychopathology— or mothers who are at risk for negative parenting behaviors—can show healthy outcomes if they have the appropriate corrective or buffering influences in their lives. In other words, biological factors affect children’s development, but they always operate in interaction with forces in the environment (Wise, 2009). The burgeoning field of epigenetics has shown that early life environments can lead to long-lasting changes in gene expression that “can leave indelible chemical marks on the brain and influence both physical and mental health later in life even when the initial trigger is long gone” (Murgatroyd and Spengler, 2011, p. 1; see also Dudley et al., 2011; Lerner and Overton, 2017; and Chapter 2 for more information). To summarize, there are key take-home messages from the above discussion of universals to ensure positive psychological, behavioral, health, and social outcomes in early childhood. First, ensure the psychological well-being of the primary caregiver, as this will inevitably affect his/her parenting and the quality of attachment; this is best done by ensuring ongoing support for mothers in their everyday lives and communities (support during the child’s early infancy will not protect the mother for the child’s entire life). One population of particular importance for intervention is mothers under a high level of chronic stress and at risk for depression—as this is strongly related to increased risk for neglect and maltreatment, which, of all parenting behaviors, is the one that most urgently requires prevention. Finally, in considering whether a child or parent has done well in spite of early adversities, it should be noted that ill effects of these adversities can become manifest later in life. At the same time, significant healing can happen, even well past childhood and adolescence, so that mothers who experience suboptimal care themselves as children can be effective caregivers if they receive appropriate support and help as they negotiate the challenges of motherhood. Conclusion 4-1: The primary caretakers of children—usually the mothers—are critical to fostering the well-being of children, especially in high-risk circumstances. Assuring the well-being of caretakers through ongoing support, extending beyond meeting basic needs, is necessary for child well-being. PREPUBLICATION COPY: UNCORRECTED PROOFS

FOSTERING CAREGIVER WELL-BEING 4-13 Conclusion 4-2: The most urgent parenting concern for families experiencing chronic stress and adversity is the potential for children’s exposure to maltreatment (by others within and outside the family). Fathers For the most part, this chapter has focused on mothers (or mother figures) because across cultures and socioeconomic settings, they are typically primary caregivers of young children (e.g., Hrdy, 2011; Luthar and Eisenberg, 2017); however, there are many instances where fathers are primarily responsible for raising children. This section reviews the importance of fathers for children’s development. Following this, the extant evidence on interventions with fathers is reviewed and future needs are discussed. While some research shows that fathers experience exclusion regarding parental involvement in child health and development (Plantin et al., 2011; Steen et al., 2012), there is empirical evidence that suggests they have an integral role in promoting the health and well- being of their children. Some evidence points to a direct relationship between fathers and specific childhood outcomes. For example, research suggests that father education and supportiveness shapes language and cognitive development in children (Cabrera et al., 2007). Furthermore, varying levels of father involvement or connectedness with children are associated with differential self-regulation and aggression in children (Vogel et al., 2006). One study has even found that positive father–child relationships, as reported by fathers, are protective from pediatric injury (Schwebel and Brezausek, 2010). In terms of father well-being, paternal depression has been associated with increased odds of child neglect (Lee et al., 2012). Other evidence suggests an indirect pathway by which fathers can influence their children’s well-being—through their mothers. Bloch et al. (2010) found that poor-quality relationships between fathers and mothers are associated with depressive symptoms, stress, substance use, and smoking among low-income mothers. Other research indicates that father involvement has a positive association with a mother’s health behaviors (e.g., seeking prenatal care in the first trimester, abstaining from drinking, drug use, and smoking) (Teitler, 2001). Finally, fathers can support maternal well-being and birth outcomes. For mothers, a supportive relationship with the father can have buffering effects on maternal depression and preterm birth (Giurgescu et al., 2018). Involving Fathers in Preventive Interventions As noted earlier in this chapter, developmental scientists have increasingly emphasized that it cannot be presumed that what helps fathers do well as parents is the same as what most benefits mothers (e.g., Grusec and Davidov, 2010). To illustrate, Lamb and his colleagues have shown that fathering can be more affected by the quality of the marital relationship (levels of satisfaction and support) than is mothering (see Lamb, 2004; Lewis and Lamb, 2003). Accordingly, it is important to attend to the gender-specific needs of parents in designing strategies to recruit and retain them in prevention programs related to their families and children (Pruett et al., 2017). Cross-national interventions further attest to the critical importance of attention to gender-specific needs of parents. Randomized trials with families affected by HIV indicated that across countries (United States, Thailand, and South Africa), men were more likely to respond to stress with flight-or-flight responses and women with tending and befriending (Rotheram-Borus et al., 2011). Accordingly, there have been efforts to design interventions to accommodate these PREPUBLICATION COPY: UNCORRECTED PROOFS

4-14 VIBRANT AND HEALTHY KIDS gender differences in both delivery formats and activities. Community-based “mentor mothers,” for example, were most beneficial for mothers seeking help via interventions, whereas men were more likely to be engaged via group activities, such as sports or vocational training. Similarly, Cabrera et al. (2015) note that fathers may be more willing to participate in a “game of basketball” than the “morning coffee” that many early childhood programs offer, and they recommend running support groups for “fathers” rather than just for “parents,” sending the message that the role of a father is valued and is supported, independent of support to mothers. In their review of existing programs for fathers, Pruett and colleagues (2017) indicate that whereas it is generally more difficult to engage fathers than mothers in preventive intervention programs, there are some avenues that seem promising. These include efforts to recruit fathers along with mothers via couples’ work in early childhood (i.e., while the father is still involved with the mother and child, before any possible estrangement, as it is much more difficult to engage fathers when strife has entered the inter-parent relationship). Pruett et al. (2017) also suggest focused efforts to make the facilities themselves more “father friendly” (e.g., by addressing implicit biases of staff that fathers will intrinsically be uninvolved and portraying pictures of fathers with babies in the program facilities). At the most basic level, other approaches would be to highlight in the media those men who are positive role models of fatherhood early in life and even bring such individuals to high schools to talk with young men on this topic, well before they become fathers. Davison et al. (2019) examine strategies for and barriers to father engagement in early obesity prevention during the child’s first 1,000 days of life. The review finds that although obesity prevention programs have great potential to engage fathers, there are a number of micro- and macro-level barriers that hinder access and participation. Applying a policy, systems, and environmental perspective, the authors recommend the following strategies to enhance father engagement: integrate father-engagement standards into national practice guidelines (e.g., AAP, ACOG), develop educational and marketing materials (e.g., pamphlets) specific to fathers, and partner with local father advocacy organizations to identify new strategies to engage fathers. Other research has homed in on preconception (Kotelchuck and Lu, 2017) and pediatric care (Yogman and Garfield, 2016) as important platforms for engaging fathers. What is clear is that speaking about promoting good parenting in gender-neutral terms will likely be a disservice to both fathers and mothers. The literature clearly delineates what mothers need most centrally to function well as mothers (again, aside from basic necessities for physical survival): authentic connections with and support from others in their everyday lives. Relationship-based strategies that are highly effective, such as those in home visiting programs for new mothers, will not necessarily generalize to new fathers, paving the way to their enhanced mental health, positive fathering behaviors, and attachment to the child. For example, in low- income African American families, mothers responded well to the tend and befriend approach; however the recruitment of biological fathers was more likely through opportunities for enhanced earnings to support their families (Jackson, 2015). Much more work is needed, therefore, on ascertaining how best to engage fathers and retain them in prevention and intervention programs. It is important to note that NIH changed the policies about gender inclusion around the 1990s, when there was a concerted move to include women in intervention trials. The NIH Office of Research on Women’s Health was formed in 1990 “in response to congressional, scientific and advocacy concerns that a lack of systemic and consistent inclusion of women in NIH-supported clinical research could result in clinical decisions being made about health care PREPUBLICATION COPY: UNCORRECTED PROOFS

FOSTERING CAREGIVER WELL-BEING 4-15 for women based solely on findings from studies of men—without any evidence that they were applicable to women” (Mazure and Jones, 2015). As researchers and practitioners think of how best to promote the well-being of young children via effective support for their primary caregivers, it would be prudent to avoid presuming that we can simply transfer program strategies and procedures from mothers to fathers. Although instances where a father is solely responsible for the child are not as common, this in no way obviates the need for understanding the most effective paths to reach and benefit these fathers. One evidence-based program that provides an avenue to reach fathers along with mothers is the Family Check-up (FCU) program (see Box 4-6 for a description of FCU as a promising model). BOX 4-6 Family Check-up Program: Promising Modela The FCU is a strengths-based intervention that reduces children’s problem behaviors by improving parenting and family management practices. Stretching back over 20 years, the FCU integrates assessment with motivation-enhancement strategies to tailor intervention goals to meet the unique needs of each family and increase family engagement. It has been implemented in a variety of settings, including public school systems, American Indian tribal communities, publicly funded health centers, hospitals, and community mental health centers. Any professional who provides services to families with children can use the FCU. Using a strengths-based, ecological, adaptive framework, the FCU focuses on children ages 2 through 17. It is based on a family-centered model derived from “basic research on social development and intervention science” (Dishion and Kavanagh, 2003, p. 3) and differs from traditional family- centered approaches by emphasizing methods to promote a family’s motivation to change (Shaw et al., 2009). By providing parents with the tools that they need to manage their children’s behaviors effectively and to build a strong and positive relationship with their children, FCU addresses the social environment as a social determinant of health. The program is multisector, engaging state research institutions, professional caregivers, mental health professionals and institutions, public schools, the Institute of Education Science, and NIH. Several studies have shown that the FCU is effective in achieving positive outcomes for families. For example, outcome data suggest that compared with the children of families who never participated in the FCU, children of families that did participate have fewer behavior and emotional problems, better emotion regulation, increased school readiness, and decreased risk for obesity (Brennan et al., 2013; Dishion et al., 2008, 2014; Lunkenheimer et al., 2008; McEachern et al., 2013; Shaw et al., 2006, 2009). a The committee used selection criteria to identify examples of promising models highlighted in this report (see Appendix A for a list of the criteria). These examples all apply developmental science and aim to advance health equity during the preconception through early childhood periods. SOURCES: ASU Reach Institute, 2018; The Center for Parents and Children, n.d. Reviews of past national-level efforts targeting fathers further attest to the importance of further work in this area. As Lu and colleagues (2010) have noted, many fathers in the United States face substantial barriers to staying involved in their children’s lives, and this is especially the case for many low-income fathers and men of color. These barriers operate at multiple levels, including intrapersonal (e.g., poor knowledge, attitudes and behaviors toward parenting) and interpersonal (e.g., strained relationship with the mother or maternal grandmother), neighborhoods and communities (e.g., high unemployment and incarceration rates, which influence social norms), cultural or societal (e.g., popular cultural perceptions of black fathers as expendable and irresponsible, racial stratification and institutionalized racism), policy (e.g., the “marriage penalty” within Earned Income Tax Credit [EITC] and Temporary Assistance for Needy Families [TANF], child support enforcement), and even historic (slavery and forced PREPUBLICATION COPY: UNCORRECTED PROOFS

