Examining Impacts of Healthy Families America on Infant Health Care.

OBJECTIVE: Healthy Families America (HFA) is an evidence-based home visiting program that provides parenting education with the overall goal of preventing child maltreatment and optimizing child development. This study compares the health care utilization and vaccination of infants enrolled in HFA with similar infants not in the program. METHODS: From January 2014 to December 2020, 604 children served statewide by HFA in Arkansas were identified in vital statistics and administrative medical claims records. Using propensity score matching, infants in HFA were matched with nonprogram control infants based on family demographics and birth characteristics. Double propensity-score adjustment method and generalized linear models were used to estimate program effects. RESULTS: In the first year after birth hospital discharge and compared to a propensity score matched cohort of infants not enrolled, those enrolled in HFA had significantly greater use of the emergency department overall (incidence rate ratios (IRR) = 1.24 [95% confidence interval (CI) = 1.07-1.43], P = .004) and for less complex conditions (IRR = 1.22 [95% CI = 1.04-1.44], P = .01), more outpatient medical appointments for child wellness (IRR = 1.09 [95% CI = 1.03-1.15], P = .003), illness (IRR = 1.17 [95% CI = 1.07-1.29], P = .001), and speech and language therapies (IRR = 2.86 [95% CI = 1.18-6.93], P = .02), and more medical visits during which vaccinations were provided (IRR = 1.09 [95% CI = 1.04-1.15], P = .002). CONCLUSIONS: Findings from the current study suggest that HFA supports increased health care utilization and visits in which vaccinations occurred during the first year of life.

Risks of adverse childhood experiences on healthcare utilization and outcomes in early childhood.

BACKGROUND: The American Academy of Pediatrics recommends all pediatricians to be ready to implement trauma-informed care, including the mitigation of impacts of Adverse Childhood Experiences (ACEs) through screening and identification of at-risk population. Reliable survey tools and knowledge of the consequences of ACEs are needed. OBJECTIVE: This study examines the healthcare utilization and diagnoses captured in insurance claims in association with the number of ACEs recorded by the Family Map Inventories (FMI). The FMI offers a comprehensive family assessment, which includes child ACEs (FMI-ACEs) using prospective, proxy risk indicators. PARTICIPANTS AND SETTING: Low-income families (N = 1647) with children aged three to five years who completed the FMI were linked to their insurance records. METHODS: Multivariable logistic and generalized linear regression models were fitted to explore the association between the number of ACEs (FMI-ACEs scores) and healthcare utilization and health outcomes. RESULTS: Children were exposed at rates of 32.4 % to zero, 31.7 % to one, 19.7 % to two, and 16.3 % to three or more ACEs. The FMI-ACEs scores were associated with greater use of non-preventive outpatient visits, filled prescriptions, and overall use of healthcare. Incidences of adjustment disorders were 4 times and attention-deficit conducts were 2 times higher among children with the highest FMI-ACEs scores than those with zero FMI-ACEs. CONCLUSIONS: This study marks the first effort to conduct insurance claims data review to ascertain association between a survey measure of ACEs and health utilization and diagnosed conditions. The association of ACEs risk screening and healthcare utilization and diagnoses was observed.

Cost-benefit analysis of home visiting to reduce infant mortality among preterm infants.

PURPOSE: The Following Baby Back Home (FBBH) visiting program, which is provided by nurse and social worker teams, supports families of low-birthweight preterm infants after discharge from a neonatal intensive care unit. Enrollment in the FBBH program has been documented to reduce the likelihood of infant death. In this study, we conducted a cost-benefit analysis of the FBBH program. DESIGN AND METHODS: Infants enrolled in the FBBH program (N = 416) were identified through administrative records. Infants in the FBBH program were propensity score matched with comparison infants to estimate the difference in healthcare costs in the first year of life. RESULTS: Infants enrolled in the FBBH program incurred similar medical care costs compared to a comparison group. Avoided deaths, program costs, healthcare costs resulted in net economic benefits of the FBBH program to avoid infant death estimate at $83,020, cost per life saved at $3080, and benefit-to-cost ratio at 27.95. CONCLUSIONS: The FBBH program's net economic benefits from avoided deaths suggest a substantial return on investment of resources, yielding benefits in excess of program and healthcare costs. PRACTICE IMPLICATIONS: It is economically beneficial to provide home visiting services to families of low-birthweight babies by a team comprised of a registered nurse and social worker.

Effects of COVID-19 on home visiting services for vulnerable families: A cross-state analysis of enrollment, engagement, and attrition patterns.

