Implementation of the "Healthy Moms, Healthy Kids" Program in Head Start: An Application of the RE-AIM QuEST Framework Centering Equity.

BACKGROUND: Marginalized mothers are disproportionately impacted by depression and face barriers in accessing mental health treatment. Recent efforts have focused on building capacity to address maternal depression in Head Start; however, it is unclear if mental health inequities can be addressed by two-generation programs in Head Start settings. Therefore, this study examined the implementation outcomes and processes of a two-generation program called "Healthy Moms, Healthy Kids" (HMHK) that provided an evidence-based depression treatment to ethnic minority Head Start mothers. METHOD: Quantitative and qualitative data were collected and merged in a convergent mixed method design in accordance with the RE-AIM Qualitative Evaluation for Systematic Translation (RE-AIM QuEST) framework. Qualitative data included interviews with 52 key stakeholders, including intervention participants and staff members, and 176 sets of meeting minutes from the implementation period. Quantitative data included intervention study data and administrative data. RESULTS: It was difficult for HMHK to reach the target population, with only 16.8% of eligible mothers choosing to participate. However, mothers who participated experienced reductions in depressive symptoms and parenting stress and shared a variety of positive impacts in interviews. The program was also more successful in enrolling Latinx mothers who were Spanish-speaking or bilingual rather than English-speaking and Black/African American mothers, limiting its reach. CONCLUSION: Providing IPT therapy groups was effective in reducing maternal depressive symptoms and stress for those who enrolled, but additional work should focus on reducing barriers to participation, considering other delivery models to meet participants' needs, and identifying culturally relevant ways to meet the needs of Black mothers.

Pandemic-Related Stress and Resilience Among Latinx Mothers with a History of Depression: Differences by Immigration Status.

This study explores the impact of the COVID-19 pandemic on low-income, Latinx mothers in Southern California with a history of depression, including undocumented mothers and members of mixed status families. Drawing participants from a parent study that provided a maternal depression intervention to Head Start mothers (n = 119), this mixed method study integrates qualitative and quantitative data in a convergent design. Thirty-four mothers completed semi-structured qualitative interviews and standardized questionnaires in the fall of 2020. Mothers shared overwhelming economic difficulties, with the majority reporting that their family income decreased and half reporting that they were unable to pay for housing. Stressors were compounded for undocumented mothers and members of mixed-status families who were excluded from major relief programs. Stress affected maternal mental health, and mothers with precarious status reported differences in functioning. Mothers also identified positive ways that they coped with adversity. Results show that Latinx mothers with a history of depression, particularly mothers with precarious immigration status, continue to suffer considerable economic, social, and emotional impacts of the COVID-19 pandemic. Social workers can support the human rights of this population by advocating for financial relief, food assistance, and the expansion of medical-legal partnerships and physical and mental health services.

Adults with a child maltreatment history: Narratives describing individual strengths that promote positive wellbeing.

BACKGROUND: Child maltreatment often has negative impacts, but some individuals have strengths that lead to better outcomes. OBJECTIVE: Describe the narratives of adults who experienced childhood maltreatment, all of whom had positive psychosocial wellbeing at average age 18 years. PARTICIPANTS AND SETTING: A purposive sample of 21 adults (mean age 27.8 years SD = 1.0) who were part of a longitudinal study on the effects of childhood maltreatment. The sample was self-described as 85.7 % female, 14.3 % male, 42.9 % Black, 33.3 % Latinx, 19.0 % White, and 4.8 % multiracial. METHODS: This descriptive qualitative study, which is part of a sequential mixed method study, used semi-structured interviews and a narrative analysis approach. Four coders completed: (1) initial reading of sample interviews (2) generating codes independently and discussion, (3) creating a codebook, (4) reviewing 10-11 transcripts each (5) reconvening to discuss/resolve differences in coding, (6) identifying themes. RESULTS: There were four themes. The first theme was seeing oneself in a good light, highlighting self-worth and helper roles. The second theme, moving forward, included letting go of their past and a future orientation. Coping with life, the third theme, included boundaries for people around them, routines, and self-sufficiency. Meaning making, the fourth theme, included insights on the effect of their maltreatment and foster care, and reflections on appreciating life and adapting to changing circumstances. CONCLUSIONS: Findings describe varied strengths that promote positive functioning after childhood maltreatment. Study themes highlight how these strengths allow adults to make meaning of their experiences and move forward successfully in life.