4-16 VIBRANT AND HEALTHY KIDS family separation among African Americans and forced removal of American Indians from their land) (Lu et al., 2010). Life course factors, such as adverse childhood experiences (ACEs) or the absence of the father’s father growing up, can also influence father involvement. As discussed in the next section, institutionalized racism against men of color leads to higher rates of incarceration that precludes many fathers from being present in their children’s lives, establishing healthy relationships, and providing the necessary support to the mother. In recognition of both the importance of fathers for child development, and the challenges fathers face, Congress has authorized and funded grants for fatherhood programs for more than a decade. Evaluation of four federally funded Responsible Fatherhood programs from 2011–2018 has yielded mixed results (Avellar et al., 2019). All four programs consisted primarily of group- based workshops covering topics such as the meaning of fatherhood, child development, co- parenting, and finding and retaining employment and even personal development topics, such as coping with stress, responding to discrimination, problem solving, self-sufficiency, and goal planning. Participation in the programs resulted in improved parenting, specifically their self- reported nurturing behavior and engagement in age-appropriate activities with children, but not in-person contact, financial support, co-parenting, earnings, or socio-emotional and mental well- being (Avellar et al., 2019). One possible explanation for the mixed results is that most extant fatherhood programs still do too little, too late. Men’s capacity to support and nurture others needs to be cultivated over their entire life course, not only after they become fathers (Lu et al., 2010). This includes their capacity to form stable, positive relationships; as discussed throughout this report, this depends on the presence of a stable, nurturing relationship with a caregiver during their own early childhood. Thus, future research on father involvement needs to take a more integrative, life course approach, studying how boys become men, men become fathers, and we as a society can better nurture the development of fatherhood across the life course. Conclusion 4-3: There is an urgent need to develop interventions well suited for fathers and other male caregivers; existing approaches that are developed for and tested with women cannot be assumed to generalize to other caregivers, with equal effectiveness, in the successful recruitment, retention, and support of men and fathers who take care of young children in prevention programs. Future fatherhood programs also need to go beyond affecting individual knowledge, attitudes, and behaviors toward changing the family, neighborhood, social and cultural contexts of fatherhood. Public policy changes to remove barriers—such as the “marriage penalty” within TANF and EITC, making child support more “father friendly” by calculating payment based on actual earnings, adjusting and forgiving arrearages, and allowing a greater amount of the child support payment to be passed through to the child—can go a long way toward strengthening father involvement. Micro- and macroeconomic policies to reduce poverty and strengthen fathers’ capacity to contribute financially to the family can also help. Most importantly, fatherhood initiatives, if they are going to succeed in advancing health equity, need to have a core objective that addresses institutionalized racism in employment, education, housing, health care, criminal justice and other systems that keep many low-income fathers and men of color from living out their true potentials in our society. PREPUBLICATION COPY: UNCORRECTED PROOFS

FOSTERING CAREGIVER WELL-BEING 4-17 Recommendation 4-1: Federal, state, and local agencies, along with private foundations and philanthropies that invest in research, should include in their portfolios research on the development of preventive interventions that target fathers and other male caregivers. Special attention should be given to the recruitment, retention, and support of men and fathers parenting young children from underserved populations. The Role of Culture as Context Anthropological perspectives on the study of children’s development, pioneered by Margaret Mead, John and Beatrice Whiting, Robert A. Levine, and others, emphasize the importance of the cultural context that embeds children, families, and institutions that are important determinants of children’s development. Subsequent elaborations by Super and Harkness (1986) labeled these influences the “developmental niche.” The developmental niche consists of “(1) the physical and social settings in which the child lives [micro systems in Bronfenbrenner’s (1979) work], (2) the culturally regulated practices of child care and child rearing [that exist in all microsystems, including family, education, and health care settings], and (3) the psychology of the caretakers” (p. 552). They expand as follows: “Regularities in the subsystems, as well as thematic continuities from one culturally defined developmental stage to the next, provide material from which the child abstracts the social, affective, and cognitive rules of the culture, much as the rules of grammar are abstracted from the regularities of the speech environment. The three components of the developmental niche form the cultural context of child development” (p. 552). More recent formulations have refined these initial theoretical postulates to articulate more specifically how culture permeates the settings that children navigate and how they impinge on development. Vygotski (1978), Rogoff (2003), and Weisner (2002) describe culture as embedded in daily routines and interactions by which the child is enculturated into patterns of behavior, language/communication, and cognitions. A recent revision of Bronfenbrenner’s bio-ecological model emphasizes how settings or microsystems through social interactions, daily routines, space, and other resource allocations enact on a daily basis cultural belief systems that may or may not align on behalf of the children’s development (Vélez-Agosto et al., 2017). Service providers and caregivers need to be cognizant that practices that may be perceived or interpreted as harmful by other groups are embedded within a complex cultural system with its own deep embedded logic. (See the section on cultural considerations for subgroups for specific examples.) For that reason, cultural differences need to be accepted, incorporated, or renegotiated as part of interventions and educational efforts. Traditional cultural practices, as unfamiliar as they might seem for some, might be sources of strengths and resilience. Subgroup Differences Although there are universal processes of development that point out the importance of the quality of intimate family relationships for early child development, there can also be powerful influences that are largely unique to particular contexts; these potent within-group processes can PREPUBLICATION COPY: UNCORRECTED PROOFS

4-18 VIBRANT AND HEALTHY KIDS affect children in both positive and negative ways. Considering the former, for example, specific processes have been identified as strengths or natural coping mechanisms that foster resilience within particular racial or ethnic groups, such as familism and respect for family obligations among Latinos and other collective-oriented cultures and effective family racial/ethnic socialization. Familism and family obligations provide the bases for family members to be involved in crisis management and the daily needs of mothers and children. Racial socialization provides children of color with an age-appropriate understanding of how racism operates and instills strengths and coping mechanisms based on positive and strong ethnic pride and identity. At the same time, these family contexts can place unique demands on children and families and lead to obstacles if they are not understood or accepted or are undermined by the majority culture; unintentionally, they might contribute to the emergence of health disparities very early in life. This section describes subgroups in which there are specific, unique risk and protective factors that can affect the quality of parent–child relationships and the child’s development; these need to be taken into account as interventions are designed to address health disparities. It should be emphasized here that ensuing discussions of subgroups does not imply that “all are the same” within them. There is invariably great heterogeneity between individuals and families within each subgroup, and it is important to recognize this, particularly in the design and implementation of interventions. Furthermore, while there may be unique risk and protective factors ascribed to these groups, the existing intervention research does not provide one-size-fits- all approaches to guide programs and policies working to serve these subgroups. These subgroups can differ from mainstream groups due to a variety of reasons, including ● Differential access to critical health-promoting resources (e.g., families not having access to safe housing and neighborhoods, preventive care, appropriate educational opportunities), ● Cultural differences due to language (e.g., non-English speakers in a monolingual English environment), religious background (e.g., Muslims) or recent migration, ● Chronic stress (e.g., groups in poverty struggling to meet basic needs, such as shelter and health care, and those facing excessive pressures to achieve, usually in well-educated affluent communities), and ● Discrimination (e.g., racial or ethnic discrimination, homophobia or discrimination against gender-atypical people [see Box 4-7 and the section on Lesbian, Gay, Bisexual, Transgender, Queer [LGBTQ] youth and families]). BOX 4-7 Children of Same-sex Parents In the last two decades, developmental researchers have provided a wealth of evidence that children of same-sex parents show patterns of adjustment that are comparable to those of heterosexual parents. Pioneered by Charlotte Patterson in the 1990s in response to heterosexist and homophobic questions in psychology, judicial opinions, and popular stereotypes, this burgeoning research in child development has shown that it is the quality of parent–child relationships, rather than having same- versus different-sex parents, that is critical for children’s adjustment (e.g., Wainright and Patterson, 2008; Wainright et al., 2004). A meta-analysis of 19 studies confirmed that children raised by same-sex parents have patterns of adjustment that are just as healthy as those of their counterparts raised by heterosexual parents (Crowl et al., 2008). PREPUBLICATION COPY: UNCORRECTED PROOFS

FOSTERING CAREGIVER WELL-BEING 4-19 Children Living in Poverty: Meeting Basic Needs As noted earlier, the most fundamental needs in Maslow’s hierarchy are related to physical survival; when parents struggle to have their basic human needs met—for shelter, food, and health care—all in the family are at risk. Parents who are preoccupied by fulfilling basic needs for themselves and their children inevitably find it challenging to attend to their children’s emotional, behavioral, and educational needs. Living in poverty is stressful on parents and can compromise the quality of their parenting behaviors, the evolving parent–child relationship, and the well-being of their developing children. As discussed in Chapter 3, one of the most studied and documented factors that affects children adversely is living in poverty (Evans, 2004). Beyond physical survival, chronic poverty places children at risk because the physiological, safety, relational, self-esteem and self- actualization needs—including those of the parents and the child—are all jeopardized; all of these need to be minimally fulfilled to prevent health disparities. Low socioeconomic status (SES) and parental education are associated with limited access and use of critical health- promoting resources, and they contribute to psychological distress and physical health disparities. Research has consistently shown that poverty creates living conditions that negatively affects parenting and the mother–child relationship. The daily stresses associated with living in poverty lead to higher incidence of maternal depression, which, as noted earlier, is linked with a poorer quality of mother-infant interaction (Jackson, 2000; Taylor and Conger, 2017). Similarly, poverty has been linked to less capacity for parenting in a consistent and loving way, since it creates high levels of psychological distress that interfere with successful parenting (Conger and Conger, 2002; McLoyd, 1990). Families living in poverty with young children represent one of the most at-risk populations for health disparities, and programs and policies targeting them (see Chapter 6 for more on economic, food, and housing security) within a prevention and early intervention framework should be a priority for our nation. Cultural Considerations for Subgroups Other groups whose family relations might be at risk are those whose cultural background (i.e., lack of familiarity or congruency with the dominant North American culture and language) limits their access to critical health-promoting resources or can become an obstacle as they operate with different daily practices and routines that are different from that dominant culture. For example, a parent with a limited grasp of the English language might impede that parent’s consideration of high-quality early intervention or preschool programs (Moss and Puma, 1995). They might also espouse different family constellations (e.g., where grandmothers are very involved in caretaking); these other adults might interfere with their family operations, as might external influences, such as educators or health care providers. Differences in acculturation among family members can also be sources of risk and resilience for families of immigrant backgrounds or members of other nondominant cultures. It has been observed that as children acculturate more than their parents (i.e., become more familiar with dominant North American culture and language), there is more conflict between parents and children (Schwartz et al., 2012). In addition, children might assume parenting tasks, such as taking on adult roles, negotiating school systems, and communicating with other officials for services (drivers’ licenses and bank accounts, for example) for their parents. The evidence on the effects of these added responsibilities on the children’s development, so-called family obligations or brokering, is mixed: in some contexts, they might be burdensome, PREPUBLICATION COPY: UNCORRECTED PROOFS