INTRODUCTION: COVID-19 has resulted in massive health and economic consequences, with effects felt most acutely by populations that were disadvantaged prior to the pandemic. For families with young children, the effects have been compounded by service interruptions, though there is a lack of empirical evidence that demonstrates how COVID-19 has affected home visiting programs. This cross-state study is the first to examine the effects of the pandemic on home visiting enrollment, engagement, and retention patterns. METHOD: Program implementation records gathered from 2017-2020 in Arkansas and Wisconsin were analyzed. Both states operate a large network of home visiting programs that serve predominantly low-income families and that are supported by the federal Maternal, Infant, and Early Childhood Home Visiting program. Trends prior to COVID were compared to post-COVID trends (March 12 to December 31, 2020) in program enrollments, service capacity, visitation frequency, service modalities, attrition rates, and service duration. RESULTS: Compared to average pre-pandemic enrollments from 2017-2019, post-COVID enrollments decreased by 33-36%. Total visits fell by 15-24%; the percentage of completed visits relative to expected visits declined more modestly. However, the average duration of services increased post-COVID while rates of early program dropout decreased. DISCUSSION: The findings suggest that enrollment and engagement in home visiting decreased during the COVID-19 pandemic, which is unfortunate given the large number of vulnerable families served nationwide. Further research is needed to examine how COVID affected both consumer and program behaviors. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Sleep as a Moderator of Young Children's Traumatic Stress and Behavior Problems: a Treatment-Referred Sample.

Empirical evidence suggests young children who have experienced trauma are at risk of developing sleep problems and behavior difficulties, but it is unclear of the specific relation between these behavioral health concerns. The primary purpose of the study is to determine whether sleep problems moderate the relation between traumatic stress and behavior problems in a sample of young children referred for treatment. A secondary purpose is to explore if sleep problems also moderate the relation between specific domains of traumatic stress (i.e., intrusion, avoidance, arousal) and behavior problems. Data from 170 preschoolers ages 3 through 5 referred for treatment were gathered at intake and utilized in this study. Results indicate sleep problems moderate the effect of overall traumatic stress on behavior problems. This statistical finding also was found with intrusive symptoms, and the moderation analyses approached significance with avoidance and arousal. Our findings highlight the importance for clinicians to assess for sleep problems when young children who have experienced trauma are referred to them for treatment, particularly if a low level of overall traumatic stress is present.

Home Visiting for NICU Graduates: Impacts of Following Baby Back Home.

BACKGROUND AND OBJECTIVES: The Following Baby Back Home (FBBH) home visiting program supports families of high-risk low birth weight preterm infants after discharge from a hospital NICU. This study compares the health care use, immunization, and infant mortality rate of low birth weight preterm infants enrolled in FBBH with similar infants not in the program. METHODS: From January 2013 to December 2017, 498 children enrolled in FBBH were identified in Arkansas vital statistics records and the Arkansas All-Payer Claims Database. Infants in FBBH were matched with children in a control group on the basis of demographics and medical conditions of the infant. Generalized linear mixed models with double propensity-score adjustment were used to estimate program effects. RESULTS: In the first year after discharge and compared with a propensity-score matched cohort of control infants, those enrolled in FBBH were significantly more likely to have higher numbers of medical appointments and more compliant immunization history. The odds of dying in the first year of life for control infants was 4.4 times (95% confidence interval: 1.2-20.7) higher than those managed in the program. CONCLUSIONS: A goal of the FBBH home visiting program is to work with parents to educate and support them as they care for their medically fragile infants. We conclude that education and support was instrumental in the infant health care use and outcome differences we observed during the first year of life.

Family functioning and involvement in home visiting: Examining program characteristics as moderators to support retention in services.

Developing strategies to improve retention in home visiting programs is critical to their success. The purpose of the study is to examine how the content provided during home visits moderates the association between family risks (economic, household functioning, and conflict) and retention in services. Parents (n = 1,322) voluntarily enrolled in Healthy Families America (n = 618) and Parents as Teachers (n = 704). Family characteristics were collected using the Family Map Inventories. Multilevel analyses showed a moderating impact of the time home visitors spent supporting parent-child interaction for all family risks examined. Moderating effects demonstrated a stronger positive association between focusing on the parent-child relationship and retention at 6 and 12 months for parents demonstrating greater needs. There were no moderating effects of child development content or case management activities with retention at 6 and 12 months. Together, families were more likely to stay in services when home visitors focused on parent-child interaction and child development, but less likely retained with more case management. Parents with greater risks were more likely to remain in services with more time focused on supporting parent-child interactions. Findings suggest the need to support our home visiting workforce in their work to promote healthy parent-child relationships.