Maternal and adolescent depressive symptoms and family conflict: An autoregressive cross-lagged examination of competing models in multi-stressed mothers and adolescents.

Maternal and adolescent depression are challenges that often co-occur. Many studies have drawn bivariate associations between maternal depressive symptoms, adolescent depressive symptoms, and family conflict, but few have examined reciprocal effects. Even among extant studies, there is a lack of clarity related to directionality of influence. Three competing theoretical models may explain the relationship between maternal depressive symptoms, adolescent depressive symptoms, and family conflict, and these processes may differ by adolescents' sex. Using three time points of data from 187 diverse mother-adolescent dyads, we fit a taxonomy of autoregressive cross-lagged structural equation models to simultaneously evaluate the competing theoretical models and also examine differences by sex using multiple-group analyses. Results indicate a symptom-driven model whereby adolescent depressive symptoms predicted increases in family conflict. Sex differences were also found. For males, but not females, greater adolescent depressive symptoms predicted subsequent increases in maternal depressive symptoms, which then predicted lower family conflict-possibly indicating maternal disengagement/withdrawal. Our findings suggest addressing adolescent depressive symptoms in order to prevent family conflict and that distinctive targets for the prevention/intervention of family conflict should account for differences by adolescents' sex.

Effect of Caregiver Depressive Symptoms on the Concordance Between Caregiver and Youth Assessment of Youth Physical Health.

OBJECTIVES: To explore how caregivers' (birth parents, adoptive parents, relative caregivers, and unrelated caregivers) depressive symptoms moderate the concordance between their and their youth's assessment of the youth's physical health symptoms, diseases, and physical health status. METHODS: Participants included 224 youth with mean age of 18.0 years (SD = 1.3) and their caregivers. Multiple-group models were run to test whether caregiver depression status moderated the concordance between youth and caregiver report of physical health outcomes. Models compared caregivers above the mean for depression in the sample (n = 62) with caregivers below the mean for depression in this sample (n = 128). RESULTS: There was a strong correlation between youth and caregiver report of pain in the last 30 days and physical health status in the caregiver group with no/fewer depressive symptoms [r (128) = 0.29, p = 0.04; r (128) = 0.59, p < 0.01], but no significant correlation between the two in the caregiver group with higher depressive symptoms [r (62) = - 0.27, p = 0.27; r (62) = - 0.14, p = 0.57]. CONCLUSIONS FOR PRACTICE: Higher caregiver depressive symptoms was associated with worse concordance between caregiver and youth assessment of the youth's pain and physical health status. These two health issues are less visible and more subjective and communication between caregiver and youth may be affected by the caregiver's depressive symptoms. Since both caregiver and youth assessments of a youth's physical health provide the best clinical data, it may be helpful for health providers to assess caregiver's mental health status to provide a more complete picture.

Effectiveness of an Interpersonal Psychotherapy (IPT) Group Depression Treatment for Head Start Mothers: A Cluster-Randomized Controlled Trial.

BACKGROUND: Maternal depression is known to be a serious problem with higher rates among poor and racial/ethnic minority mothers that can have numerous negative impacts on their children. These mothers have less access to effective care and may be wary of traditional mental health care because of the stigma. The purpose of this study was to test whether an adaptation of an Interpersonal Psychotherapy group for perinatal depression could be effective in reducing depressive symptoms of mothers whose children were enrolled in Head Start. METHODS: Forty-nine mothers, randomized by site, were recruited into the intervention group, 70 into the control group. They were measured on depressive symptoms, parenting stress, parenting behavior, and parent child interaction at intake, at end of the group, and 6 months following. RESULTS: The intervention group was lower in depressive symptoms at the end of treatment with a further decrease 6 months post intervention. There was no change in the control group. The intervention group also improved in parenting stress. LIMITATIONS: The sample size for the intervention group was smaller than desired. CONCLUSIONS: This study supports the effectiveness of this 12 session IPT group which was highly effective for a population of Head Start mothers. It is a strategy that can be adapted to other settings that serve low income mothers.