4-20 VIBRANT AND HEALTHY KIDS while in others they seem to be protective (Dorner et al., 2008; Fuligni and Pedersen, 2002). When taken to extremes and in developmentally inappropriate ways, however, taking on these roles is unhealthy for children. In recent years, the increased number of parental deportations and separation of parents and children at the southern U.S. border has led to an increasing number of children of immigrant background being traumatized and pushed into developmentally inappropriate parenting roles, which will lead to increasing relationship disturbances and subsequent health disparities (Bouza et al., 2018). In other instances, traditional cultural practices that are appropriate in their original context clash with mainstream North American institutions, and these cultural practices inadvertently place children in at-risk pathways and contribute to problems in family relationships. As an example, many societies (i.e., Korean, Japanese) do not use direct verbal communications with infants and young children. Yamamoto and Li (2011) have shown that some preschools make Asian American students feel inadequate because their quietness, a desirable trait in their home culture, is considered a “problem” in the preschool environment. By contrast, acknowledging and fostering bicultural competencies in families, children, and service providers offers a good foundation for fostering early development in diverse populations (Ho, 2015; Padilla, 2008). Finally, as presented in Chapter 3, discriminatory practices by systems, institutions, and the population at large can affect family relationships. Cultural mistrust from years of oppression from dominant groups, such as those experienced by African Americans, American Indians/Alaska Natives (AI/ANs), and immigrants of various races and nationalities in this country, might interfere with family functioning. Cultural mistrust can be transmitted intergenerationally, as promoting mistrust has been identified as a particular type of ethnic racial socialization practice (Hughes et al., 2006). These attitudes permeate relationships with others, including with family members and health care providers (Moseley et al., 2007). Mothers and other main caregivers from other cultural backgrounds might not only have problems accessing supports from mainstream institutions but also experience family conflicts because the experiences of parents and children with mainstream institutions might differ. Although these factors can be listed individually, multiple factors are present in many individuals, families, neighborhoods, and regions (e.g., rural versus urban). This is why theoretical frameworks have emphasized the multiplicity of factors that are usually present in creating health disparities (Coll et al., 1996). Moreover, new theories of intersectionality refer to those processes as differential access to power and as exclusion from benefits and assets and the existence of oppression and privilege at many societal levels (Bowleg, 2012; Brown et al., 2016; Hankivsky and Christoffersen, 2008). Among the strongest factors associated with health disparities are gender, SES, and race (Becares and Priest, 2015; NASEM, 2017; Williams et al., 2010). In many instances, these factors are multiplicative, not additive, throughout childhood and adulthood. At the same time, the protective factors that are unique for these populations need to be considered. The “immigrant paradox” refers to the findings that across physical and mental health and in educational and occupational outcomes, children and adults of immigrant backgrounds outperform native-born children, in spite of having been poorer and less acculturated to the dominant North American culture (García Coll and Marks, 2012). This phenomenon is poorly understood: it is unclear if motivational factors impel first and second generations to excel; if acculturation to poverty and its association with detrimental lifestyles and choices places subsequent generations at risk; or if discrimination and racism is more obvious to PREPUBLICATION COPY: UNCORRECTED PROOFS

FOSTERING CAREGIVER WELL-BEING 4-21 subsequent generations, and therefore its pernicious effects influence subsequent generations more. Regardless, the traditional notion of rapid acculturation and complete assimilation as the successful model for incorporating immigrants has been questioned based on this evidence, and models of biculturalism and promotion of ethnic pride (Umaña-Taylor et al., 2014) are suggested as alternatives for successful incorporation. Finally, studies point out that state- and country-level policies that support families of immigrant background lead to fewer health disparities in youth (Filindra et al., 2011; Marks et al., 2018). Children in Foster Care and Children with Incarcerated Parents As discussed in the previous sections, a healthy (positive) relationship with main caregivers is one of the basic cornerstones of children’s development and necessary to prevent many health disparities. There are populations that, for a variety of reasons, lack the stability and quality of parenting needed to promote their children’s development. Children in foster care and whose parents have been incarcerated often have multiple stressful life events before removal from parental care (Leve et al., 2012; Murray et al., 2012). The actual parental incarceration or loss of child custody is usually preceded by involvement with illegal activities and/or parental substance abuse, unstable housing, domestic violence and/or child neglect or abuse. These children might be exposed to extreme stress, particularly during the prenatal period, when the in utero child should be especially targeted at the first indication of any family relational difficulties. Children in Foster Care Children in foster care are overrepresented as a group in health disparities (Goemans et al., 2015, 2016; Leloux-Opmeer et al., 2016; Leve et al., 2012). In most instances, these children’s parents have lost or given up their parental rights because they cannot provide their children stable, healthy relationships and other critical health-promoting resources needed for their well-being. However, children from certain racial and ethnic populations are disproportionately represented in the child welfare system. For example, AI/AN families are twice as likely to be investigated as the national population of families, and cases are twice as likely to be substantiated, with AI/AN children three times as likely to be placed in foster care as the national population of children (see Table 4-1 for data on this disproportionality) (Hill, 2007). Disruptions in attachment and other regulatory processes are consistently found in this population (Barone et al., 2017; Goemans et al., 2016; Leloux-Opmeer et al., 2016; Vasileva and Petermann, 2018). However, it has been found that foster care does not ameliorate these problems and actually might lead to more negative adaptive functioning after 1 year in such placement (Goemans et al., 2015). TABLE 4-1 Disproportionate Foster Care of AI/AN Children: 15 States with the Highest Rates PREPUBLICATION COPY: UNCORRECTED PROOFS

4-22 VIBRANT AND HEALTHY KIDS SOURCE: NICWA, 2017. Policies and practices of parental removal and replacement need to be carefully implemented. The stability of nurturing and supportive relationships, as described earlier in this chapter, are crucial considerations for these populations (Jones Harden, 2004). If parents are unavailable or incapable of providing such conditions, placement with other family members, foster parents, or adoption are advisable, but only if these substitute parents can, in turn, provide stability and responsive parenting. That means that the quality and timing of care provided by family substitutes, including foster and/or kinship care and/or adoption or the reunification with the original biological family, has to be carefully planned and implemented, to avoid re- traumatizing children through their interactions with these systems (Font et al., 2018). In terms of supportive policies, the passage of the Family First Prevention Services Act in 2018 provides an opportunity to advance evidence-based child welfare policies through the investment of federal funds in children at risk for foster care, in foster family homes, or in qualified residential treatment programs or other special settings.3 Most notably, the legislation provides support for programs and practices to keep children with their families safely (e.g., allowing states to use Title IV-E funds to prevent children’s entry into foster care) (NCSL, 2019). Children with Incarcerated Parents Incarceration is more prevalent in marginalized populations, adding to these populations’ multiple risks for poor health outcomes. Analysis of incarceration rates shows much higher rates in low-income, minority populations (Acker et al., 2019; Wildeman and Wang, 2017). It has been widely documented that discriminatory policies and practices in the definitions of crimes, arrests, sentencing, and incarceration practices lead to an overrepresentation of low-income and minority populations, which has resulted in widespread incarceration within these communities (Acker et al., 2019; NRC, 2014). These higher rates not 3 H.R.253—Family First Prevention Services Act of 2017. PREPUBLICATION COPY: UNCORRECTED PROOFS

FOSTERING CAREGIVER WELL-BEING 4-23 only affect the developing mother–child relationship but also disrupt the networks of support for parents frequently found in other family or neighborhood members. Research clearly demonstrates the negative effects of parental incarceration on the child (Christian, 2009; Wildeman and Wang, 2017). Parental incarceration usually leads to family financial and housing instability and to more mental disorders and physical health problems in the partner (the parent who stays behind), which in turn is associated with higher incidence of child abuse and neglect (Acker, 2019). Various studies, including a meta-analysis, show that parental incarceration is associated with higher risks of children’s antisocial behaviors, learning disabilities, and behavioral problems (Murray et al., 2012; Turney, 2014). Long-term educational, occupational, and physical and mental health outcomes as well as criminal behaviors are all related to parental incarceration (Acker et al., 2019). Given the importance of attachment to the primary caregiver, maternal incarceration is believed to be more detrimental for young children than paternal incarceration and a serious risk factor for future psychopathology (Murray and Murray, 2010; Parke and Clarke-Stewart, 2001; Shlafer and Poehlmann, 2010). This is concerning, given that almost 80 percent of incarcerated women are mothers (McCambell, 2005). For that reason, policies and practices that ensure adequate access and visitation to the incarcerated parent and promote healthy attachments is seen as a fundamental need and right of the child(ren) left behind (UNM, 2011). LGBTQ Parents and Children The parents and children that do not conform to normative gender expression and sexual orientation schemas of society (the LGBTQ community) are also placed at risk by contextual circumstances. The current cultural, religious, and political climate in the United States is divided on the acceptance and approval of these behaviors. Although research indicates that same-sex parents have been found to raise children with the similar developmental outcomes as those of opposite-sex parents (see Box 4-7), about one third of the population still expect negative impacts on children (Drake, 2013). From an equity perspective, the LGBTQ community has historically gained rights for families through legislation and court precedence, such as the Supreme Court decision to uphold same-sex marriage as a constitutional right in 2015.4 This landmark court case was instrumental in securing marital benefits (e.g., financial, social) for same-sex couples and their children. As of 2016, 20 states and DC had enacted legislation that prohibits discrimination based on sexual orientation and gender identity or expression in employment, housing, and public accommodations—all are critical to promoting healthy development for children. Even with such laws and policies, members of these populations are often subjected to discriminatory acts and microaggressions (IOM, 2011). Some have to “hide” their orientation and expressions from family, friends, and coworkers, which sometimes lead to the adoption of high-risk behaviors, such as unprotected sex, or internalizing disorders, such as depression, self- injurious behavior, and anxiety (IOM, 2011). Others may passively accept or actively repudiate discriminatory acts, exclusions, verbal and physical aggressions, and microaggressions as they express and adopt these less normative behaviors. These varied reactions to homophobia and discrimination can be associated with high levels of chronic stress and contribute to long-lasting health disparities (IOM, 2011). 4 Obergefell v. Hodges, 576 U.S. (2015). PREPUBLICATION COPY: UNCORRECTED PROOFS

