A number of studies have documented the mental health needs of at-risk mothers in home visitation. In particular, maternal depression leads to numerous negative outcomes in both mothers and children. Research shows that up to 60% of mothers in home visiting experience clinically significant depression during the first three years of the child’s life, that for many mothers major depressive disorder has a persistent and chronic course, and that up to 74% of mothers have been victimized by violence and trauma. In response, we developed In-Home Cognitive Behavioral Therapy, an evidence-based treatment that has been adapted for use in depressed mothers in home visitation.

Moving Beyond Depression™: Bringing Effective Treatment to Home Visiting Programs

Moving Beyond Depression™ (MBD), a program of Every Child Succeeds, was developed to scale up the availability of IH-CBT and effective identification strategies for home visiting programs around the country. MBD provides state and regional home visiting programs with training and support in screening for and identifying depression in mothers, mastering and implementing IH-CBT with fidelity and effectiveness, and evaluation tools and procedures to measure impact.

Home visiting programs were created to provide low-income mothers and their young children with training, teaching and support during the critical first years of life. Engaging and incorporating fathers into home visiting through an integrated co-parenting intervention has the potential to significantly improve psychosocial outcomes in children participating in home visitation by strengthening the working relationship between mothers and fathers, creating a nurturing and supportive environment for growing children, and reducing exposure to parental conflict.

We have partnered with Mark Feinberg, PhD, of Pennsylvania State University to test an adapted version of Family Foundations (FF), an evidence-based program focused on enhancing co-parenting, for the home visiting population in Every Child Succeeds. Data from Every Child Succeeds indicates that many fathers are actively involved with their children in the six months following birth, with 86 percent seeing their children weekly and 67 percent daily.

These rates drop off significantly over time, and reduction in positive father involvement is linked to mother-father co-parenting and relationship difficulties. Given the large investment that has already been made in HV programs, there is a compelling and urgent need to amplify its impacts by fostering positive co-parenting and father engagement.

A major challenge for long-term prevention programs such as home visitation is retention of families over the full course of service. Several studies document premature dropout in home visitation programs, with up to 50 percent of clients leaving programs after one year. There are numerous reasons why families drop out of services, including relocation, difficulty scheduling home visits and dissatisfaction with services. Understanding the reasons why families stay or leave home visitation programs, and designing strategies to help them remain engaged in the services, is an important focal point of our research.

Recently Funded Research

Increasing Retention in Home Visitation

R40 funded by the Maternal and Child Health Bureau: This study is a randomized controlled clinical trial of motivational interviewing (MI) to enhance retention and promote program adherence for 232 first-time mothers receiving home visitation. MI is a client-centered strategy that focuses specifically on increasing motivation and commitment to change. Mothers in four agencies (two each in HFA and NFP models were randomly assigned to MI or “home visitation as usual” (HVAU) conditions. Half of the home visitors were trained in MI procedures. Mothers and children were assessed at enrollment, and again at nine and 18 months later. In addition to measuring retention, we collected data on maternal and child psychosocial functioning. The other half of test subjects (HVAU) received an attention-control condition.

We hypothesized that (1) the MI condition would be superior to HVAU in terms of retention and program adherence, (2) MI would result in benefits in both the HFA and NFP models, (3) mothers with higher levels of depression and trauma history would be more likely to be retained relative to their counterparts, and (4) retained mothers in the MI condition would still have better outcomes than retained mothers in the HVAU condition.

Data analyses are currently being conducted.

Home Visiting Implementation

The Ammerman lab conducts ongoing research into topics in home visiting that go beyond our main research subjects. These include topics such as infant mortality, supporting mothers in breast feeding their infants, identifying and intervening in intimate partner violence, and maternal substance abuse. These efforts are conducted with Every Child Succeeds.

Quality Improvement in Home Visiting

Although improvement science is an integral part of manufacturing and healthcare, its application to prevention is still in its early stages. Through our involvement with Every Child Succeeds, we are investigating opportunities to apply quality improvement to home visitation. We have implemented tools and procedures such as key driver analyses, process maps, trend charts, red-green charts and control charts, and we have helped implement the use of a web-based system that collects data on home visiting in real time (eECS). We are currently conducting ongoing improvement projects to demonstrate the effectiveness of QI approaches in home visiting settings.

Ammerman directs the Every Child Succeeds participation in the Design Options for Home Visiting Evaluation (DOHVE) Team. Established as part of the Patient Protection and Affordable Care Act, the DOHVE Team provides technical assistance to states, tribes, and territories that are expanding their home visiting services as part of The Maternal, Infant, and Early Childhood Home Visiting program (MIECHV), directed by HRSA.

Participation in Other Research

Ammerman is a co-investigator on the Cincinnati Home Injury Prevention (CHIP) Study. The PI on this study is Kieran J. Phelan, MD (Cincinnati Children's). The CHIP Study is an NICHD-funded R01 investigation of the efficacy of an injury prevention enhancement to home visiting.

Ammerman is a co-investigator on the STAT ED study on which the PI is Jacqueline Grupp-Phelan, MD. This CDC-funded study seeks to examine the efficacy of a motivation-enhanced approach to identifying and improving linkage to mental health services in suicidal children and teens who are seen in emergency department settings.