Barriers to Implementing a Group Treatment for Maternal Depression in Head Start: Comparing Staff Perspectives.

Although providing depression treatment for Head Start mothers may improve child wellbeing, interventions have not been widely used for this purpose. This failure may be due to the characteristics of clients, interventions, or the systems of care in which services are delivered. This study explored barriers to implementing Interpersonal Psychotherapy-Group with ethnic minority Head Start mothers, including differences in the level of staff consensus regarding barriers, which may predict implementation success. Barriers included resource challenges, cultural and linguistic differences, and participant concerns, and staff demonstrated low to moderate consensus. Results emphasize the importance of engaging diverse stakeholders in implementation.

The Young Adolescent Project: A longitudinal study of the effects of maltreatment on adolescent development.

The Young Adolescent Project (YAP) is an ongoing longitudinal study investigating the effects of abuse and neglect on adolescent development. It is a multidisciplinary study guided by a developmental, ecological perspective, and designed to consider the physical, social, and psychological effects of childhood maltreatment through the transition from childhood to adolescence. Four waves of data collection have been completed, ranging from early (Mean age = 10.95) to late adolescence (Mean age = 18.24). Members of the maltreated group (n = 303) were selected from new cases that had been opened by the Department of Child and Family Services, whereas the comparison group (n = 151) were not involved with child welfare but lived in the same neighborhoods as the maltreated group. The study assessed a wide variety of domains including physical development (e.g., height, weight, body mass, pubertal development); physiological reactivity (e.g., cortisol); cognitive abilities; mental health (e.g., symptoms of depression, anxiety, trauma, and aggression); risk behavior (e.g., sexual activity, delinquency, or substance use); social development (e.g., self-esteem, competence, and social support); family environment; and exposure to community violence. Overall, our findings demonstrated the pervasive and persistent adverse effects of child maltreatment both within and across domains, but they also identified maltreated youth with positive functioning. Our hope is that this work will help move us toward identifying targets for intervention to cultivate resilience and positive adaptation after early maltreatment experiences.

Mothers' Perceptions of Help-Seeking for Depression in Head Start: A Thematic, Discourse Analysis by Language Group.

Maternal depression poses a threat to the well-being of poor minority mothers and their young children, but significant disparities remain in the access and utilization of treatment among this population in the United States. Providing group treatment in early childhood education settings like Head Start may be an effective way to address this public health concern. However, intervention developers would benefit from understanding potential barriers and facilitators to engagement with this population, particularly those related to cultural and linguistic differences. Focus groups were conducted to explore perceptions of help-seeking for depression among English and Spanish-speaking Head Start mothers as part of a larger effectiveness study. Thematic and discourse analysis strategies were used to examine similarities and differences across English and Spanish language groups. Results revealed similar and divergent concerns about broader environmental stressors and striking differences in the processes of group formation. Findings demonstrate the importance of addressing structural factors, developing flexible interventions, and tailoring interventions for both English-speaking and Spanish-speaking groups.

Linkage between teen mother's childhood adversity and externalizing behaviors in their children at age 11: Three aspects of parenting.

BACKGROUND: Experiences of childhood adversity are consistently associated with compromised behavioral health later in life. Less clear is the intergenerational influence of maternal childhood adversity on developmental outcome in children. Completely unknown are the mechanisms linking teen mother's childhood adversity to child developmental outcomes. OBJECTIVE: The present study tested whether aspects of parenting (parenting stress, physical discipline, and disagreement with grandparents) served as the pathways between teen mother's childhood adversity and the externalizing behaviors of their offspring at age 11, by gender. PARTICIPANTS AND SETTING: Data were from a longitudinal panel study of teen mothers and their children, the Young Women and Child Development Study (N = 495; 57% male). METHODS: The pathways from teen mother's childhood adversity to their offspring's externalizing behavior were tested by two subscales: rule-breaking behavior and aggressive behavior. In addition, multiple-group analysis was examined for potential gender differences. RESULTS: Teen mother's childhood adversity was positively associated with greater use of parenting stress (ß = 0.16, p < .01) and physical discipline (ß=0.11, p < .05). In addition, parenting stress, physical discipline, and disagreement with grandparent were all associated with increased rule-breaking and aggressive behaviors in children. Multiple group analysis revealed that the path between physical discipline and externalizing behavior differed by gender, with the path only significant for girls. CONCLUSIONS: These findings have implications for early intervention efforts that emphasize the need to intervene with children and parents, particularly helping teen mothers gain knowledge and skills to offset the impact of their experiences of childhood adversity on their parenting behaviors.