4-24 VIBRANT AND HEALTHY KIDS While sexual orientation and gender identity may be more salient during adolescence, there is evidence to suggest that LGBTQ children demonstrate their inclinations to gender- atypical behaviors and same-sex orientation quite early (Rae et al., 2019). Many parents identify cross-dressing, toy preferences, and identification with heroes/heroines as displaying these preferences as early as the infancy and toddler years. As the typical puberty age has dropped, the issues that used to arise later in adolescence (i.e., identity, dating) are moving into childhood. The LGBTQ population of children and youth is overrepresented in the adoption of risky behaviors and psychopathology. The IOM (2011) report on The Health of Lesbian, Gay, Bisexual, and Transgender People identified the following key findings from the literature about LGBTQ youth during childhood and adolescence: • LGBTQ youth are at increased risk for suicidal ideation and attempts a depression. • Rates of smoking, alcohol consumption, and substance use may be higher among LGBTQ than heterosexual youth. • The homeless youth population contains a disproportionate number of LGBTQ youth. Some research suggests that young transgender women are also at significant risk for homelessness. • LGBT youth report experiencing elevated levels of violence, victimization, and harassment compared with heterosexual and non-gender-variant youth. • Families and schools appear to be two possible focal points for intervention research. These findings are corroborated by data from the Youth Risk Behavior Survey, which identify LGBTQ youth as being at risk for bullying, intimate partner violence, and sexual assault (CDC, 2017). Children in High-Achieving Schools As noted at the outset of this section, the standouts in groups of children and families exposed to high levels of chronic stress include those at both extremes of SES. Evidence of the challenges facing children and families in poverty, summarized here, have been reviewed extensively in the literature, with studies burgeoning around publication of the landmark Special Issue of Child Development on poverty over 20 years ago (Brooks-Gunn and Duncan, 1997; Elder, 2018; Huston et al., 1994). By contrast, the evidence showing that youth in high-achieving contexts are an at-risk population is nascent, and the findings are counterintuitive for most. Extant evidence of adjustment difficulties among these children is presented here, following by consideration of why this subgroup might merit attention in this particular report, which is focused on family-based prevention for children known to be at risk given life adversities. With regard to the existing evidence on children of well-educated, relatively affluent parents, studies using varied samples and methods have converged in indicating relatively high levels of adjustment problems, likely linked with long-standing, ubiquitous pressures to excel at academics and extracurricular activities. Studies of students attending high-achieving schools (HASs) (public and independent; day and boarding; in different parts of the country) have consistently determined that they show rates of clinically significant problems, notably depression, anxiety, rule-breaking, and substance use, at rates that are (a) much higher than national norms and (b) sometimes higher than those in urban poverty (the latter is particularly true for substance misuse; see (Luthar and Kumar, 2018; Luthar et al., 2013). Two large-scale analyses of national datasets in the United States and Norway (Coley et al., 2018; Lund et al., 2017) have confirmed a U-shaped association between community-level affluence and students’ PREPUBLICATION COPY: UNCORRECTED PROOFS

FOSTERING CAREGIVER WELL-BEING 4-25 adjustment problems; in fact, students at the more affluent schools had the highest levels of substance use. In a recent longitudinal study spanning 50 years, Gollner et al. (2018) showed that students at an HAS had poorer outcomes decades later than their counterparts at middle- achievement schools. The authors said that constant social comparisons among a population of largely talented students were likely implicated in this result, which led to lower educational expectations of the self. Similarly, a collection of three studies involving fifth- to tenth-graders in Germany (Pekrun et al., 2019) showed that in all three schools, being in a high-achieving context, had negative links with self-concept and emotions, and conversely, being in less-HASs was better for self-concept and emotion. Over time, accumulating evidence on this population has led to global statements about the high levels of risk among these youth. Almost a decade ago, Koplewicz et al. (2009) referred to their problems as “an epidemic.” A recent report on adolescent wellness, released by the RWJF, noted the following four as the most critical “high-risk” environments: exposure to poverty, trauma, discrimination/racism, and high pressure to achieve, usually found in relatively affluent communities (Geisz and Nakashian, 2018). Importantly, risks can be further exacerbated for vulnerable populations in HAS settings. Recent research has shown that African American boys in relatively high SES communities reported significantly higher depression and substance abuse, probably as a result of greater discrimination/racism in their communities—likely dominated by white families (Assari and Caldwell, 2018; Assari et al., 2018a,b; Lewis and Van Dyke, 2018). There is value, therefore, in considering issues of racial socialization for children of color who have the “double jeopardy” of having few children who look like them in their schools, neighborhoods, and communities. With regard to why this subgroup of children and families might be relevant for this report on early childhood and equities in adaptation, two factors are relevant; one has to do with “sleeper effects” and the other with the need for early prevention. With regard to the first issue (as has been discussed earlier), the charge of this committee is not just to prevent problems that are manifested in early childhood—temper tantrums or bed-wetting—but, equally, those whose seeds are sown in early childhood and then “incubate” and become evident by early adolescence. It is clear that the prevention of problems among HAS youth (and other youth who suffer poor outcomes due various types of adversity) cannot start when they are already teens; by then, a great deal of damage has already been done. Instead, what is needed is attention to these issues among parents when the children are still young. In fact, there are recent suggestions that the effects of high-achieving environments can be seen as early as preschool (Pekrun et al., 2019). Second, there is a great deal of preventive potential in working with families in these settings toward raising awareness of the nature of risks and potential problems. Unlike low- income communities, where an influx of resources is often needed for prevention, in this case, dissemination of accumulated evidence from science, with associated recommendations (Luthar et al., 2013), can be helpful. It is particularly important for parents to (a) understand the level and seriousness of adjustment problems that researchers have recurrently documented in HASs and (b) be vigilant in their own homes, starting from early childhood, against being overly invested in the child’s “resume-building” (Gollner et al., 2018; Luthar and Kumar, 2018 Pekrun et al., 2019). It is also critical to note that just as children in high-achieving contexts can be vulnerable, so can their mothers (who are, again, as in most contexts, their primary caregivers). Panel studies over time have shown that well-educated mothers have shown substantial increases in hours PREPUBLICATION COPY: UNCORRECTED PROOFS

4-26 VIBRANT AND HEALTHY KIDS spent on activities related to their children, with increases greater than those among well- educated fathers and less well-educated mothers or fathers (Kalil et al., 2012; Ramey and Ramey, 2010). In terms of sheer hours, therefore, this group can be especially stretched thin and chronically stressed. Cross-disciplinary studies have established other factors that can challenge their well-being, including the “invisible labor” involved in being responsible for overseeing schedules and activities of all in the household (see Ciciolla and Luthar, 2019; Lareau and Weininger, 2008; Yavorsky et al., 2015). A recent study showing increases in depression over the last decade in the high-income groups, and among women in particular, provides additional testimony to the seriousness of these issues (Twenge et al., 2019). Changes over time were examined for four cohorts/generations and considering four groups of family incomes. The findings showed that cohort increases in serious psychological distress were the largest in the highest income group. Among adolescents, time period increases in rates of a major depressive episode were the largest in the highest income group and smallest in the lowest-income group; among adults, the cohort increase in suicidal ideation was largest and smallest in the highest-and lowest-income groups, respectively. The authors concluded that “with the exception of adult MDE and suicide attempts, the cohort increases were the largest and most consistently seen among those with the highest income” (Twenge et al., 2019, p. 10). Additionally, among adults, the increases in mood disorder indicators and all suicide related variables (suicidal thoughts, plans, and attempts) were consistently higher among women than men. The evidence on youth and families in high-achieving contexts were reviewed above in some detail because this is a newly identified at-risk group, encompassing at least 20–25 percent of the U.S. population (e.g., Twenge et al., 2019). Additionally, despite the seriousness of problems that are increasingly documented, there remains reluctance to afford attention to them in research and policy (Geisz and Nakashian, 2018). In addition to HAS families, there are other such groups that are increasingly being identified as showing high vulnerability relative to norms, such as subgroups based on sexual identity and preference. Questions on both these dimensions are now arising among children at younger and younger ages (often well before adolescence), creating stress and confusion for the child as well as parents. Children who identify as neither male nor female but rather as “nonbinary” show elevated rates of anxiety, depression, and other psychological difficulties, as do children who identify not as heterosexual but as lesbian, gay, bisexual, or questioning. Regarding transgender youth, considerations of gender reassignment are also now coming up in many families well before adolescence. All of these subgroups will need concerted attention in the years ahead, in terms of understanding how best to help both children and parents effectively negotiate these issues at home and outside it, such as in the children’s peer groups. Youth from Asian backgrounds are yet another illustration of a group that is potentially vulnerable but rarely included in discussions of children at risk. These children are often thought of as both privileged and “model minorities” (e.g., Lee et al., 2009; Ngo and Lee, 2007), but in fact, many U.S. families of Asian origin actually live in low-SES households. Further, issues of discrimination affect Asian youth, arguably, just as they do other racial and ethnic minorities. At the same time, Asians are not considered as an ethnic minority group in discussions of discrimination, prejudice, and stereotype (Wong and Halgin, 2006) the way that youth from African American, Latino, or AI/AN backgrounds are. It is important to emphasize that this is not a zero-sum game; research and policy attention to the needs and challenges of Asian PREPUBLICATION COPY: UNCORRECTED PROOFS

FOSTERING CAREGIVER WELL-BEING 4-27 Americans by no means implies detracting from the very real and well-documented challenges faced by other ethnic minority groups in the United States. In addition to including such neglected subgroups in discussions of those needing attention to prevention, more attention to risk processes that were not an issue at the time that From Neurons to Neighborhoods (NRC and IOM, 2000) was released is also warranted, and social media is critical in this regard. In discussions of why there continue to be increases in children’s depression since the early 2000s, social media is often noted as a major factor (Hoge et al., 2017). Yet, there remain several questions about which aspects of social media use are truly damaging to children’s mental health. Possibilities range from the amount of time spent on social media to spreading rumors about others, being the victim of bullying, “sexting” and accessing pornography, and constant social comparisons or feeling “less than” others. In Chapter 3, there is a section devoted to the problem of bullying even among young children; clearly, there is a lot of work that still remains to reduce this major risk process—and, now, to also disentangle and address the new challenges introduced by the widespread use of social media from young ages onward. As Weisz and colleagues (2019) note, the nature of childhood disorders may be changing faster than our treatments are: “Threats to youth mental health are becoming more diverse and multiform…. Current threats encompass pressures to excel as well as new pressures to excel in increasingly competitive academic and social environments, images conveyed via advertising and social media that could make anyone feel inadequate, risks of harm via text messages and cyberbullying, and even fear of being gunned down at school” (p. 233). To summarize, as policy makers and prevention scientists think about groups of young children and caregivers whose life circumstances are likely to place them at high risk for adjustment problems, the needs of all families need to be taken into consideration. Low levels of maternal education, coexisting with poverty and often single motherhood, clearly spell risks for adjustment problems and parenting difficulties among mothers, as noted earlier. At the same time, there are other groups that are increasingly being identified as requiring attention in future prevention efforts, including children and parents in extremely fast-paced, stressful, competitive communities, and sexual minority youth. Similarly, there are new risk processes that have arisen in the last couple of decades that potentially have strong negative effects on children and merit concerted attention in future research and policy when considering what should and should not be prioritized in preventive interventions. In conclusion, psychologists, educators, and other health professionals need to work with groups of families that are especially vulnerable due to exposure to high levels of stress or adversity, with efforts beginning from preconception onward. These efforts will involve harnessing protective processes, and minimizing risk factors, in interventions that have a sound basis in developmental theory, science, and cumulative research evidence; have shown promising results in prior prevention studies; and are pragmatic (i.e., can feasibly be taken to large scale in the real world). Conclusion 4-4: Specific subgroups of children have unique needs and challenges when adjusting to adversity. Careful attention to potent subculture-specific processes need to be considered in working with subgroups well known to face serious inequities in relation to mental health—including families experiencing chronic poverty, immigrants, LGBTQ children and LGBTQ parents, and those where children are separated from parents due to incarceration or foster care. Among the groups more recently identified as being at PREPUBLICATION COPY: UNCORRECTED PROOFS

