Faculty Bibliography

The COVID-19 pandemic increased maternal depression and anxiety, imperiling both mothers' own wellbeing and that of their children. To date, however, little is known about the extent to which these increases are attributable to economic hardships commonly experienced during the pandemic: income loss, job loss, and loss of health insurance. Few studies have examined the individual impacts of these hardships, and none have lasted beyond the first year of the pandemic. This study harmonizes data from six evaluations of pediatric-based parenting programs for women with young children and low incomes across three U.S. cities (N = 1,254). Low-income mothers are of special interest because their families have been disproportionately affected by economic shocks due to COVID-19, and mothers of young children have been more distressed than other mothers by COVID-19. The studies' combined window of observation lasted from the onset of the pandemic to over three years later. Results indicate that income loss, job loss, and health insurance loss were all significantly associated with depression and anxiety. When each hardship was assessed net of the others, lost income was associated with more than a two-fold increase in the odds of anxiety, and a lost job and lost health insurance were associated with 50% and 90% greater odds of depression, respectively. Associations between hardships and maternal mental health did not diminish over time during the window of observation. These associations are likely to have been even greater in the absence of generous social policies enacted during the pandemic.

Early literacy promotion in pediatric primary care supports parents and caregivers in reading with their children from birth, offering counseling in interactive, developmentally appropriate strategies and providing developmentally and culturally appropriate and appealing children's books. This technical report reviews the evidence that reading with young children supports language, cognitive, and social-emotional development. Promoting early literacy in pediatric primary care offers a strengths-based strategy to support families in creating positive childhood experiences, which strengthen early relational health. An increasing body of evidence, reviewed in this report, shows that clinic-based literacy promotion, provided with fidelity to an evidence-based model, has benefits for children, for parents and caregivers, and for pediatric physicians and advanced care providers as well. Reading with young children supports early brain development and the neural "reading network," and improves school readiness. High-quality literacy promotion is especially essential for children who face disparities and inequities because of social factors, systemic racism, and socioeconomic risk. All families benefit from high-quality and diverse books and from developmentally appropriate guidance supporting interactions around books and stories. Thus, literacy promotion can be a universal primary prevention strategy to strengthen families and support healthy development. Partnerships at community, local, and state levels offer opportunities for integration with other programs, services, and platforms. Literacy promotion in primary care pediatric practice, recognized by the American Academy of Pediatrics as an essential component since 2014, has become increasingly common. There are successful models for public funding at federal, state, county, and municipal levels, but sustainable funding, including payment to pediatric physicians and advanced care providers, remains a need so that the benefits of pediatric early literacy promotion and the joys of books and shared reading can truly be offered on a population level.

Children's mental health problems are pressing social, economic, and public health concerns in the U.S. While pediatric primary care offers important venues to integrate mental health services for children and their families, new challenges, including widening educational, economic, and health disparities in the context of structural racism and COVID-related social isolation, underscore the need for innovative approaches. The authors reviewed 6 innovative methods in pediatric care that have helped address these issues and amplify intervention efforts focused on children's mental health. Limitations and future directions for research and clinical practice in pediatric mental health services are also discussed.

OBJECTIVE:To test the feasibility of implementing The Pittsburgh Study's (TPS) Early Childhood Collaborative, a population-level, community-partnered initiative to promote relational health by offering accessible preventive parenting program options for families with young children. STUDY DESIGN/METHODS:TPS partnered with healthcare and community agencies serving families in Allegheny County, Pennsylvania, to enroll and screen 878 parents of 1,040 children 4-years-old and under. Participants were assigned to one of four tiered groups based on identified needs: (1) universal, (2) targeted/universal, (3) secondary/tertiary, or (4) tertiary programs. Parents were offered choices in empirically supported parenting programs within group ranging from texting programs to intensive home visiting. Program selection was optional. Chi-square tests were conducted to examine the likelihood of selecting a program by group. RESULTS:About 25% of participants were assigned to each tiered group; 78% of parents chose to enroll in a parenting program. In general, parents with higher levels of adversity were more likely to select a parenting program compared with those reporting less adversity, including secondary/tertiary versus targeted/universal groups (81.4% vs. 72.8%), and tertiary versus universal and targeted/universal groups (83% vs. 74.1% and 72.8%, respectively; p < .001). CONCLUSION/CONCLUSIONS:Our high program enrollment rate supports the feasibility of TPS. TPS successfully engaged families in the study by offering choices in, and optimizing accessibility to, parenting programs. TPS is highly aligned with recent recommendations by the American Academy of Pediatrics for tiered approaches as part of a broad public health strategy for supporting early relational health.