Training Residents in Maternal Depression Care to Improve Child Health: A CERA Study.

BACKGROUND AND OBJECTIVES: Untreated maternal depression negatively impacts both the mother and her children's health and development. We sought to assess family medicine program directors' (PDs) knowledge and attitudes regarding maternal depression management as well as resident training and clinical experience with this disorder. METHODS: Data were gathered through the Council of Academic Family Medicine's (CAFM) Educational Research Alliance (CERA) national survey of family medicine PDs in US and Canadian programs, from January through February, 2018. RESULTS: Surveys were completed by 298 PDs (57.1% response rate) who were majority male (58.9%) and white (83.8%). Nearly all (90.2%) PDs agreed that family physicians should lead efforts to minimize the impact of maternal depression on child well-being. According to PD report, in the family medicine clinics where residents train, most (77.3%) have a clinic process that ensures that routine screening for depression occurs, and 54.4% do some screening of mothers during pediatric visits. Only 18.2% report routinely taking steps to minimize the impact of the mothers' depression on child well-being. Finally, 41.3% of PDs reported being familiar with the literature on the impact of maternal depression on children; self-reported familiarity was significantly associated with more comprehensive resident training on this topic. CONCLUSIONS: Family medicine residency program directors are supportive of training in maternal depression, though their current knowledge is variable and there are opportunities to enhance care of mothers and children impacted by this common and serious disorder.

Adverse Childhood Experiences of Urban and Rural Preschool Children in Poverty.

Adverse childhood experiences (ACEs) have long-term health consequences. Young children in the southern part of the United States (US) are at greater risk than children in other parts of the US. This study assessed preschool children ACEs using a family-friendly tool, the Family Map (FMI), and compared children living in rural/urban areas while examining the potential moderation of race. The FMI-ACE score was examined as a total and two sub-scores. We found that race did not moderate the FMI-ACE score but that Black children (Cohen's d = 0.52) and children in urban and large rural areas were at highest risk (Cohen's d = 0.38). However, the subscale FMI-ACEs parenting risk was moderated by race such as that Black children were less at risk in rural areas than urban (Cohen's d = 0.62). For FMI-ACEs environmental risk, race moderated risk such that Black children were most at risk in large rural areas but less so in small rural areas (Cohen's d = 0.21). Hispanic children were most at risk in small rural areas and least in large rural environments. Findings from this study suggest that targeting the most at-risk children for interventions should consider the context including race and location.

Adverse Childhood Experiences in Infancy and Toddlerhood Predict Obesity and Health Outcomes in Middle Childhood.

BACKGROUND: The Adverse Childhood Experiences (ACEs) study articulated the negative effects of childhood trauma on adult weight and health. The purpose of the current study is to examine the associations between ACEs in infancy and toddlerhood and obesity and related health indicators in middle childhood. METHODS: We used data collected from a sample of low-income families enrolled in the national evaluation of Early Head Start (EHS). Data come from 1335 demographically diverse families collected at or near children's ages 1, 2, 3, and 11. An EHS-ACE index was created based on interview and observation items from data collected at ages 1, 2, and 3, which were averaged to represent exposure across infancy and toddlerhood. At age 11, children's height and weight were measured and parents were asked about their child's health. RESULTS: Children were exposed at rates of 30%, 28%, 15%, and 8% to one, two, three, and four or more EHS-ACEs, respectively. Logistic regressions revealed significant associations between EHS-ACEs in infancy/toddlerhood and obesity, respiratory problems, taking regular nonattention-related prescriptions, and the parent's global rating of children's health at age 11. Across all outcomes examined, children with four or more ACEs had the poorest health. Compared with children with no ACE exposure, the odds of each of the examined health outcomes were over twice as high for children who experienced four or more ACEs. CONCLUSIONS: Findings highlight that ACEs experienced very early in development are associated with children whose health is at risk later in childhood.

Correction to: Keeping Our Eyes on the Prize: Focusing on Parenting Supports Depressed Parents' Involvement in Home Visiting Services.

The article "Keeping Our Eyes on the Prize: Focusing on Parenting Supports Depressed Parents' Involvement in Home Visiting Services", written by Lorraine M. McKelvey, Shalese Fitzgerald, Nicola A. Conners Edge and Leanne Whiteside­Mansell, was originally published electronically on the publisher's internet portal (currently SpringerLink) on 28 May 2018 without open access.

Adverse experiences in infancy and toddlerhood: Relations to adaptive behavior and academic status in middle childhood.