4-28 VIBRANT AND HEALTHY KIDS high risk for chronic stress are children and parents, particularly mothers, in high- achieving, relatively affluent communities. Recommendation 4-2: Federal, state, local, tribal, and territorial agencies, along with private foundations and philanthropies that invest in research, should include in their portfolios research on the development of interventions that are culturally sensitive and tailored to meet the needs of subgroups of children known to be vulnerable, such as those living in chronic poverty, children from immigrant backgrounds, children in foster care, and children with incarcerated parents. In addition to addressing major goals relevant for children in general (e.g., fostering caregiver well-being and minimizing maltreatment), programs need to include components that specifically address unique, powerful risk and protective processes within these subgroups of children. As discussed above, it cannot be assumed that evidenced-based interventions and promising models developed in specific populations will work in other contexts. The validity and adaptability of interventions need to be empirically tested in groups that differ greatly in the sources of chronic stress and cultural backgrounds. INTERVENTIONS TO PROMOTE RELATIONAL SUPPORTS AND CAREGIVER WELL-BEING As developmental scientists have emphasized the critical importance of relational supports for the well-being and thus mothers’ parenting, intervention trials have shown strong benefits of relational interventions. Indeed, the core components of several effective interventions suggest that over and above learning particular skills, it is improvements in mothers’ overall well-being, within the context of supportive relationships, that is the most critical “engine” underlying the positive changes. To illustrate, the Incredible Years intervention by Webster-Stratton and colleagues (2001) targets children’s school readiness and parenting skills while helping parents to cope with personal problems; parents are able to form valuable support networks with “buddies” from parent groups (Borden et al., 2010). Ammerman and colleagues’ (2005) Every Child Succeeds program for depressed mothers provides in-home cognitive behavior therapy and a supportive home visiting component. A cardinal component in Dozier’s Attachment and Biobehavioral Catch-up (ABC) is consistent respect, warmth, and support displayed by project staff or therapists to participating mothers (Dozier et al., 2005). This section focuses on interventions with the strongest evidence base to foster healthy child development through supporting caregivers. First, there is a discussion of the evidence on home visiting, a well-established model for providing services to children and families, and the following section describes a range of interventions that have shown promise. The committee presents these as opportunities to use the science to drive action on caregiver and child well- being; however, the presentation of these interventions does not indicate prioritization of one over another. Different populations will require varying interventions based on their needs and context, in addition to specific tailoring to meet these unique needs depending on the population. PREPUBLICATION COPY: UNCORRECTED PROOFS

FOSTERING CAREGIVER WELL-BEING 4-29 Home Visiting Programs One of the earliest program models built around the notion of supporting caregivers is home visiting. Home visiting programs in the United States focus on promoting child health and development by providing parenting support and other child-centered services in the home (e.g., developmental screenings and referrals to services and treatment) to at-risk families from the prenatal stage to through age of six (HRSA, n.d.). One of the primary goals of home visiting is to improve child health and educational outcomes. Home visiting programs have provided services to families in the United States since the late 1800s (Minkovitz et al., 2016), but the 2010 federal Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) led to the expansion and supported standardization of home visiting implementation and evaluation. In fiscal year 2018, the MIECHV program served approximately 150,000 parents and children in 76,000 families across all 50 states, DC, 5 territories, and 23 tribal and urban AI/AN communities, providing nearly one million home visits annually and 5.2 million home visits between 2012 and 2018 (HRSA, n.d.). By law, state and territory awardees have to spend the majority of their MIECHV program grants to implement evidence-based home visiting models, with up to 25 percent of funding available to implement promising approaches that will undergo rigorous evaluation.5 Tribal home visiting programs are encouraged to select evidence-based home visiting curricula, but as the research evidence is limited, this is not a program requirement. Most tribal home visiting programs chose to implement evidence-based curricula with cultural adaptations developed with intensive community input and engagement, which enhanced family engagement and retention (Pratt and Chapman, n.d.). Home visiting services may also receive support from many other federal, state, and local public and private sources. This section summarizes the evidence on home visiting, highlighting a few exemplar programs. Given the multidisciplinary and cross-sector nature of this topic, the chapters later in the report will discuss home visiting with respect to specific levers in certain domains to enhance or support such programs. (See Chapters 5 and 7 for more on the role of the health system and of ECE, respectively.) Summary of the Evidence on Home Visiting Programs A growing body of evidence suggests that home visiting by a nurse, a social worker, or an early educator during pregnancy and in the first years of a child’s life improves a whole host of child and family outcomes, including promotion of maternal and child health, prevention of child abuse and neglect, positive parenting, child development, and school readiness. The positive impact continues well into adolescence and early adulthood. For example, in a 19-year follow-up of a randomized controlled trial (RCT), Eckenrode et al.(2010) found that relative to the comparison group, girls in the pregnancy and infancy nurse-visited group were 58 percent less likely to have been arrested and 43 percent less likely to have been convicted. Nurse-visited girls born to unmarried and low-income mothers also had fewer children and less Medicaid use. One meta-analysis examined the impact of 18 implementation factors (including staff selection, training, supervision, and fidelity monitoring) and four study characteristics (publication type, target population, study design, comparison group) in predicting program outcomes (Casillas et al., 2016). The greatest program effects were found to be on increased 5 See https://mchb.hrsa.gov/maternal-child-health-initiatives/home-visiting-overview for more information (accessed June 8, 2019). PREPUBLICATION COPY: UNCORRECTED PROOFS

4-30 VIBRANT AND HEALTHY KIDS positive parenting and reduced likelihood of maltreatment; the former had the largest effects. The programs were significantly less effective for children’s health and behavior. Further, provision of high-quality supervision and fidelity monitoring were key factors associated with beneficial outcomes. Programs serving families with one or more risk factors had significantly greater effect sizes compared to programs serving all families. Avellar and Supplee (2013) reviewed the research on home visiting, and nearly 9 out of 12 programs (of the 32 reviewed) that met evidence-based criteria also showed favorable effects on children’s social-emotional development or behavioral problems. Five programs showed one or more favorable effects on cognitive development, and five showed improvements in reductions in some aspect of child maltreatment (only six of the programs assessed maltreatment). Another meta-analysis examined the effect of home visiting on six outcomes: birth outcomes, parenting behavior and skills, maternal life course, child cognitive outcomes, child physical health, and child maltreatment (Filene et al., 2013). Mean effect sizes were significant and positive for three of the six outcome domains: maternal life course outcomes, child cognitive outcomes, and parent behaviors and skills (Filene et al., 2013). Effect sizes for birth outcomes were significantly larger for programs that used nonprofessional home visitors, matched clients and home visitors on race and/or ethnicity, or included problem solving. Effect sizes were larger for parent behaviors and skills programs that addressed parental substance use and taught parents developmental norms and appropriate expectations, discipline and behavior management techniques, and responsive and sensitive parenting practices. Improved child maltreatment outcomes were associated with problem solving and teaching parents how to select alternative caregivers for children. The effects on children’s cognition were better in programs that taught parents responsive and sensitive parenting practices or “required parents to role-play or practice skills during home visits. Using professional home visitors was a significant predictor of better child physical health outcomes, as was teaching discipline and behavior management techniques” (Filene et al., 2013, p. S104). Following a review of the research literature in 2018 (Sama-Miller et al., 2018), the Home Visiting Evidence of Effectiveness (HomVEE) project, established by the Administration for Children and Families (ACF) in the Department of Health and Human Services (DHHS), identified 20 home visiting models as meeting criteria of effectiveness to recommend for state- based home visitation programs (OPRE, 2018). Based on the available high- or moderate-quality studies, the review showed that most of these programs have multiple favorable effects with sustained impact, with Healthy Families America and Nurse-Family Partnership (NFP) showing favorable impact across the greatest breadth of outcomes. Most models had favorable impacts on primary measures of child development, school readiness, and positive parenting practices; none of the models, however, showed impacts on a primary measure of reductions in juvenile delinquency, family violence, and crime (Sama-Miller et al., 2018). A national evaluation of the effectiveness of the MIECHV program from 2012 to 2017, based on random assignment of families, found statistically significant positive effects in 4 out of 12 confirmatory outcomes: the quality of the home environment, the frequency of psychological aggression toward the child, the number of Medicaid-paid child emergency department (ED) visits, and child behavior problems (Michalopoulos et al., 2019). Most estimated effects are similar to but somewhat smaller than the average found in past studies of individual home visiting models. Differences in effects among the evidence-based models are generally consistent with the models’ focuses. For example, Parents as Teachers produced the largest increase in PREPUBLICATION COPY: UNCORRECTED PROOFS

FOSTERING CAREGIVER WELL-BEING 4-31 parental supportiveness, and NFP produced the largest reduction in ED visits for children (Michalopoulos et al., 2019). Potential to Reduce Disparities The field of home visiting research continues to expand, with researchers identifying measurement frameworks (West et al., 2018) and factors contributing to implementation and replication (Paulsell et al., 2014). The state and tribal MIECHV recipients are required to implement rigorous program evaluations, which also help inform best practices and identify model programs and approaches and support the development and implementation of cultural adaptations necessary to ensure program retention, engagement, and cultural fit (Denmark et al., 2018; Hiratsuka et al., 2018). While the evidence remains limited for significant improvements in the reduction of health disparities, some studies have demonstrated that home visiting resulted in improved outcomes and so offered savings in terms of a return on investment of $2–$4 for every dollar spent (Cannon et al., 2017). Among nondepressed mothers or families without multiple Child Protective Services (CPS) reports prior to study enrollment, home visiting was associated with a significantly lower likelihood of CPS report recidivism. These results indicate potential for home visiting to prevent maltreatment recidivism but, importantly, suggest that home visiting approaches, with weekly in- home visits by a trained home visitor, is warranted for mothers exhibiting significant depressive symptoms or families with extensive CPS histories (Jonson-Reid et al., 2018). However, among 220 low-income home visiting enrollees in a regional setting, mothers who experienced maltreatment in childhood had a heightened risk for membership in the mild and moderate- severe depression subgroup trajectories (Teeters et al., 2016). Mothers reporting higher social support saw a significant reduction in the risk of experiencing either mild or moderate-severe depression subgroup trajectories, while mothers reporting an increased belief in having control over one’s life (LOC) also saw a significantly reduced risk for assignment in either the mild or moderate-severe subgroups. Moreover, the depression score of mothers experiencing moderate to high depression was not significantly lower while enrolled in home visiting, though the depression scores for mothers at the minimal and mild levels of depression were significantly lower over time (Teeters et al., 2016). These results suggest the effect of home visiting may also depend on maternal depression level, demonstrating that tailoring home visiting curricula to best fit maternal risk factors may be warranted. Exemplar Programs and Promising Practices The NFP home visiting curriculum has demonstrated multiple positive outcomes, including a reduction in domestic violence reports (Eckenrode et al., 2017). Mothers receiving visits from nurse home visitors had fewer health care encounters for injuries and higher ratings of the home environment and parent’s reports of caregiving (Kitzman et al., 1997; Macmillan et al., 2009; Olds et al., 1997; Zielinski et al., 2009). NFP is the only home visiting program to have statistically significant positive effects over time on substantiated cases of child maltreatment. Healthy Families New York, a Healthy Families America–accredited home visiting program, has demonstrated positive effects for fathers’ participation. Families with father participation were more than four times as likely to be retained, and engaged fathers were more likely to live at home with the child and to remain emotionally involved at 6 months (McGinnis et al., 2018). The Family Spirit home visiting intervention is the only program that has demonstrated PREPUBLICATION COPY: UNCORRECTED PROOFS