OBJECTIVE:To test the feasibility of implementing The Pittsburgh Study's (TPS) Early Childhood Collaborative, a population-level, community-partnered initiative to promote relational health by offering accessible preventive parenting program options for families with young children. STUDY DESIGN/METHODS:TPS partnered with healthcare and community agencies serving families in Allegheny County, Pennsylvania, to enroll and screen 878 parents of 1,040 children 4-years-old and under. Participants were assigned to one of four tiered groups based on identified needs: (1) universal, (2) targeted/universal, (3) secondary/tertiary, or (4) tertiary programs. Parents were offered choices in empirically supported parenting programs within group ranging from texting programs to intensive home visiting. Program selection was optional. Chi-square tests were conducted to examine the likelihood of selecting a program by group. RESULTS:About 25% of participants were assigned to each tiered group; 78% of parents chose to enroll in a parenting program. In general, parents with higher levels of adversity were more likely to select a parenting program compared with those reporting less adversity, including secondary/tertiary versus targeted/universal groups (81.4% vs. 72.8%), and tertiary versus universal and targeted/universal groups (83% vs. 74.1% and 72.8%, respectively; p < .001). CONCLUSION/CONCLUSIONS:Our high program enrollment rate supports the feasibility of TPS. TPS successfully engaged families in the study by offering choices in, and optimizing accessibility to, parenting programs. TPS is highly aligned with recent recommendations by the American Academy of Pediatrics for tiered approaches as part of a broad public health strategy for supporting early relational health.

OBJECTIVE:To examine associations between cognitive stimulation in the home at 6 months and maternal feeding styles at 24 months, direct intervention effects of Smart Beginnings (SB) on feeding styles, and potential indirect effects of SB on feeding styles via earlier intervention effects on cognitive stimulation. STUDY DESIGN/METHODS:Single-blind, two-site randomized clinical trial (RCT) of the SB intervention. SB integrates PlayReadVIP, a universal, pediatric primary care-based program, and Family Check-Up (FCU), a targeted secondary home-based parenting intervention. Mother-infant dyads (N=327) were randomized at birth to standard pediatric care or the SB intervention. Linear regression analyses determined associations between cognitive stimulation at 6 months and maternal feeding styles at 24 months, a secondary data analysis. Direct intervention impacts on feeding styles, a secondary RCT outcome, were also assessed and mediation analyses explored intervention effects on feeding styles via earlier intervention impacts on cognitive stimulation. RESULTS:Cognitive stimulation was significantly associated with higher responsive and lower indulgent feeding styles. SB mothers were less likely to exhibit pressuring styles compared with controls (Effect Size [ES]=-0.12, p=0.02). Although no direct intervention effects were found on responsive or indulgent feeding styles, indirect effects of SB were evident on these feeding styles through intervention-induced increases in cognitive stimulation in the SB group. CONCLUSION/CONCLUSIONS:This study found positive linkages between cognitive stimulation in the home and later feeding styles. Additionally, the SB intervention was associated with less pressured feeding and indirect pathways mediated by intervention effects on cognitive stimulation. Implications for early childhood parenting interventions are discussed.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Housing insecurity is associated with adverse effects on child growth and development cross-sectionally; less is known about its cumulative, long-term effects. This study describes longitudinal experiences of housing insecurity during childhood from infancy (age 1 year) to adolescence (age 15 years) and examines their associations with adolescent health outcomes. METHODS:Using data from the Future of Families and Child Wellbeing Study, we created a composite measure of housing insecurity using 5 indicators (eg, skipping a rent or mortgage payment, eviction) for participants at ages 1, 3, 5, 9, and 15 years. We used group-based trajectory modeling to identify distinct patterns of housing insecurity, sociodemographic predictors of these patterns, and how these patterns relate to adolescent health outcomes. RESULTS:We identified 3 trajectories of housing insecurity from infancy to adolescence: secure, moderately insecure, and highly insecure. Adolescents who experienced moderately and highly insecure housing had decreased odds of excellent health (adjusted odds ratio, 0.81; 95% confidence interval [CI], 0.69-0.95; adjusted odds ratio, 0.67; 95% CI, 0.50-0.92, respectively) and more depressive symptoms (adjusted incidence rate ratio, 1.05; 95% CI, 1.02-1.08; 1.13; 95% CI, 1.08-1.19, respectively) than adolescents with secure housing. Adolescents who experienced highly insecure housing reported significantly higher anxiety symptoms (adjusted incidence rate ratio, 1.05; 95% CI, 1.003-1.113). CONCLUSIONS:Housing insecurity starting in infancy was associated with poorer adolescent health outcomes. These longitudinal patterns emphasize the need for novel screening mechanisms to identify housing insecurity when it emerges, as well as policies to prevent housing insecurity and its associated health outcomes.