Findings from the Adverse Childhood Experiences (ACE) study articulated the negative effects of childhood trauma on long-term well-being. The purpose of the current study is to examine the associations between ACEs experienced in infancy and toddlerhood and adaptive behavior and academic status in middle childhood. We used data collected from a sample of low-income families during the impacts study of Early Head Start (EHS). Data were collected by trained interviewers demonstrating at least 85% reliability with protocols. Data come from 1469 socio-demographically diverse mothers and children collected at or near ages 1, 2, 3, and 11. At ages 1, 2, and 3, an EHS-ACEs index was created based on interview and observation items. The EHS-ACEs indices were averaged to represent exposure across infancy and toddlerhood. At age 11, parents were asked about school outcomes and completed the Child Behavior Checklist. Across development, children were exposed to zero (19%), one (31%), two (27%), and three or more ACEs (23%). Logistic regression analyses, controlling for EHS program assignment, and parent, school, and child characteristics, showed ACEs were significantly associated with parental report of the child: having an individualized educational program since starting school and in the current school year, having been retained a grade in school, and problems with externalizing and internalizing behavior, as well as attention. Findings suggest that ACEs influence children's behavioral and academic outcomes early in development.

Keeping Our Eyes on the Prize: Focusing on Parenting Supports Depressed Parents' Involvement in Home Visiting Services.

Objectives Improving family retention and engagement is crucial to the success of home visiting programs. Little is known about retaining and engaging depressed parents in services. The purpose of the study is to examine how home visit content moderates the association between depression and retention and engagement. Methods The sample (N = 1322) was served by Healthy Families America (n = 618) and Parents as Teachers (n = 704) between April 1, 2012 and June 30, 2016. Parents averaged 23 years (SD = 6). Nearly half of the parents were White (48%) and the majority was single (71%). Depression was screened with the Patient Health Questionnaire-2. Home visitors reported the percent of time focused on particular content and parent engagement at every home visit. Results Multilevel regression analyses showed the amount of time that home visitors spent supporting parent-child interaction moderated the association between depression and retention at 6 (B = .08, SE = .03, p = .003) and 12 (B = .1, SE = .03, p < .001) months, such that there was a stronger positive association for depressed parents. The main effects of child development focused content and retention at 6 (B = .07, SE = .01, p < .001) and 12 (B = .08, SE = .01, p < .001) months were positive, while effects of case management focused content at 6 (B = - .06, SE = .01, p < .001) and 12 (B = - .07, SE = .01, p < .001) months were negative. Conclusions Families were more likely to be retained when home visitors focused on child development and parent-child interaction, but less likely with more case management focus. Parents with positive depression screens were more likely to remain in services with more time spent focused on supporting parent-child interactions.

Application of Noninferiority Tests to Examine the Food Insecurity-Obesity Relationship in Children.

This study applies non-inferiority testing to assess the relationship between child weight and food security status in a sample of 808 children between 3 and 5 years old who were attending an urban, state-funded preschool program. Most families were African American (72.3%). Analyses were conducted using non-inferiority testing to evaluate the overweight-food security association. Odds of being overweight in the Food Insecure (FI) group were .643 (95% CI .525 to .788) while odds from the Food Secure (FS) group were .570 (95% CI .464 to .697), OR=1.127 (P=.004). These findings held across sub-groups of gender, race, and family conflict. Children whose parent indicated education beyond high school showed a reversal with FI odds of overweight less than FS odds (OR=.663). As illustrated in this study, non-inferiority testing provides an alternative analytic approach to examining the association between FI and weight in children.

Test of a Conceptual Model to Explain Television Exposure of Head Start Children.

Excessive television (TV) viewing by children can lead to negative health and developmental outcomes. Using structural equation modeling, this study tests a conceptual model to understand social and familial factors associated with TV exposure among a sample of 767 Head Start families with children between the ages of 3 and 5 years. Fit statistics suggested that the overall model provided an acceptable fit to the observed data. Specifically, significant structural paths suggest that parents' social support affects child TV exposure. Additionally, lower levels of social support were associated with significantly greater parental stress, which also predicted child TV exposure. Findings suggest that physicians and other team members of the patient-centered medical home may benefit from broad-based interventions that address familial factors to combat excess TV exposure among children. Urging parents to turn off the TV could fail to address the underlying causes of child TV exposure.

Adverse childhood experiences: Screening and health in children from birth to age 5.