Longitudinal associations of maternal depression and adolescents' depression and behaviors: Moderation by maltreatment and sex.

This study explored the longitudinal relationships among maternal depressive symptoms, children's depressive symptoms, aggression, and rule breaking and tested the moderating effects of maltreatment and child sex. A sample of 175 biological mother-child dyads (86 maltreated and 89 comparison) were seen at three time points, beginning at an average child age of 10.87 years. Results from cross-lagged models showed maternal depressive symptoms were related to higher levels of children's depressive symptoms but not children's aggression or rule breaking. Rule breaking predicted maternal depressive symptoms only in the comparison group. Child sex moderated some relationships. Boys' depression predicted maternal depressive symptoms, whereas maternal depressive symptoms predicted aggression among girls. There was no evidence in this sample that child maltreatment increased the effects of maternal depressive symptoms on child outcomes. These results suggest that attention in clinical practice to the importance of addressing maternal depression as well as addressing children's functioning should continue into adolescence. (PsycINFO Database Record

Patterns and correlates of co-occurrence among multiple types of child maltreatment.

This study examined the patterns and correlates of the types of maltreatment experienced by adolescents aged 9-12, participating in an ongoing longitudinal study on the impact of neglect on children's development. Using case record abstraction, the study compared the child protection classification and findings from the case record abstraction with regard to the rates of four types of maltreatment (i.e. physical, sexual, emotional abuse and neglect) as well as co-occurrence across multiple types of maltreatment. Next, the study examined the frequently observed patterns of child maltreatment. Finally, the study investigated whether aspects of caretaker functioning and the detailed incident characteristics in the cases of neglect differed by the number of different types of maltreatment the children experienced. Results showed significant discrepancies between the Child Protective Service classification and case record abstraction. Child Protective Service classification considerably underestimated the rate of co-occurrence across multiple types of maltreatment. Neglect accompanied by physical and emotional abuse was the most common form. Some of the caretaker functioning variables distinguished the number of types of maltreatment. Based on the findings, future-research directions and practice implication were discussed.

Overweight and obesity among maltreated young adolescents.

PURPOSE: (1) To identify and compare rates of body mass index (BMI)≥ 85% (overweight/obesity) and BMI ≥ 95% (obesity) in maltreated versus comparison young adolescents; (2) to determine whether demographic/psychological characteristics are related to high BMI; (3) to determine whether type of maltreatment is related to high BMI in maltreated young adolescents. METHODS: We compared a sample of maltreated young adolescents to a comparison sample of adolescents from the same neighborhood. The maltreated sample (n=303) of young adolescents (ages 9-12) came from referrals from the county child welfare department in Los Angeles, CA from new cases of maltreatment opened in specified zip codes. A comparison sample (n=151) was recruited from the same zip codes. The total sample (both maltreated and comparison) was 77% Black or Hispanic and 23% White or biracial with 53% males and 47% females. A stepwise logistic regression was used to examine predictors of high BMI with demographic/psychological covariates and maltreatment group. The maltreated young adolescents were selected and the logistic model included all covariates as well as an interaction between gender and each maltreatment type (neglect, sexual, and physical abuse). RESULTS: Maltreated young adolescents were similar to comparison adolescents in obesity prevalence (27.1% and 34.4%, respectively), although comparison young adolescents were 1.7 times more likely to have overweight/obesity than the maltreated young adolescents (95% CI=1.13-2.76). No demographic variables predicted high BMI. For the comparison young adolescents, depression slightly increased the odds of overweight/obesity (OR=1.08, 95% CI=1.01-1.15). Being neglected reduced the odds of being in the overweight/obesity and obesity group when combining genders. For females, but not males, sexual and physical abuse slightly reduced the odds of obesity. CONCLUSIONS: Both the maltreated and comparison young adolescents had a high prevalence of overweight and obesity, which puts them at risk for health problems. Maltreatment reduced the odds of having a high BMI for adolescents in this study, which is opposite to research in adults. Further exploration of the mechanism of how maltreatment is related to weight as adolescents age, with specific emphasis on differences between genders, is needed.

