Faculty Bibliography

OBJECTIVES/OBJECTIVE:Maternal stress has been associated with early child obesity through pathways related to decreased exclusive breastfeeding and increased non-responsive maternal-infant feeding styles. We sought to gain an in-depth understanding of how maternal stress, sadness, and isolation are perceived to affect feeding, in order to inform modifiable targets of intervention. METHODS:We conducted semi-structured qualitative interviews with Hispanic mothers living in poverty with young infants between 3 and 7 months old (n=32) from the intervention group of a randomized controlled trial of an early child obesity prevention intervention (Starting Early Program). Bilingual English-Spanish interviewers conducted the interviews, which were audio recorded, transcribed, and translated. Building on an existing theoretical framework developed by the National Scientific Council on the Developing Child, we used an iterative process of textual analysis to code the transcripts, until thematic saturation was reached. RESULTS:Three key themes were described: 1) maternal stress responses were varied and included: positive (brief and mild), tolerable (sustained but limited long-term impacts), or toxic stress (sustained and severe); 2) buffers included support from family, infants, health care providers, social service programs, and community organizations; 3) perceived effects on infant feeding: decreased breastfeeding due to concerns about stress passing directly through breast milk and indirectly through physical closeness, and increased non-responsive feeding styles. CONCLUSIONS:Maternal stress, particularly toxic stress, was perceived to negatively affect infant feeding. Mothers reported disrupting healthy feeding to avoid infant exposure to stress. Interventions to enhance buffering may help to mitigate toxic stress and promote healthy feeding interactions.

Infants learn and develop within an ecological context that includes family, peers, and broader built and social environments. This development relies on proximal processes-reciprocal interactions between infants and the people and environments around them that help them understand their world. Most research examining predictors of proximal processes like parent-child interaction and parenting has focused on elements within the home and family. However, factors like the neighborhood built environment may also exhibit an influence, and may be particularly critical in infancy, as socioeconomic disparities in cognition and language emerge early in life. Moreover, influence from the built environment could independently exacerbate these disparities, as research indicates that neighborhood impacts may be especially relevant for families living in neighborhoods that have experienced disinvestment and therefore have been under-resourced. The current study examines these questions by determining the association of neighborhood vacancy rate and observed physical disorder-indicators of poverty, residential stability, and long-term structural discrimination-with parental cognitive stimulation among predominantly Black/African-American families in Flint, Michigan. Flint is particularly salient for this study because vacancy rates and disinvestment vary widely across the city, driven by its long-time status as a city struggling economically. Regression analyses controlling for caregiver education, mental health, and social support indicated that vacancy rate and physical disorder negatively predicted parental cognitive stimulation. Moreover, there were significant interactions between the built environment and social support, indicating that, particularly for parent-child shared reading, vacancy rate and physical disorder predicted reduced shared reading only when parents had limited social support. These results have important implications for public policy around vacant property demolition and neighborhood reinvestment programs, as they indicate that the neighborhood built environment is associated with parenting behaviors that have important impacts on infants' learning and development.

This paper describes the Smart Beginnings Integrated Model, an innovative, tiered approach for addressing school readiness disparities in low-income children from birth to age 3 in the United States through universal engagement of low-income families and primary prevention in pediatric primary care integrated with secondary/tertiary prevention in the home. We build on both public health considerations, in which engagement, cost and scalability are paramount, and a developmental psychopathology framework (Cicchetti & Toth, Journal of Child Psychology and Psychiatry, and Allied Disciplines 50:16-25, 2009), in which the child is considered within the context of the proximal caregiving environment. Whereas existing early preventive models have shown promise in promoting children's school readiness, the Smart Beginnings model addresses three important barriers that have limited impacts at the individual and/or population level: (1) identification and engagement of vulnerable families; (2) the challenges of scalability at low cost within existing service systems; and (3) tailoring interventions to address the heterogeneity of risk among low-income families. Smart Beginnings takes advantage of the existing platform of pediatric primary care to provide a universal primary prevention strategy for all families (Video Interaction Project) and a targeted secondary/tertiary prevention strategy (Family Check-Up) for families with additional contextual factors. We describe the theory underlying the Smart Beginnings model, some initial findings from its recent application in two cities, and implications for changing social policy to promote school readiness beginning during very early childhood.

Poverty-related disparities appear early in life in cognitive, language, and social-emotional development, and in growth, especially obesity, and have long-term consequences across the life course. It is essential to develop effective strategies to promote healthy behaviors in pregnancy and the early years of parenthood that can mitigate disparities. Primary preventive interventions within the pediatric primary care setting offer universal access, high engagement, and population-level impact at low cost. While many families in poverty or with low income would benefit from preventive services related to both development and growth, most successful interventions have tended to focus on only one of these domains. In this manuscript, we suggest that it may be possible to address both development and growth simultaneously and effectively. In particular, current theoretical models suggest alignment in mechanisms by which poverty can create barriers to parent-child early relational health (i.e., parenting practices, creating structure, and parent-child relationship quality), constituting a final common pathway for both domains. Based on these models and related empirical data, we propose a strength-based, whole child approach to target common antecedents through positive parenting and prevent disparities in both development and growth; we believe this approach has the potential to transform policy and practice. Achieving these goals will require new payment systems that make scaling of primary prevention in health care feasible, research funding to assess efficacy/effectiveness and inform implementation, and collaboration among early childhood stakeholders, including clinicians across specialties, scientists across academic disciplines, and policy makers.