4-32 VIBRANT AND HEALTHY KIDS efficacy in American Indian communities. To date, it has only been implemented in three rural, tribal communities in the Southwest. Nevertheless, Family Spirit has seen that high-risk mothers had significantly greater parenting knowledge (effect size = 0.42) and parental locus of control (effect size = 0.17), fewer depressive symptoms (effect size = 0.16) and externalizing problems (effect size = 0.14), and lower past-month use of marijuana (OR = 0.65) and illegal drugs (OR = 0.67). Moreover, children in Family Spirit had fewer externalizing (effect size = 0.23), internalizing (effect size = 0.23), and dysregulation (effect size = 0.27) problems (Barlow et al., 2015). Culture is embedded across many important components of parenting, and it has only recently been actively integrated into home visiting services. However, few culturally specific home visiting curricula have sufficient evidence to be deemed evidence-based practices. Some are considered promising, with some positive quasi-experimental support for program, family, and child outcomes. For example, Kulia I Ka Nu‘u works with families with children 2.5–5 years old using a Montessori approach with Native Hawaiian culture to support parents in building their child’s school readiness and school success (Yoshimoto et al., 2014). Parent educators help families learn more about Native Hawaiian values and practices and incorporate these cultural values into the curriculum, which includes literacy, math, art, social studies, and science. Kulia I Ka Nu‘u is unique to the island of O‘ahu. Pulama I Na Keiki (PINK) provides services to Native Hawaiian families prenatally to 3 years of age. PINK supports families in identifying and learning more about cultural traditions and how strengthening cultural knowledge contributes to family life. Parent educators provide culturally based information about prenatal health, childbirth, child development, and child rearing (Yoshimoto et al., 2014). Expanding the Impact of Home Visiting To maximize the impact of effective home visiting programs, there is a need to expand their reach by scaling them to larger and different populations; currently, only 40 percent of U.S. counties provide home visiting services, with 13 states offering home visiting in 75 percent of counties and 10 states providing it in 10 or fewer counties (NHVRC, 2017). In 2017, more than 300,000 families received home visiting services, though the National Home Visiting Research Center estimates that about 18 million additional families could benefit but were not being reached (NHVRC, 2018).The MIECHV program was reauthorized in 2018 at a funding level of $400 million annually through 2022 (Sandstrom, 2019). To address remaining unmet needs, the federal program needs to be funded at a much higher level in the next reauthorization. States can further expand support for evidence-based home visiting services through state general funds, Medicaid financing, or braiding of different funding streams (Johnson, 2019). Presently, 20 states are using Medicaid to expand state capacity and reduce unmet needs for home visiting services, including considering universal home visiting, such as in Oregon and Washington State. Many states are using a Medicaid State Plan Amendment to support home visiting services under targeted case management benefit; other states, such as Maryland and South Carolina, had made home visiting demonstration or pilot projects part of a larger Medicaid 1115 or 1915(b) waiver. South Carolina is braiding approximately $17 million in philanthropic investments with $13 million in Medicaid funding through a 1115 waiver to finance a pay-for-success approach. Under this approach, private (and public) funders provide up-front capital to expand social services through a “social impact bond;” the government pays for all or part of the program only if it measurably improves the lives of participants (Johnson, 2019). South Carolina has committed an additional $7.5 million in payment if independent evaluators find positive results PREPUBLICATION COPY: UNCORRECTED PROOFS

FOSTERING CAREGIVER WELL-BEING 4-33 from expanded home visiting services (Johnson, 2019). Scaling up requires more than simple replication of an effective home visiting model to reproduce positive effects. It entails the careful consideration and balance of fidelity, spread, and tailoring models for local adaptation. To support fidelity in the home visiting field, Paulsell et al. (2014) argue that two conditions need to be met: 1) research on efficacy, effectiveness, and dissemination need to document challenges that threaten fidelity; and 2) the field needs to standardize measurement and improve understanding of valid and reliable fidelity measures within and across models. While model fidelity is an important mediator of program success, home visiting implementation requires flexibility to tailor the program to the needs and/or assets of the community or population being served. This is especially critical when applying an equity approach, so that all children and families receive the services that they need. One strategy may be for the MIECHV program to work with model developers in identifying core program elements across models, while allowing state grantees to choose additional elements from various models to enhance and tailor the core program to the differential needs and vulnerabilities of individual families and communities. Additionally, others have proposed proportionate universalism—a tiered approach where every new parent in a community receives at least one home visit, while the quantity and intensity of follow-up services are adjusted to the needs and assets of high-risk families, to improve program cost-effectiveness (Marmot et al., 2010). (See the section on Synthesizing the Evidence for Conclusion 4-5 on applying a tiered approach to services.) Most importantly, as the committee discusses in Chapter 5, home visiting must not become yet another siloed prenatal and early childhood service. Future evidence-based home visiting programs need to continue to partner with, coordinate, colocate with, and expand the reach and impact of other ECE programs and the future redesigned advanced medical home. Home visiting can thus serve as a linchpin between health care, social services, and early childhood education. Lastly, the relatively modest impact of the MIECHV program demonstrated in the national evaluation has been observed in other early childhood programs that scaled up from RCTs to population-wide interventions (Center on the Developing Child at Harvard University, 2016). Studies that focus on average effects may mask wide variation in impacts if they do not or cannot account for the differential susceptibilities of individuals, families, or communities. Often, RCTs cannot easily be adjusted, adapted, or enhanced after randomization (see Chapter 1 for a discussion about the limitations of RCTs). Future home visiting and ECE research needs to move beyond searching for one-size-fits-all solutions to define more precisely which intervention works best for which patients or populations under what circumstances. Researchers, program leaders, and policy makers should focus on expanding the concept of precision home visiting that advances which programs and activities are best for which family, in which communities, and for what outcomes. Recommendation 4-3: To strengthen and expand the impact of evidence-based home visiting programs: • Federal policy makers should expand the Maternal, Infant, and Early Childhood Home Visiting Program. • The Health Resources and Services Administration and the Administration for Children and Families should work with program developers to increase flexibility for states and communities, to tailor the program to the needs and/or assets of the community or population being served. PREPUBLICATION COPY: UNCORRECTED PROOFS

4-34 VIBRANT AND HEALTHY KIDS • Federal, state, local, tribal, and territorial agencies overseeing program implementation should continue to strengthen programmatic coordination and policy alignment between home visiting, other early care and education programs, and medical home. State policy makers should further expand support for evidence-based home visiting services through general funds, Medicaid, and braiding of multiple funding streams. HRSA and ACF should continue to assure program effectiveness and accountability of the expanded program. Expansion of home visiting programs should be done in conjunction with the expansion of other public investments and services. Given the resources needed to provide high-quality home visiting, cost is an important consideration. Yarnoff et al. (2019) developed and piloted a tool to standardize the collection of home visiting data, in addition to assessing program costs for 45 local implementing agencies that participate in MIECHV. The study reported an average cost per family served of $12,556 for agencies serving less than 100 families, versus $7,117 for agencies serving more than 100 families.6 Burwick et al. (2014) conducted a cost analysis for 25 implementing agencies and found that the average estimated annual cost to operate a home visiting program was $580,972.7 Costs varied drastically from program to program, ranging from $206,426 to $1,207,054. Estimating and comparing costs of home visiting programs—and by extension, of expanding them—can be difficult for a number of reasons. As noted above, program costs vary, and this could be attributable to the services offered, duration, transportation costs—particularly in rural and/or tribal communities—and family and agency characteristics (Burwick et al., 2014; Yarnoff et al., 2019). Further research is needed to understand how to expand home visiting programs cost effectively, and a tiered approach would provide tailored services based on family needs (see Conclusion 4-5 for more on a tiered approach). Finally, strengthening programmatic coordination and alignment across sectors, as indicated in the recommendation, could potentially reduce costs. Other Evidence-based Programs Focusing on Mothers Outside of home visiting, perhaps the first program to explicitly target mothers’ well- being is Lieberman’s Infant Parent Psychotherapy (IPP), designed with the recognition that a critical prerequisite in working with mothers at high risk for maltreating their infants is attention to the women’s own psychological needs. The program has been expanded for work with mothers and toddlers (TPP), and therapeutic strategies combine cognitive behavioral, psychodynamic, and social learning theories. A cardinal ingredient, however, is high empathy and support for the mother, with recognition that “…the most effective interventions are not spoken but rather enacted through the therapist’s empathic attitude and behavior toward the mother as well as the baby (Lieberman and Zeanah, 1999, p. 556). A number of studies have now documented the benefits of IPP and TPP, implemented with mothers across diverse settings (see Lieberman et al., 2011). 6 The study authors calculated cost of the program per family by dividing total program costs by the average monthly number of families served by the agency and then calculated weighted mean cost per family served as the sum of costs across all agencies divided by the sum of families served. 7 The cost analysis was conducted using “the ‘ingredient’ or resource cost method, which involved itemizing the types of resources (or ingredients) needed to provide services, gathering information on the types and value of resources used by each agency during the study period, and aggregating costs to estimate total program costs” (Burwick et al., 2014, p. xii). PREPUBLICATION COPY: UNCORRECTED PROOFS

