Linda S. Beeber, PhD, RN, CNS,BC, FAAN
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Parenting Enhancement Boosts In-Home Interpersonal Psychotherapy
for Low-Income Mothers with Depressive Symptoms
Linda S. Beeber, PhD, RN, CNS,BC, FAAN School of Nursing, University of North Carolina at Chapel Hill
Diane Holditch-Davis, PhD, RN, FAAN Duke University School of Nursing
Todd Schwartz DrPH Regina Canuso, MSN, RN, CNS, BC
Virginia Lewis, B. A. School of Nursing, University of North Carolina at Chapel Hill
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Acknowledgements
• The National Institute of Mental Health (Beeber, PI: RO1 MH065524)
• Staff of the “HILDA” Project and the participating Early Head Start programs (North Carolina & New York)
• The mothers who taught us how to help.
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Depressive Symptoms are Prevalent
• 40-59% of low-income mothers Mayberry, Horowitz, & Declercq, 2007
• Limit coping with stressors• Reduce benefit of education & work programs Feder et al., 2009; Mickelson, 2008
• Add to reproduction of multigenerational poverty• Compromise parenting Lovejoy, Graczyk, O'Hare, & Neuman, 2000
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• Shorter, less child-centered interactions Rosenblum, 1997; Zeanah, 1997; Zlochower, 1996
• Less sensitive, responsive interactions Cohn & Tronick, 1989; Weinberg, et al,1998; Hammen, 1991
• Less frequent touch, play, joy Rosenblum, 1997; Bettes, 1988; Stepakoff, 2000
• Negative judgments of child’s behavior Koschanska, 1987; Murray, 1996; Radke-Yarrow, 1990
• Highly stimulating, “rough touch” Cohn, 1989; Weinberg, 1998
At Moderate Levels Depressive Symptoms Compromise Parenting
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Negative Outcomes in the Infant and Toddler (> 6 mos duration)
• Smaller fetal body & head growth El Marroun, et. al., 2012
• Delayed language & developmental milestones Lyons-Ruth,1986; Murray, 1996; Zeanah, 1997
• Negative affect & severe tantrums Goodman, 1993; Needlman, 1991
• Less positive affect toward self Cicchetti, 1997
• Lowered resilience to environmental risks Barnard, 1985
• Less confidence in social situations Hart, 1999; Gross, 1994 & 1995
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Beyond the 0-3 Era
• School-aged children of symptomatic mothers:– conduct disorders– social difficulties– learning/language problems that persist– limited achievement (Campbell, Morgan-Lopez, Cox, & McLoyd, 2009
• Require remedial services • At risk for depression and suicide in adolescence/adulthood
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Interventions
• Barriers: Transportation difficulties, childcare needs, stigma, competition with meeting basic needs
• Problems with acceptability, fidelity, adequate retention Appleby, Warner, Whitton, & Faragher, 1997; Cooper, Murray, Wilson,
& Romaniuk, 2003; Spinelli & Endicott, 2003; Miranda et al., 2006;
van Doesum, Riksen-Walraven, Hosman, & Hoefnagels, 2008
• Psychotherapy offered in the home - a solution• Miranda (2006) suggested embedding mental health
intervention into existing, trusted community entity
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Intervention: Adapted Interpersonal Psychotherapy (IPT)
• Specific for depression Klerman & Weissman, 1984
• Evidence-supported & effective • Tested with middle- & low-income postpartum mothers in
traditional clinic model Weissman, Markowitz, & Klerman, 2007; Forman, et. al. , 2008;
Grote et al., 2009)
• Forman, et al, (2008): reduction of depressive symptoms alone did not change critical views of mother toward child or parenting behaviors
• Beeber, et al. (2010) found that critical views of child could be reduced along with depressive symptoms
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Intervention: Adapted Interpersonal Psychotherapy (IPT)
• Our team: – Adapted IPT to low-income, limited literacy mothers &
added depression-specific parenting guidance Beeber, Perreira & Schwartz, 2008
– Designed delivery to fit into Early Head Start (EHS) programming
– Two RCT’s showed adapted IPT effective in reducing symptoms & changing perceptions
Beeber, et al., 2004 & 2010
– Had not yet shown impact on parenting behaviors after symptoms reduced
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Purpose: Primary Aim
Deliver the adapted IPT and parenting enhancement guidance (IPT + PE) to low-income, mothers
Test effect on mothers’:
• Depressive symptom severity• Responsiveness while interacting with child
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Hypotheses
• Compared to mothers who received an attention control condition, mothers receiving IPT+PE would demonstrate:
• less depressive symptom severity at 14 weeks, 22 weeks, and 1 month following completion of treatment (26 weeks)
• more positive involvement & developmental stimulation and less negative control at 26 weeks
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Design• Randomized, two-group, repeated
measures design• Four measurement points:
– Baseline (T1)– Mid-intervention - 14 weeks (T2)– Termination - 22 weeks (T3)– 1-month post-termination – 26
weeks (T4)• IPT+PE: Psychiatric Mental Health
APRNs • Attention-control condition: RNs with
no mental health preparation
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Sample:
• 226 low-income mothers • Child 6 weeks – 30 months old enrolled in EHS• Northeast & southeast US; Urban, rural & suburban• ≥ 16 Center Epidemiological Studies-Depression scale
(CES-D) Radloff, 1977
• 15 years of age or older• No regular counseling or psychotherapy• No psychotropic medications• Able to consent or have a guardian consent
