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Linda S. Beeber, PhD, RN, CNS,BC, FAAN

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

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Linda S. Beeber, PhD, RN, CNS,BC, FAAN

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  1. 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

  2. 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.

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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; vanDoesum, Riksen-Walraven, Hosman, & Hoefnagels, 2008 • Psychotherapy offered in the home - a solution • Miranda (2006) suggested embedding mental health intervention into existing, trusted community entity

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. Results: Sample Characteristics

  21. 827 Mothers Screened ˂ 16 on the CES-D N = 398 (48%) ˃ 16 on the CES-D N = 429 (52%)

  22. 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

  23. Results: Depressive Symptoms

  24. HRSD Reduction at Each Timepoint by Group

  25. Results: Maternal Responsiveness

  26. Maternal Responsiveness Operationalized

  27. 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

  28. Additional Analyses

  29. Post-hoc Analyses Pairwise change from T1 to T4 in both intervention and attention-control groups showed significant within-group reductions

  30. Conclusions, Implications, Future Studies • Reached unserved mothersand 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

  31. 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

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