Longitudinal relations between depressive symptoms and externalizing behavior in adolescence: moderating effects of maltreatment experience and gender.

Among the explanations for the high rates of co-occurrence between depressive symptoms and externalizing behavior is the possibility of direct causal associations between the two symptom groups. However, the mechanisms by which co-occurrence arises may not be the same across etiologically significant variables. A gender-balanced sample of 303 adolescents (ages 9-12 at the first assessment) with carefully assessed histories of maltreatment experience and 151 demographically matched nonmaltreated adolescents were assessed over the period of 1 year. Multiple-group cross-lagged panel analyses assessed the equivalence of longitudinal relations between depressive symptoms and externalizing behavior for gender/maltreatment status groups. Consistent with previous findings, the results suggest that girls, particularly maltreated girls, who exhibit early externalizing behavior are at high risk for the development of subsequent depressive symptoms.

Parenting Attitudes, Family Environments, Depression, and Anxiety in Caregivers of Maltreated Children.

This study evaluated parenting attitudes, family environments, depression, and anxiety in a sample of primarily minority urban mothers to better understand maltreating mothers (n = 83), who retain custody of their children and how they are similar to and different from foster mothers (n = 50), kin caregivers (n = 52) of maltreated children, and comparison mothers (n = 100) from the same communities. Maltreating mothers were distinguished by their much higher levels of depression and anxiety from other mothers. In addition, like foster mothers, maltreating mothers were less likely to approve of corporal punishment. Foster mothers were higher in organization and lower in empathy than other groups. There were no differences by race/ethnicity on study dimensions. Higher education, however, was related to more favorable parenting attitudes and family environments. Practice implications related to appropriate services are suggested.

Child neglect: definition and identification of youth's experiences in official reports of maltreatment.

OBJECTIVE: The purpose of this study was to describe the nature of neglect in child welfare clients, to describe these experiences, to examine its typologies, and to understand how different types of neglect co-occurred with each other and with other types of maltreatment. METHODS: Case record abstraction was conducted on the child welfare case records of an urban, ethnically-diverse sample of youths (n=303) identified as maltreated by a very large public child welfare agency. We utilized the Maltreatment Case Record Abstraction Instrument (MCRAI) which was based on the work of Barnett et al. (1993) as modified by English and LONGSCAN (1997). Thirteen items of parental behavior deemed neglectful were coded and organized into 5 subtypes of neglect (care neglect, environmental neglect, medical neglect, educational neglect, supervisory neglect). RESULTS: Neglect was present in 71.0% of the sample as compared to the 41.0% classified as neglected by CPS records. Neglect was accompanied by other types of maltreatment in 95% of the cases. Children who were neglected had more reports of maltreatment and experienced a greater number of different types of maltreatment than those who were maltreated, but not neglected. The most common type of neglect was supervisory neglect (72.5%) followed by environmental neglect (61.6%). With the exception of medical neglect, all types of neglect were significantly correlated with each other. CONCLUSIONS: The abstraction resulted in rich data showing that under a one-word label of neglect, the nature of neglect that the youngsters actually experienced was quite diverse and heterogeneous in its phenomenology. Furthermore, neglect is pervasive for children in the child welfare system and official classifications underestimate its occurrence. Neglect does not happen in isolation; children who are reported as neglected are likely to experience other forms of maltreatment. PRACTICE IMPLICATIONS: Official classifications should not be used in determining interventions for children and families. Interventions for neglected youngsters should be individualized to address the complexity of children's experiences.

Do Maltreated Children who Remain at Home Function Better than Those who Are Placed?