FOSTERING CAREGIVER WELL-BEING 4-35 Another program with a strong emphasis on respect, warmth, and support by intervention staff to participating mothers is Dozier’s ABC. In this program, goals are to target insecure early attachments by intervention services to foster caregivers’ positive qualities, including responsiveness, nurturance, and their own attachment states of mind (Dozier et al., 2002). The program has been refined and tested in RCTs across more than 20 years. Results show that those receiving the intervention showed significant gains compared to control groups, which included better quality of attachment between mothers and children and improved self-regulation in both (Bernard et al., 2015; Bick and Dozier, 2013; Dozier et al., 2002). See Box 4-8 for more on the ABC program as an example of a promising model. BOX 4-8 Attachment and Biobehavioral Catch-up (ABC) Program: Promising Modela Developed in 1994, the ABC Intervention is an internationally available training program for caregivers of infants and toddlers through early adolescence, including high-risk birth parents and caregivers of young children in foster care, kinship care, and adoptive care. Parent coaches conduct 10 weekly home visits, approximately 60 minutes each. The model is designed to help caregivers provide nurturance even when children do not appear to need it, mutually responsive interactions in which caregivers follow children’s lead, and nonfrightening care. Parent coaches provide immediate feedback on the caregivers’ interaction with the child to help the caregivers attend to the target behaviors. The model also incorporates homework and video feedback. While the original version included children from 6–48 months old, the model has been updated to include two different versions: 1) infants (6–24 months) and 2) toddlers (24–48 months). The model is based on attachment theory and stress neurobiology, and it addresses the social and physical environments by helping caregivers sensitively respond to children’s behavioral signals, enhancing children’s behavioral and regulatory capacities, and fostering the development of secure attachments between children and their caregivers. The model was developed by academic researchers and continues to be evaluated by them, though it has expanded significantly since its origin. ABC has partnered with state agencies, community-based nonprofits, or religiously affiliated funds. NIH also funds many of their research projects. Infant ABC coaches are trained intensively and supervised for 1 year, while toddler ABC coaches have to receive additional training afterward. The project originated at the University of Delaware, and certified ABC parent coaches are currently available across the United States in communities in Delaware, Hawaii, Idaho, Kansas, Kentucky, Louisiana, Maryland, Michigan, Minnesota, New York, North Carolina, North Dakota, Ohio, Oklahoma, and Pennsylvania. Internationally, ABC coaches are available in Australia, Germany, Norway, Russia, South Africa, and Sweden. The program was designed to address inequities in social environments that affect children exposed to trauma in early childhood. Positive interactive experiences can stimulate healthy development of the central nervous system, foster a positive sense of self, and help maltreated children learn to accurately interpret and respond to emotional, environmental, and social cues. Four independent RCTs support the efficacy of ABC and suggest that it is effective in improving attachment and helping regulate both biology and behavior in at-risk children (see, for example, Bernard et al., 2015; Lind et al., 2014). In addition to findings from these RCTs, researchers have also found evidence to support ABC’s efficacy through dissemination studies with pre- and postintervention assessments. a The committee used selection criteria to identify examples of promising models highlighted in this report (see Appendix A for a list of the criteria). These examples all apply developmental science and aim to advance health equity during the preconception through early childhood periods. SOURCES: ACF, 2018; Attachment Biobehavioral Catch-up, 2017 Yet another program with focused attention to the well-being of mothers is the Relational Psychotherapy Mothers Group intervention (RPMG) (Luthar and Suchman, 2000), developed for mothers at risk for maltreating their children—specifically, low-income women with histories of PREPUBLICATION COPY: UNCORRECTED PROOFS

4-36 VIBRANT AND HEALTHY KIDS substance abuse. As with IPP and ABC, core therapeutic components in RPMG include a strong emphasis on empathy, genuineness, and warmth and using insight-oriented approaches to improve parenting skills and efficacy. There were two major differences between RPMG and programs for mother–child dyads, both related to potential for scaling up. The first was the choice of a group format rather than individual sessions, thus potentially reaching more women for an hour of clinicians’ time. Second, RPMG was designed for mothers of children from birth through adolescence, with developmental issues addressed as part of the program, again allowing for inclusion of a wide range of women. Results of two clinical trials showed benefits of RPMG. Compared to treatment as usual in their methadone clinics, mothers who received the 24-week intervention showed lower risk for child maltreatment —by mothers’ and children’s reports— and better personal adjustment as well as both mothers’ and children’s reports of child maladjustment and on mothers’ drug use via urinalyses (Luthar and Suchman, 2000). At 6 months posttreatment, RPMG recipients continued to be at an advantage, although the magnitude of group differences was reduced. In the second trial, RPMG was compared to relapse prevention therapy (RPT). RPMG mothers again fared better than RPT mothers at posttreatment per mothers’ self-reports, children’s reports, and urinalyses (Luthar et al., 2007). But again, at 6 months of follow-up, they lost many of their gains. These findings collectively indicate that even after external interventions are completed, it is critical to ensure continuity in supports for mothers who are vulnerable to depression and other mental illness. Similar messages have emerged from Olds et al.’s (2007) widely used, efficacious program, the NFP, which provides regular home visits for low-income, single mothers by a warm, supportive nurse. These home visits begin in the prenatal months and continue through the babies’ second birthdays. Yet, as Golden and colleagues (2011) underscore, mothers’ needs for help are not necessarily resolved when children reach 2 years old. In fact, mothers who have received this program report widespread, continuing depression in their communities, with many women desiring and needing support from others who can be reliable sources of caring over time. In view of this accumulated work, therefore, one critical challenge for those working with vulnerable mothers is to ascertain how these mothers might continue to receive support even when time-limited supportive interventions cease, and in this regard, peer-based interventions are promising. Specifically, there is potential value in groups run by “graduates” of supportive programs who receive subsequent training and supervision in facilitating groups for peers (see Bryan and Arkowitz, 2015). Reportedly, this strategy has been used successfully with mothers who themselves had experienced perinatal depression, who regularly met with other women who were currently depressed. Bryan and Arkowitz (2015) conducted a meta-analytic review and found that peer-administered interventions (PAIs) produced substantial reductions in symptoms of depression. The magnitude of beneficial changes over time was significantly greater than those in no treatment conditions and was also comparable to non-peer-administered interventions. Interestingly, PAIs that were administered purely by peers were more effective than those that also involved a professional in the treatment, in a secondary role. In future efforts to use such peer-based groups for mothers, some have suggested drawing upon a type of model (not the intervention itself) that has been used extensively for decades and with minimal costs: the 12-step model (see Luthar et al., 2015). Community-based meetings in this program, specifically Alcoholics Anonymous, benefit more than 1.3 million Americans, and its benefits can be equal to or even greater than those of professional interventions (Kelly et al., 2012). A major “active ingredient” in this program, again, is ongoing access to dependable, PREPUBLICATION COPY: UNCORRECTED PROOFS

FOSTERING CAREGIVER WELL-BEING 4-37 authentic supports; members speak of unconditional acceptance with others sharing similar challenges and their ability to reach out to others when in distress. In the future, there could be value in using such community-based groups to promote resilience in at-risk mothers. Sustaining the type of supportive connections that mothers came to depend upon in the active phase of relational interventions might be possible with continued weekly meetings (Luthar, 2015). This has been a recurrent theme in prevention and policy: scientists increasingly urge the use of networks that already exist in communities, bringing them to bear in interventions that become self-sustaining over time (Luthar, 2015). To illustrate, within affordable housing complexes, Antonucci and colleagues (2014) described programs focused on creating mutually supportive networks among residents. Kazdin and Rabbitt (2013) described several low-cost, feasible, and effective interventions using lay people (rather than professional therapists), including hair stylists in beauty salons, trained to assess depression and to provide appropriate referrals. Hoffman and Hayes (2019) underscored the potential value of training paraprofessionals in the specific procedures that highly trained clinicians have identified as being most promising in engendering improved mental health. An alternative approach is to deliberately foster women’s connections with reliable others in their everyday lives over the duration of a formal, relational intervention. This was the strategy used in an RCT of the Authentic Connections Groups (AC Groups) program at the Mayo Clinic, tested with mothers who were health providers—a professional group at high risk for depression, burnout, and even suicide, compared to norms. From the start of the 3-month program through the end, there was a focused, concerted effort to have women reach out to their “go-to committees” in their personal lives; thus, authentic connections were forged both within the groups and outside of them, in the mothers’ everyday lives. In comparison with a control group (given 1 hour of freed time over 3 months to attend groups, as were intervention mothers), AC Groups women showed significantly greater gains across multiple adjustment indexes ranging from depression and self-compassion to lowered burnout at work and decreased levels of cortisol (Luthar et al., 2017). Moreover, effect sizes across outcomes were generally in the moderate range, and gains were still stronger 3 months after the intervention program was over (partial eta squares of 0.08–0.19; median, 0.16; according to Cohen (1988), partial eta squares correspond to the following effect sizes in the real world: .02 is small; .13 is medium; and .26 is large). The success of these in-person AC Groups led to efforts to conduct them in a virtual format, via videoconferencing, to achieve potentially wider and easier dissemination (Luthar et al., in press). Results of this study indicated the successful completion of five different virtual groups (n 3–6 women each, for a total of 23), with the sample involving mostly mothers, most with advanced (graduate) degrees and almost all in high-pressure careers. As with the in-person version, the 3-month program had zero dropouts. Participants’ mean ratings of the groups’ effectiveness were 9.6 of 10, and the “Net Promoter Score” (percent of promoters subtracting percent of detractors) fell in the exceptionally high range (Luthar et al., in press). Open-ended responses emphasized participants’ appreciation of access to robust, authentic connections with other caring women (which endured well after the program was completed). Given the low cost and ease of access—from mothers’ own workplaces, homes, or even while traveling—such virtual groups might be considered a useful model to be explored further in future work with mothers (indeed, the use of virtual connections have been increasingly emphasized; see Hofman and Hayes, 2019; Weisz et al., 2019). In concluding this section on interventions, the literature reviewed suggests the value of a PREPUBLICATION COPY: UNCORRECTED PROOFS

4-38 VIBRANT AND HEALTHY KIDS tiered approach to psychological interventions for mothers at risk due to their life adversities, along with their children, and as early as possible—preferably prenatally. All approaches involve ensuring strong, dependable supports for the mother or other primary caregiver. At the broadest level of interventions, there is particular promise in those that bring together mothers in communities or virtually to provide such mutual, ongoing support. For women needing greater psychological help, time-limited, evidence-based group therapies, emphasizing connections and mutual support and making maximal use of existing resources, would be useful. The most intensive level would be one-one one interventions, such as those involving home visiting or work with mother–child dyads to enhance strong attachment quality. Given the critical need to support caregiver well-being and to prevent child maltreatment (see Conclusions 4-1 and 4-2), in addition to the review of high-quality interventions that are offered in community settings for families, the committee offers the following recommendation to support the development and implementation of such interventions. Recommendation 4-4: Policy makers at the federal, state, local, territorial, and tribal levels and philanthropic organizations should support the creation and implementation of programs that ensure families have access to high-quality, cost-effective, local community-based programs that support the psychosocial well-being of the primary adult caregivers and contribute to building resilience and reducing family stress. Measures to be Used In concluding this section, there is consideration of measures that should be included in evaluating results of large-scale preventive interventions targeting young children and their mothers. At a minimum, there should be brief assessments of the mothers’ depressive symptoms, stress, feelings of rejection to the child, any involvement with CPS, and intimate partner violence (IPV), as well as the degree to which they have positive, buffering relationships in their lives. Possible measures include the 20-item Zung Self-Rating Depression Scale (Zung, 1965), 10-item Perceived Stress Scale-10 (Cohen et al., 1983), and 10-item subscale on parental undifferentiated rejection from the Parental Acceptance-Rejection Questionnaire (PARQ; Rohner et al., 1980). For supportive relationships, potential measures might include the Satisfaction with Friends subscale (four items from the Inventory of Parent Experiences; Crnic, 1983) and two single items that have consistently shown significant, robust links with multiple aspects of mothers’ well- being: “Do you feel seen and loved for the person you are, at your inner core?” and “When you are deeply distressed, do you feel comforted in the ways you need?” (Ciciolla and Luthar, 2019; Luthar and Ciciolla, 2015). Finally, if any studies propose additional expensive assessments to inform future interventions (such as, biomarkers as mediators, moderators, or outcomes), researchers need to explain how the findings from these will be applied not only in laboratory- based RCTs but also in large-scale interventions reaching vulnerable children and families in their own home, school, and community settings. Given the need to identify individuals at risk for early adversity and toxic stress, the committee offers the following recommendation to close a gap in the system. Furthermore, screening requires alignment with available services for children and families (see Chapters 5 and 8 for more on screening and alignment with services). Recommendation 4-5: Health care providers who care for pregnant women and children should routinely track levels of individual health and social risk among PREPUBLICATION COPY: UNCORRECTED PROOFS