BACKGROUND:Reach Out and Read (ROR) is a multi-component pediatric literacy promotion intervention. However, few studies link ROR components to outcomes. We examine associations between receipt of (1) multiple ROR components and (2) clinician modeling, a potential best practice, with enhanced home literacy environments (EHLEs) among Latino families. METHODS:Infant Read Scale). We used mixed models with clinician as a random effect, adjusting for covariates. RESULTS:440 Latino parent-infant dyads were included. With no components as the reference category, receipt of 1 component was not associated with EHLE. Receipt of 2 components (standardized beta = 0.27; 95%CI: 0.12-0.42) and 3 components (standardized beta = 0.33; 95% CI: 0.19-0.47) were associated with EHLE. In separate analyses, modeling was associated with EHLE (standardized beta = 0.16; 95%CI: 0.06-0.26). CONCLUSION/CONCLUSIONS:Findings support modeling as a core ROR component. Programs seeking to enhance equity by promoting EHLE should utilize such strategies as anticipatory guidance and clinician modeling in addition to book distribution. IMPACT/CONCLUSIONS:Reach Out and Read, a multi-component literacy promotion intervention, leverages primary care to promote equity in children's early language experiences. However, few studies link Reach Out and Read components to outcomes. Among Latino parent-infant dyads, we found that implementation of two and three components, compared to none, was associated with enhanced home literacy environments, following a dose response pattern. Parent report of clinician modeling was associated with enhanced home literacy environments. Literacy promotion programs seeking to enhance equity by promoting enhanced home literacy environments should utilize strategies in addition to book distribution, including anticipatory guidance and modeling, to maximize impact.

BACKGROUND:The Video Interaction Project (VIP) is a healthcare-based intervention that provides real-time video-feedback of parent-child play and reading interactions to families with children aged 0 to 36 months. Although evidence from randomized controlled trials demonstrates improved early relational health, including responsive parenting, after three to five VIP visits, the minimal effective dose in real-world implementations is unknown. This study aimed to determine the minimal effective dose of VIP during a real-world implementation for changing responsive parenting behaviors. METHODS:We performed a longitudinal prospective study of 183 dyads at a public hospital pediatric clinic. Responsive parenting behaviors were assessed with an observational checklist utilized as part of standard VIP practice at baseline and two follow-up VIP visits. RESULTS:Multilevel models adjusted for baseline sociodemographics (child's sex and age, and maternal education) and time between visits showed that responsive parenting behaviors during parent-child reading and play significantly increased after a single VIP visit (Cohen's d = 0.52, p < 0.05) with additional impact following completion of a second visit (cumulative for 2 visits: d = 0.76, p < 0.05). CONCLUSIONS:A single VIP visit is associated with increased responsive parenting behaviors. Findings support offering VIP widely, regardless of capacity to ensure attendance at multiple visits. IMPACT/CONCLUSIONS:This is the first study showing the minimal effective dose of the Video Interaction Project (VIP) for increasing responsive parenting behaviors. Responsive parenting behaviors increased by over 22% following a single VIP visit, with a cumulative increase of 37% following the second visit compared to baseline. Findings have important implications for implementation and scalability of pediatric-based preventive programs that support early relational health through activities such as reading and play.