Parenting Enhancement Boosts InHome 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
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.
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
At Moderate Levels Depressive
Symptoms Compromise Parenting
•
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
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
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
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
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
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
Purpose: Primary Aim
Deliver the adapted IPT and parenting
enhancement guidance (IPT + PE) to lowincome, mothers
Test effect on mothers’:
• Depressive symptom severity
• Responsiveness while interacting with child
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
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
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
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
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
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
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
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
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
Results: Sample Characteristics
827 Mothers Screened
˂ 16 on
the CES-D
N = 398
(48%)
˃ 16 on
the CES-D
N = 429
(52%)
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
–
White
–
Mixed/Native American/
–
61%
27%
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
Results:
Depressive
Symptoms
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
Results:
Maternal
Responsiveness
Maternal Responsiveness
Operationalized
Positive Involvement
Developmental
Stimulation
Negative Control
Near proximity to child
Warm touch
Smiling at child
Looking at child
Playing with child
Affectionate gestures
Total interaction time
with child
Child-centered talking
Teaching the child
Shouting at child
Hostility toward child
Slapping or spanking
child
Scolding or derogation
of the child
Restriction of the child
(except for safety)
(HOME sub-scale II)
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
Additional Analyses
Post-hoc Analyses
Perceived
Stress
Social
Support
Seeking
Self-Efficacy
Intervention
p<.001
p <.02
p < .01
AttentionControl
p<.001
p <.02
p < .01
Pairwise change from T1 to T4 in both intervention
and attention-control groups showed significant
within-group reductions
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
Questions????
Linda S. Beeber
beeber@email.unc.edu
The University of North Carolina at Chapel Hill
School of Nursing Tel: (919) 843-2386 FAX: (919) 966-0984
CB #7460, Chapel Hill, NC 27599-7460