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Intervention• Engagement via nurse-client relationship Peplau, 1952 & 1988
• IPT+ PE (Interpersonal Psychotherapy + Parenting Guidance) Weissman, M. M., Markowitz, J. C., & Klerman, G. L., 2007
• 10 in-person in-home visits, 4-5 telephone booster sessions, 1 termination session
• Content:– Depression linked to transition, dispute, loss, interpersonal
deficit– Focus on depressive symptoms that compromise parenting– Specific strategies to enact and evaluate– Relapse prevention strategies
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Intervention
• Assessed for depression, suicide/infanticide risk and parenting interactions
• Distressing depressive symptoms addressed immediately
• Parenting guidance offered as symptoms diminished• Interactive, personalized skill sheets kept work focused• PMH APRN Nurses:
– Manualized training– Weekly audit of notes & periodic training for fidelity– Weekly conference call for supervision & support
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Attention-Control Condition
• Health education in format identical to intervention
• Relationship strategies to engage mothers• RNs followed a strict content protocol• Assessed for crisis; no discussion of
personal matters• Weekly conference supervision to detect
drift from protocol
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Depressive Symptoms & Depression
• Depressive symptoms: Hamilton Rating Scale for Depression (HRSD)
Hamilton, 1960
• Depression: Structured Clinical Interview for DSM-IV (SCID – Research version) First, Spitzer, Gibbon, & Williams, 2001
–Major Depressive Episode (MDE)–Minor Depression
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Parenting Outcome Measures
•Maternal Responsiveness : – Maternal Child Observation (behaviors from unstructured, videotaped interactions coded in 10-second epochs) Holditch-Davis, et al, 2007
– Home Observation for Measurement of the Environment (HOME – 6 subscales)
(observer-rated behaviors of mother) Caldwell & Bradley, 1980
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Additional Measures
•Maternal Self-Efficacy: General Self-efficacy Scale Schwarzer & Born, 1997
•Social Support Seeking: Social Support Seeking Inventory Greenglass, Fiksenbaum & Burke, 1996
•Perceived Stress: Everyday Stressors Index Hall & Farel, 1988
•Maternal demographic characteristics
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Results: Sample Characteristics
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827 Mothers Screened
˂ 16 on the CES-DN = 398(48%)
˃ 16 on the CES-DN = 429(52%)
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Demographics• Sample size: 226 (114 Intervention; 112 attention-control)• Age: 26.0 (sd 5.7)• Education: 11.9 yrs (sd 2.2)• Ethnicity
– Black/African American 61%
– White 27%
– Mixed/Native American/
Hawaiian/Pacific Islander/Asian 8%
– Unreported 4%• Working : 43% • Living without a Partner: 63%• Child age & gender: 24.9 mos. (sd 13.5); 52% female; 56% chronic health problems• Depressive symptom severity: 16.2 (sd 7.7)• Depression: 24% MDE 35% Minor Depression
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Results: Depressive Symptoms
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HRSD Reduction at Each Timepoint by Group
Group Baseline Time 2 Time 3 Time 4
Intervention 16.8 (7.8) -4.7 -4.8 -5.0
Attention-Control 15.7 (7.6) -4.5 -4.9 -5.3
P-value Group Difference
n/s n/s n/s n/s
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Results: Maternal
Responsiveness
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Maternal Responsiveness Operationalized
Positive Involvement Developmental Stimulation
Negative Control
Near proximity to child Warm touchSmiling at childLooking at childPlaying with child Affectionate gesturesTotal interaction time with child
Child-centered talkingTeaching the child
Shouting at childHostility toward childSlapping or spanking childScolding or derogation of the childRestriction of the child (except for safety)
(HOME sub-scale II)
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Maternal Responsiveness
• Compared to the ACTAU mothers, mothers receiving IPT + PE showed a significant increase in positive involvement between
Time 1 and Time 4 (26 weeks)
(T4 [26 weeks]: t = 2.22, df = 156, p < .03)
• N/S differences in developmental stimulation and
negative control
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Additional Analyses
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Post-hoc Analyses
Perceived Stress
Social Support Seeking
Self-Efficacy
Intervention p<.001 p <.02 p < .01
Attention-Control
p<.001 p <.02 p < .01
Pairwise change from T1 to T4 in both intervention and attention-control groups showed significant within-group reductions
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Conclusions, Implications, Future Studies
• Reached unserved mothers and vulnerable children• RNs providing health education reduced symptoms as effectively as
adapted IPT+PE• HOWEVER, only mothers receiving IPT+PE showed significant
increase in positive involvement• 75% of mothers in the intervention group completed seven or more
IPT/parenting enhancement sessions (higher than comparison – 36%)
• Further studies: – longer window to observe changes in parenting and child
outcomes– Test hybrid model of RN +APRN model to make it cost-effective
and change enduring behaviors
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Questions????
Linda S. Beeber [email protected]
The University of North Carolina at Chapel HillSchool of Nursing Tel: (919) 843-2386 FAX: (919) 966-0984
CB #7460, Chapel Hill, NC 27599-7460