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

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

• 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

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 low-income, 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-DN = 398(48%)

˃ 16 on the CES-DN = 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 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

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 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)

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

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

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 HillSchool of Nursing Tel: (919) 843-2386 FAX: (919) 966-0984

CB #7460, Chapel Hill, NC 27599-7460