INTRODUCTION: Adverse childhood experiences (ACEs) have lifetime consequences for health and development. This study examined whether there is evidence to support a screening approach that assesses children's current exposures to risks that act as proxies for ACEs, measured in a way that falls below a threshold of explicit abuse, neglect, or illegal behavior. METHOD: We used data collected during routine home visitations of at-risk children aged 0-5. Home visitors used the Family Map Inventories (FMI; Whiteside-Mansell et al., 2007) to screen ACEs and measure health outcomes, and the Ages and Stages Questionnaire (3rd ed.; ASQ-3; Squires, Twombly, Bricker, & Potter, 2009) to screen child development. Parents (N = 2,004) were 28 years of age on average and most were White (60%). Children were 32 months of age on average and equally divided on gender (51% male). RESULTS: Children were exposed at rates of 27%, 17%, 11%, and 11% to 1, 2, 3, and 4 or more FMI-ACEs, respectively. Logistic regressions revealed significant associations between FMI-ACE scores and health environments and outcomes for children, including health risks in the home (e.g., safety and secondhand smoke exposure), underuse of preventive health care, and overuse of emergency medical treatment. In terms of development, having four or more FMI-ACEs was associated with the child having a chronic health condition and screening at risk for delay in at least one area of development. DISCUSSION: Findings highlight the potential use of questionnaires and in-home observations to measure and intervene in potentially developing ACEs. Further, our screening was associated with children whose health was at risk very early in development. (PsycINFO Database Record

Foundations for screening adverse childhood experiences: Exploring patterns of exposure through infancy and toddlerhood.

Adverse childhood experiences (ACEs) have lifetime consequences for health and development. Identification of ACEs early in childhood provides the potential to intervene before health and development are impaired. This study examined the timing and duration of exposure to ACEs experienced by children from low-income families from ages one to three years to identify whether there were patterns of exposure when infants and toddlers were most vulnerable. We were able to confirm the early negative consequences on cognitive, health, and behavior outcomes previously reported in young children using a national, longitudinal data set of parents and children from low-income households (N=2250). Using Finite Mixture Models, five classes of exposure were identified for children, Consistently Low (63.8%), Decreasing (10.3%), High at Age 2 (11.4%), Increasing (10.4%), and Consistently High (4%). The Consistently Low and Consistently High classes had the most and least optimal development across all domains, respectively. When examining child development outcomes among children with variable exposures to adversities, we found that for cognitive, language, and physical development, the most proximal ACEs were more robust for predicting child outcomes. For socioemotional health, exposure at any time from one to three to ACEs had negative consequences. As a whole, findings from this study highlight the need to consider ACEs screening tools that are both time-sensitive and permit a lifetime report.

Assessing adverse experiences from infancy through early childhood in home visiting programs.

The general aim of early intervention and home visiting programs is to support families to minimize Adverse Childhood Experiences (ACEs). However, assessing children's exposure to these risks is complicated because parents serve as the conduit for both measurement and intervention. The primary aims of the study were to develop an assessment of children's exposure to ACEs and to examine concurrently measured parental child abuse and neglect potential and child social-emotional functioning. Home visiting programs in a southern state implemented the Family Map Inventories (FMI) as comprehensive family assessment and child screenings (N=1,282) within one month of enrollment. Children (M=33 months of age, SD=20) were exposed at rates of 27% to one, 18% to two, 11% to three, and 12% to four or more FMI-ACEs. FMI-ACEs were associated with increased parental beliefs and behaviors associated with child abuse and neglect. FMI-ACEs also significantly predicted the likelihood of the child having at-risk social-emotional development; children with 4 or more FMI-ACEs were over 6 times more likely than those with none to have at-risk scores. The findings add to our understanding of the negative impact of trauma on children and families. Assessing these risks as they occur in a family-friendly manner provides a platform for early intervention programs to work with families to increase family strengths and reduce the impacts of adverse experiences for their children.

Supporting Family Engagement in Home Visiting with the Family Map Inventories.

The purpose of this study was to examine the feasibility and usefulness of a universal screening tool, the Family Map Inventory (F MI), to assess family strengths and needs in a home visiting program. The FMI has been used successfully by center-based early childcare programs to tailor services to family need and build on existing strengths. Home visiting coordinators (N = 39) indicated the FMI would provide useful information, and they had the capacity to implement. In total, 70 families who enrolled in a Home Instruction for Parents of Preschool Youngsters (HIPPY) program were screened by the coordinator. The results of the FMI provided meaningful information about the home and parenting environment. Overall, most caregivers provided high levels of school readiness and parental warmth and low levels of family conflict and parenting stress. On the other hand, many families did not provide adequate food quality, exhibited chaotic home environments, and practiced negative discipline. This study demonstrated that the FMI is a feasible and useful option to assess comprehensive family needs in home visiting programs. It also demonstrated that the FMI provided home visiting coordinators a system to measure family strengths and needs. This could provide an assessment of program effectiveness and changes in the family's environment.