The majority of children in the child welfare system remain with their maltreating parents, yet little is known about their level of functioning and whether they are in need of mental health intervention. The purpose of this study was to evaluate the mental health functioning of an ethnically diverse sample of 302 maltreated children and 151 non maltreated children ages 9-12 to see if there were differences between those who remained at home, those placed in kin care, non-relative foster care or a comparison group of children who were not maltreated. Children were evaluated on multiple measures of mental health functioning, both self report and caregiver report. Results showed that the maltreated children did not differ by placement type but did score significantly higher than the comparison children on many measures. There were substantial numbers of maltreated children scoring in the clinical range of measures in all placement types with over 60% of those remaining with birth parents being seen as functioning at a level that indicated a need for mental health intervention. While fewer comparison children had scores indicating a need for mental health care, the numbers were higher than noted in national studies. Implications of the findings are presented.

Emotional abuse in a sample of multiply maltreated, urban young adolescents: issues of definition and identification.

OBJECTIVE: The main purpose of this paper is to use the Brassard and Donovan [Brassard, M. R. & Donovan, K. L. (2006). Defining psychological maltreatment. In M. M. Freerick, J. F. Knutson, P. K. Trickett, & S. M. Flanzer (Eds.), Child abuse and neglect: Definitions, classifications, and a framework for research (pp. 151-197). Baltimore, MD: Paul H. Brookers Publishing Co., Inc.] framework to examine and describe the nature of emotional abuse experienced by a sample of urban, ethnically diverse male and female youth (N=303) identified as maltreated by a very large public child welfare agency. METHODS: Case record abstraction was conducted on the DCFS records of these maltreated youth using the Maltreatment Case Record Abstraction Instrument (MCRAI) which was based on the work of Barnett et al. [Barnett, D., Manly, J. T., & Cicchetti, D. (1993). Defining child maltreatment: The interface between policy and research. In D. Cicchetti & S. L. Toth (Eds.), Advances in applied developmental psychology: Child abuse, child development and social policy (pp. 7-73). Norwood, NJ: Ablex Publishing Corp.] as modified by English and LONGSCAN [English, D. J., & the LONGSCAN Investigators. (1997). Modified maltreatment classification system (MMCS). Retrieved from http://www.iprc.unc.edu/longscan/]. Fifteen items of parental behavior deemed emotionally abusive were coded and organized into four subtypes of emotional abuse (spurning, terrorizing, isolating, exploiting/corrupting) using the Brassard and Donovan (2006) framework. RESULTS: Using this coding system, almost 50% of the sample were found to have experienced emotional abuse in contrast to 9% identified at the time of referral by DCFS. Most of the emotionally abused youth also experienced physical abuse (63%) and/or neglect (76%) as well. The most frequent subtype of emotional abuse experienced was terrorizing. Most youth experienced more than one subtype. CONCLUSIONS: Emotional abuse, while frequent, was seldom the focus of the child protection services investigation. The nature of this abuse was not minor, but rather likely to be dangerous to the mental health and well-being of these children. Further more emotional abuse, in this sample of young adolescents, at least, was likely to be accompanied by other forms of maltreatment, especially physical abuse and/or neglect. These findings have important implications for practice and the direction of future research. PRACTICE IMPLICATIONS: All those who interact with child welfare clients must recognize the prevalence of emotional abuse in maltreated children so that appropriate interventions are instituted. Screening for emotional abuse should be part of all intake referrals and when confirmed should be noted in official records. When children are placed, foster parents (both kin and non-kin) need training on the prevalence and consequences of emotional abuse, and strategies to help their foster children recover from the aftermath. When children remain with maltreating parents, emotional abuse should be a focus of the interventions designed to help maltreating parents with more effective parenting strategies and also should be a focus of the interventions designed to help the child recover from the consequences of maltreatment.

Maternal depression and adolescent behavior problems: an examination of mediation among immigrant Latino mothers and their adolescent children exposed to community violence.

This study examines the psychological and behavioral effects of exposure to community violence of 47 Latino mothers and their young adolescent children. Using data gathered from multiple sources, this study tests the associations between lifetime exposure to community violence, maternal depression, and child behavior problems. More than 80% of the youngsters ranging from age 11 to 14 years and 68% of the mothers reported being exposed to at least one act of community violence either as a victim or as a witness. Analyses reveal that maternal depression is a mediator of child behavior problems, reducing the direct effect of community violence exposure by more than 50%. Findings suggest that maternal depression is a factor more important than child's community violence exposure in contributing to young adolescents' behavioral problems.