Faculty Bibliography

OBJECTIVE:Little is known about how parenting interventions might influence families' access to related healthcare services during early childhood. This study describes the effects of a parenting intervention, Smart Beginnings (SB), on referrals to early intervention (EI) or early childhood special education (ECSE) after evaluation within a predominantly Black/Latine sample with low incomes. SB is a tiered intervention integrating a universal parenting program delivered in primary care clinics (PlayReadVIP) with a targeted home visiting program (Family Check-Up). METHODS:Data were drawn from a randomized controlled trial of SB, with sites in NYC and Pittsburgh, PA. The 280 families (132 treatment; 148 control) were 43% Black, 47% Latine, 37% Spanish-speaking, and 100% Medicaid-eligible. Hierarchical logistic regressions examined associations between expressive vocabulary and problem behaviors (internalizing and externalizing symptoms) at 2 years, and the impact of the SB intervention on the likelihood of EI/ECSE evaluation and service referrals based on evaluation results by 4 years. RESULTS:Across sites, children's lower expressive vocabulary and higher problem behaviors at 2 years predicted receiving EI/ECSE evaluation and service referrals by age 4. Assignment to the SB intervention reduced the likelihood of evaluations leading to referrals for EI/ECSE service. CONCLUSIONS:Results from this RCT showed that children with early behavior and language challenges were more likely to receive EI/ECSE evaluation and services by preschool-age. Children assigned to SB were less likely to be referred for services. Studying factors that predict EI/ECSE involvement for children from historically marginalized populations can help promote equity in early care systems.

Parenting in very early childhood (0-2 years) provides important context for children's socioemotional development. The present study aims to address limitations of extant parenting literature, namely the reliance on white, middle-class samples and use of variable-centered approaches that often mask the rich heterogeneity of parenting styles. Using data from an efficacy trial of a tiered parenting program to promote school readiness, the current study examined parenting styles across three waves when children were 6, 18, and 24 months with a sample of Black/African American and Latina mothers with low incomes using person-oriented, latent class analysis. Based on multiple fit indices and interpretability, a three-class model was found to best fit the data. Two of the three parenting classes were identified for both Black/African American and Latina groups across all three ages: one was characterized by high levels of sensitivity, positive regard, and language quality/quantity (High Support and Warmth) and the other was characterized by moderate levels of these indicators (Moderate/Low, Moderate, and Moderate/High Support and Warmth). The third class varied the most between groups and over time. For Black/African American mothers, the third class was characterized most notably by the level of directiveness (ranging from High at 6 months, Moderate at 18 months, and Low at 24 months). For Latina mothers, this class was characterized by varying levels of directiveness and stimulation that were High at 6 months and Moderate at 18 and 24 months. Within most classes, mean levels of parenting behaviors varied by age. Findings emphasize the importance of considering age, culture, and time when assessing maternal parenting from infancy to toddlerhood.

The goal of this study was to examine the impacts of the Smart Beginnings (SB) intervention, a tiered model that combines universal primary prevention and targeted secondary prevention, on parental negative affect during discipline and children's externalizing behavior. Analyses included 273 families who were randomly assigned to SB or control groups at birth. Parental negative affect during discipline and child externalizing behavior were assessed through parent report at age four and six, respectively. Compared to the control group, families in SB had significantly reduced parental negative affect during discipline, with indirect effects on children's externalizing behavior through impacts on parent affect during discipline, both for the full sample and specifically for families with increased risks. Findings suggest that interventions aimed at promoting positive parent-child interactions may have important impacts on parenting behaviors and may prevent the onset of child behavior problems, with important implications for the implementation of preventive interventions. This study examined the impacts of the Smart Beginnings (SB) tiered model, which combines universal primary prevention and targeted secondary prevention, on parental negative demeanor during discipline-negative parental behavioral traits that are expressed through anger, verbal aggression, or demeaning behavior-and children's externalizing behavior. Analyses included 273 families randomly assigned to SB or control groups at birth. Parental negative demeanor during discipline was assessed through parent report (Socolar Discipline Survey) at age four and child externalizing behavior (CBCL) at age six. Compared to controls, regression analyses indicated that families in SB had significantly reduced parental negative demeanor during discipline, with mediation analyses suggesting indirect effects on child externalizing through impacts on parent demeanor during discipline, moderated by family risk level. Findings indicate that interventions aimed at promoting positive parent-child interactions may impact parenting behaviors and prevent onset of child behavior problems, with important implications for implementation of preventive interventions.

Parenting in very early childhood (0-2 years) provides important context for children's socioemotional development. The present study aims to address limitations of extant parenting literature, namely the reliance on white, middle-class samples and use of variable-centered approaches that often mask the rich heterogeneity of parenting styles. Using data from an efficacy trial of a tiered parenting program to promote school readiness, the current study examined parenting styles across three waves when children were 6, 18, and 24 months with a sample of Black/African American and Latina mothers with low incomes using person-oriented, latent class analysis. Based on multiple fit indices and interpretability, a three-class model was found to best fit the data. Two of the three parenting classes were identified for both Black/African American and Latina groups across all three ages: one was characterized by high levels of sensitivity, positive regard, and language quality/quantity (High Support and Warmth) and the other was characterized by moderate levels of these indicators (Moderate/Low, Moderate, and Moderate/High Support and Warmth). The third class varied the most between groups and over time. For Black/African American mothers, the third class was characterized most notably by the level of directiveness (ranging from High at 6 months, Moderate at 18 months, and Low at 24 months). For Latina mothers, this class was characterized by varying levels of directiveness and stimulation that were High at 6 months and Moderate at 18 and 24 months. Within most classes, mean levels of parenting behaviors varied by age. Findings emphasize the importance of considering age, culture, and time when assessing maternal parenting from infancy to toddlerhood.

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 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.