OBJECTIVE:To test breastfeeding duration and responsive parenting as independent predictors of infant weight change from birth to 12 months, and to test the moderating effect of a tiered parenting intervention on relations between breastfeeding and responsive parenting in relation to infant weight change. METHODS:Mother-infant dyads (N = 403) were participants in the ongoing Smart Beginnings (SB) randomized controlled trial testing the impact of the tiered SB parenting model that incorporates two evidence-based interventions: Video Interaction Project (VIP) and Family Check-Up (FCU). The sample was low income and predominantly Black and Latinx. Responsive parenting variables (maternal sensitivity and intrusiveness) came from coded observations of mother-infant interactions when infants were 6 months. Continuous weight-for-age (WFA) z-score change and infant rapid weight gain (RWG) from 0 to 12 months were both assessed. RESULTS:Longer breastfeeding duration was significantly associated with less WFA z-score change. The relationship between breastfeeding duration and WFA z-score change was significant only for infants in the intervention group. Intrusive parenting behaviors were also associated with greater WFA z-score change after accounting for breastfeeding duration. CONCLUSIONS:This study is one of the first to test both breastfeeding and parenting in relation to infant weight gain in the first year. Findings may have implications for family-focused child obesity prevention programs.

OBJECTIVE:To determine feasibility and explore effects of literacy promotion using e-books versus board books on the home reading environment, book reading, television use, and child development. METHODS:Randomized controlled trial comparing digital literacy promotion (DLP) using e-books to standard literacy promotion (SLP) using board books among Medicaid-eligible infants. DLP participants received e-books on home digital devices, while SLP participants received board books at well visits between 6 and 12 months of age. Differences in StimQ Read Subscale (StimQ-Read) scores, parent-reported reading and television use, and Bayley Scales of Infant Development-3rd Edition (Bayley-3) scores between groups were assessed using intention-to-treat analysis. RESULTS:A total of 104 Medicaid-eligible infants were enrolled and randomized from 3 pediatric practices. There were no differences in sociodemographic characteristics between groups at baseline. Children in the DLP group initially had lower StimQ-Read scores but showed similar increases in StimQ-Read scores over time as children in the SLP group. Parents in the DLP group reported greater use of digital devices to read or engage their child (65% vs 23%, P < .001) but similar board book reading and television viewing. There were no differences between groups in cognitive or motor scale scores, but DLP participants had marginally lower language scales scores (DLP 85.7 vs SLP 89.7; P = .10) at the 6-month follow-up. CONCLUSIONS/DISCUSSION/UNASSIGNED:Literacy promotion using e-books was feasible and associated with greater e-book usage but no difference in board book reading, television viewing, or home reading environment scores. A potential adverse impact of e-books on language development should be confirmed in future study.

OBJECTIVE:To determine the effect of adding a video and text messages to Reach Out and Read (ROR) on parent-reported literacy activities compared to the standard version. STUDY DESIGN/METHODS:We conducted a mixed methods hybrid type I effectiveness-implementation randomized trial in a community health center that serves low-income Latino families. We assessed shared reading frequency and the StimQ Reading subscale, at enrollment and 6-month follow-up and the StimQ Parent Verbal Responsivity subscale, Parent Reading Belief Inventory, and Survey of Wellbeing of Young Children-Milestones at follow-up. We randomized 160 parent-child dyads to ROR or ROR plus video and text messages (enhanced ROR). We collected process data on ROR and engagement with texts. We interviewed 15 enhanced ROR participants. We analyzed quantitative data using regression and qualitative data using immersion/crystallization. RESULTS:One hundred thirty-seven parent-child dyads completed the study (87% Latino, mean child age 9 months). We found differences in the StimQ Reading subscale (B = 0.32; P = .034) and marginal differences in attitudes about reading favoring enhanced ROR. Between-group differences for shared reading frequency, verbal responsivity, and developmental delay were not significant. Qualitative themes provided insight into the enhanced ROR including how it encouraged parents, remaining barriers like competing priorities and lack of social support, and unanticipated benefits (ie, parent appreciation for attention on their families' wellbeing). CONCLUSIONS:A video and text message enhancement to ROR resulted in modest improvements in the home literacy environment over ROR alone. Additional strategies are needed to overcome potent barriers faced by low-income families.

Fathers' involvement in early childhood is important for children's physical, emotional, and cognitive development, particularly in low-income families. However, little is known about the longitudinal relations between early father involvement and children's later physiological responses to chronic stress and behaviors impacted by stress in the context of poverty. These issues are particularly important among Latinx immigrant families who face significant psychosocial and poverty-related risk. In the current study, we examined the relationship between father involvement in infancy and physiological chronic stress in the middle childhood period, as measured through hair cortisol concentration (HCC), and several behavioral measures (attention problems, working memory) in a Latinx immigrant sample with low income. Father involvement in infancy predicted children's later HCC, and working memory in second to third grade. Father involvement also moderated the effect of HCC on working memory, such that increased HCC predicted better working memory when fathers were not involved. These findings suggest that the fathers' involvement in infancy has lasting impacts on health and behavior and that associations between physiological and behavioral measures of stress may be moderated by differences in early father involvement.