FOSTERING CAREGIVER WELL-BEING 4-39 mothers and children over time, using periodic assessments via a short set of scientifically validated measures. SYNTHESIZING THE EVIDENCE To summarize, major conclusions deriving from this chapter include the following. Promoting resilience in childhood rests, first, on ensuring the well-being of children’s primary caregivers—usually, their mothers—and this requires the mothers’ ongoing access to strong, supportive relationships, beyond meeting basic needs for survival. Maltreatment is of utmost importance among the various parenting behaviors that should be targeted in preventive interventions; minimizing neglect and abuse by caregivers and others needs to be a top priority. Gender specificity is advised in interventions for parents, with separate delineation of how mothers and fathers each are most effectively recruited, retained, and helped in interventions. When considering children who need preventive interventions, there are several subgroups whose unique challenges need to be considered. These include subgroups that have been extensively documented in past research to be at risk—such as children in chronic poverty, those separated from their parents, and recent immigrants—and those shown more recently as contending with high stress and distress, such as children and families in high-achieving communities and youth who are in the minority based on gender identification and sexual orientation. As future interventions for mothers and children are taken to large scale, it will be useful to employ a tiered approach, with the intensiveness of services increasing with the level of the mother’s distress. At a fundamental level, universal, supportive interventions for mothers from pregnancy onward are needed. This includes using existing resources for supportive group-based interventions (e.g., organized in their own communities, such as in preschools or schools) that are, where possible, led by peers and/or accessed virtually. Universal interventions also need to include at least one home visit after birth, to ascertain if mother and child have the supports they need, and, if difficulties are found, to provide connections to local resources for the family. Conclusion 4-5: A tiered approach is needed for families known to be at risk due to their life adversities, with appropriate investment of resources to expand delivery of promising cost-effective programs and assessments via scientifically sound measures of critical constructs. This includes the need for: • Universal, supportive interventions for mothers and • More resource-intensive programs. To promote these first-level, universal programs, federal, state, and local agencies overseeing program implementation could develop and monitor community-based support groups for mothers within existing programs, such as the Maternal, Infant, and Early Childhood Home Visitation program, Head Start, Early Head Start, and Women, Infants, and Children (WIC). Care providers within these programs require appropriate referral sources for mothers and children who need intensive, one-on-one care (e.g., through home visiting). Enhanced coverage by major insurance providers for programs offering group-based care, support, and therapeutic interventions for mothers is also necessary (see Chapter 5 for more in health care needs for this population). To identify mothers who might need more intensive services, a brief battery of questionnaires should be used as a screening tool. Specifically, measures of maternal stress and PREPUBLICATION COPY: UNCORRECTED PROOFS

4-40 VIBRANT AND HEALTHY KIDS depression (described in this chapter) should be routinely administered at prenatal and pediatric “well-baby” visits. Those mothers who manifest high distress will need referral to programs that offer evidence-based therapeutic interventions. Intensive programs for mothers in distress can be group or individual. Programs that are short term and involve groups of women, such as AC Groups or the Mental health Outreach for Mothers (MOMS) Partnership, can help to maximize both reach and cost-effectiveness. (See Box 4-8 for information on the MOMS Partnership as a promising model.) Where necessary, mothers in serious distress need to be referred to more resource intensive, one-on-one programs, such as ABC and Infant/Toddler-Parent Psychotherapy. Home visiting, with concurrent referrals to available supports as needed—formal and informal—should exist within the community. Ideally, all types of intensive services would be coordinated with the pediatricians’ offices, in a team- based approach to providing care (see more on team-based approaches in the health care setting in Chapter 5). BOX 4-8 MOMS Partnership: Promising Modela Based in New Haven, Connecticut, the MOMS Partnership is an evidence-based, community- driven initiative that offers mental health and trauma-related services and parenting and job readiness programs to single mothers in at-risk neighborhoods (Center on the Developing Child, 2019). The program recruits participants by “meeting” mothers at locations they frequent (i.e., grocery stores, laundromats, shelters, community colleges, libraries, and nail and hair salons) (White et al., 2018).The program’s mission is “to reduce depressive symptoms and increase social and economic mobility among overburdened, under-resourced mothers, thereby strengthening generations of families to flourish and succeed” (MOMS Partnership, n.d.-c). Beginning in 2010 and in partnership with mothers and community partners, the program has conducted surveys to identify and understand the needs of pregnant women, parents, other caregivers, and families in the community (Smith, 2018). Findings from more than 4,000 interviews have directly informed the design of the program. The program delivers a “bundle” of local services, including those to build skills (e.g., for stress management and work success), community mental health ambassadors, referral to local services and resources, and social networks and support (Smith, 2018). The program has demonstrated promising initial outcomes, including findings from a 2012– 2016 RCT in New Haven public housing and multigenerational outcomes from two quasi-experimental studies (Smith, 2018).Evaluation of the program has shown that at completion, 76 percent of participants have fewer depressive symptoms and participants experience a 67 percent decrease in parenting stress (MOMS Partnership, n.d.-a). Beginning in 2019, the MOMS Partnership will replicate its program in Washington, DC, through a partnership with the DC Department of Human Services and via DC’s TANF program (Clayton et al., 2018; MOMS Partnership, n.d.-b).The MOMS Partnership has also collaborated with Vermont Reach Up, that state’s TANF program, to replicate the program in Vermont by 2020. a The committee used selection criteria to identify examples of promising models highlighted in this report (see Appendix A for a list of the criteria). These examples all apply developmental science and aim to advance health equity during the preconception through early childhood periods. It will be critical to allocate resources to monitoring the quality of interventions delivered. All intervention programs need to be culturally sensitive, be adapted to community needs, have clear procedures for the selection and training of clinicians, and have mechanisms in place to ensure fidelity and quality of services. Support is needed for programs across tier levels of delivery, universal and intensive. Furthermore, taking an ecological perspective on promoting caregiver well-being and attachment would require supportive policies that facilitate healthy PREPUBLICATION COPY: UNCORRECTED PROOFS

FOSTERING CAREGIVER WELL-BEING 4-41 social connections and family cohesion during these critical years of early life. For example, paid parental leave following the birth of a child is one policy that has evidence for shaping child and family outcomes (AEI-Brookings Working Group on Paid Family Leave, 2017). (See Chapter 6 for a full discussion and Recommendation 6-1 on implementing paid leave.) Finally, in evaluating the effectiveness of programs for at-risk mothers and their children, measures need to focus on those maternal dimensions that are known to strongly affect the mother–child relationship and hence child well-being. This would include measures of maternal depression and stress, feelings of rejection or hostility to the child, available support for mothers, and any contact with CPS. These assessments should be a routine part of prenatal, postnatal, and pediatric visits, along with other physical health indexes that are assessed and recorded. Careful, balanced consideration of all these aspects of intervention design, delivery, and measurement— with all the investment of resources called for by each aspect—is critical to move toward meaningfully increasing equity in well-being, considering America’s most vulnerable children and families. REFERENCES ACF (Office of Family Assistance). 2018. Implementing Attachment and Biobehavioral Catch-up intervention. https://homvee.acf.hhs.gov/Implementation/3/Attachment-and-Biobehavioral-Catch- Up--ABC--Intervention-Model-Overview/51 (accessed January 11, 2019). Acker, J., P. Braveman, E. Arkin, L. Leviton, J. Parsons, and G. Hobor. 2019. Mass incarceration threatens health equity in America. Princeton, NJ: Robert Wood Johnson Foundation. Adams, T. R., E. D. Handley, J. T. Manly, D. Cicchetti, and S. L. Toth. 2019. Intimate partner violence as a mechanism underlying the intergenerational transmission of maltreatment among economically disadvantaged mothers and their adolescent daughters. Development & Psychopathology 31(1):83–93. AEI-Brookings Working Group on Paid Family Leave. 2017. Paid family and medical leave: An issue whose time has come. Washington, DC: The Brookings Institution. Ammerman, R. T., F. W. Putnam, J. Stevens, L. J. Holleb, A. L. Novak, and J. B. Van Ginkel. 2005. In- home cognitive behavior therapy for depression: An adapted treatment for first time mothers in home visitation. Best Practices in Mental Health 1:1–14. Antonucci, T. C., K. J. Ajrouch, and K. S. Birditt. 2014. The convoy model: Explaining social relations from a multidisciplinary perspective. Gerontologist 54(1):82–92. Assari, S., and C. H. Caldwell. 2018. High risk of depression in high-income African American boys. Journal of Racial and Ethnic Health Disparities 5(4):808–819. Assari, S., F. X. Gibbons, and R. L. Simons. 2018a. Perceived discrimination among black youth: An 18- year longitudinal study. Behavioral Sciences 8(5). Assari, S., B. Preiser, M. M. Lankarani, and C. H. Caldwell. 2018b. Subjective socioeconomic status moderates the association between discrimination and depression in African American youth. Brain Sciences 8(4). ASU Reach Institute. 2018. Family check-up for providers. https://reachinstitute.asu.edu/family-check- up/agencies (accessed May 2, 2019). Attachment Biobehavioral Catch-Up. 2017. The Attachment Biobehavioral Catch-up (ABC) program. http://www.abcintervention.org/about/ (accessed January 11, 2019). Avellar, S. A., and L. H. Supplee. 2013. Effectiveness of home visiting in improving child health and reducing child maltreatment. Pediatrics 132:S90–S99. Avellar, S., R. Covington, Q. Moore, A. Patnaik, and A. Wu. 2019. Effects of four responsible fatherhood programs for low income fathers: Evidence from the parents and children together evaluation. PREPUBLICATION COPY: UNCORRECTED PROOFS

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Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity Get This Book
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Children are the foundation of the United States, and supporting them is a key component of building a successful future. However, millions of children face health inequities that compromise their development, well-being, and long-term outcomes, despite substantial scientific evidence about how those adversities contribute to poor health. Advancements in neurobiological and socio-behavioral science show that critical biological systems develop in the prenatal through early childhood periods, and neurobiological development is extremely responsive to environmental influences during these stages. Consequently, social, economic, cultural, and environmental factors significantly affect a child’s health ecosystem and ability to thrive throughout adulthood.

Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity builds upon and updates research from Communities in Action: Pathways to Health Equity (2017) and From Neurons to Neighborhoods: The Science of Early Childhood Development (2000). This report provides a brief overview of stressors that affect childhood development and health, a framework for applying current brain and development science to the real world, a roadmap for implementing tailored interventions, and recommendations about improving systems to better align with our understanding of the significant impact of health equity.

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