Month: February 2015

Promoting Cross Collaborative Research Efforts and Implications for Excellence in Practice

The Michigan Infant/Toddler Research Exchange (MITRE) is comprised of researchers from Central Michigan University, Eastern Michigan University, Michigan State University, Wayne State University, and the University of Michigan whose research focuses on infants, toddlers, their families and caregivers.

MITRE faculty reflect diverse disciplinary backgrounds in human development, early childhood education, pediatrics, nursing, psychiatry, psychology, social work, and family therapy. Faculty utilize a variety of theoretical and conceptual frameworks in their studies, including infant mental health, attachment theory, transactional models of development and gene X environment models to better understand how intersections between biological, psychosocial, familial, cultural and community contexts influence children’s growth and development. Faculty study a range of topics including early social-emotional development, motor development, early obesity risk, family processes and functioning associated with infant/toddler development, parental and caregiver reflective functioning, and early language and communication skills in the context of parent-child relationships. MITRE researchers have strong interests in the implications of research for best practices in early intervention and support programs and in early education environments and they are involved in community-based research efforts working in collaboration with programs such as Early Head Start, Head Start, Community Mental Health, pediatric and family clinics, and local childcare and early education facilities. The goals of the MITRE are to provide a forum for Michigan researchers to (a) discuss key issues in applied research focused on infants, toddlers, families, and caregivers and to share resources and exchange ideas, (b) foster cross-university research, and (c) to serve as a resource for the state in research to practice initiatives.

To learn more about MITRE, visit http://www.beeslab.org/mi-infanttoddler-research-exchange.html.

Over the coming year, MITRE will be contributing a series to the Infant Crier. The series topics include: attachment-based interventions, reflective functioning and mentalization, individual differences in development, fathers, emotion socialization, and families in trauma. We hope you enjoy the series.

There is a significant need for effective, evidence-based and practice-informed interventions to support parenting among high risk, overburdened families, and programs that focus both on enhancing sensitive parenting as well as improving parent mental health have a substantial potential for positive impact on a broad range of outcomes, including parental, child and family system functioning.  For example, increasing a parent’s ability to accurately perceive, interpret and respond to his/her infant’s cues has been shown to improve child attachment security, whereas sensitively augmenting protective factors such as enhancing coping skills or access to support and clinical care can ameliorate some of the common consequences of parental mental illness.  Infant mental health (IMH) home visiting, as practiced in Michigan, is a strong model of intensive intervention to address exactly the concerns faced by at-risk families.  However, not all families are eligible or ready to engage in the IMH program, for example, due to internal barriers such as a history of trauma and wariness about engaging with providers.  Thus there remains a need for treatment-engagement interventions that work to address and minimize barriers, and for those in need, provide a safe context for connecting to providers and entry into more intensive care.

The need for evidence-based and practice-informed strategies aimed to enhance both parenting and parent mental health also presents rich opportunities for research-provider partnerships in the development and evaluation of new and existing program models.   We describe here two preventive intervention programs that were developed in Michigan and are currently implemented at multiple sites across the state.  Both were developed, implemented, and evaluated in close collaboration with community providers across the state, and thus provide an illustration of meaningful academic-community partnership, with a common focus on meeting the needs of Michigan’s vulnerable families through best-practice service delivery.   Mom Power (Muzik et al., in press) is a brief multifamily group preventive intervention designed to engage high-risk mothers of infants and young children, and Strong Military Families (Rosenblum & Muzik, 2014) is an adaptation of the Mom Power model, specifically designed to meet the needs of military and veteran families with young children.

Mom Power: a Multifamily Preventive Intervention Approach to Engaging High-Risk Traumatized Mothers with Young Children

Mom Power is a manualized (Muzik, Rosenblum, Schuster, & Ribaudo, 2013) brief multifamily parenting and self-care group intervention program for high-risk mothers with infants and young children; the program involves three individual and ten 2½-hour-long group sessions.  Most of the mothers who participate in the program have trauma histories and/or mental health problems of their own, including a high prevalence of maternal depression, anxiety and posttraumatic stress.  The intervention aims to 1) increase sensitive parenting, 2) teach positive stress coping to alleviate mental health symptoms, and 3) facilitate social support and connections to community resources.  Mom Power is based on 5 key therapeutic “pillars”:  (1) Social Support is enhanced by creating a shared group experience, with opportunities for informal relationship building during shared meal-times and the Mom Group, as well as through involvement of other parenting support individuals in the mothers’ natural network. (2) Given the central importance of attachment relationships in early development, the Parenting Education curriculum emphasizes responsiveness and sensitivity to young children’s separation experiences.  In the Mom Group, participants are introduced to key topics in parenting and child development, observe video interactions and apply concepts learned, engage in activities designed to develop and practice skills, and reflect on interactions with their own children.  Parents are introduced to attachment concepts, with an emphasis on helping parents identify children’s emotional needs and provide a secure base and safe haven as needed.  In addition, group leaders emphasize the need for “Balanced Parenting,” that is, encouraging parents to integrate being both “strong and in charge” as well as “warm and kind” in their everyday interactions with their children.  (3) The Self-Care/Stress-Reduction curriculum addresses mothers’ needs for hands-on strategies for reducing their own levels of stress in order to provide Balanced Parenting and support their children’s needs.  Each Mom Group session includes hands-on practice of evidence-based stress-reduction “skills” including guided breathing, relaxation, or mindfulness. This has the added benefit of helping mothers prepare for reuniting with their children in a calm, relaxed state. (4) Child Routines and Parent-Child Interaction are supported by a child curriculum that emphasizes creating safe, predictable routines; acknowledging “goodbyes” when mothers leave for their class; developmentally appropriate play-based activities; and observation of and support for reunions when mothers return from their group.  These brief separations and reunions provide an opportunity for “real-time” practice, negotiating feelings about separations and return, and helping mothers to identify and respond to their children’s needs for support. Mothers are encouraged to anticipate, observe, and reflect upon these separations and reunions, as well as identify ways they might want to “try something new” to address their children’s feelings during separation/reunion at the next session.  (5) Individual meetings with mothers are held mid-way through the 10-week intervention to provide opportunities for Connecting Families to Care, including individualized referrals to relevant community resources, including mental health home visiting when indicated.  The program incorporates circles of support and caring with clear attention to the parallel process: we aim to provide a secure base and safe haven to the mothers in part by ensuring attention to the needs of staff for safe haven and secure base, with regular debriefing and use of reflective supervision for parent and child group leaders.

The Mom Power program was developed in close collaboration with several community based health clinics in Southeastern Michigan, and with support from the Department of Community Health. The curriculum was developed iteratively through an iterative process of getting input from Mom Power intervention facilitators, as well as the participating mothers who experienced the program.  Thus, the curriculum is founded both on bottom-up (input from community) and top-down (theory-driven and evidence-based) principles. As the model was trial implemented through Community Mental Health, other agencies expressed interest, underscoring the demand for this type of brief treatment-engagement, preventive intervention model.  Yet from a research perspective, there was a need for continued evaluation of the model to build the evidence-base and confirm its efficacy for improving parenting and parent mental health.  We thus employed a “hybrid” approach to evaluation, that is, engaging in dissemination of the model through community provider training and concurrent ongoing evaluation of the efficacy of the model through involvement of providers in evaluation activities.  This approach allows us to identify not only whether the program works in rigorously controlled ‘scientifically ideal’ circumstances, but also how it is implemented and its efficacy in ‘real world’ contexts of community-based practice.

Results of this evaluation undertaking have been very encouraging.  Our pilot data indicated that not only was Mom Power associated with improvements in parenting (including capacity for reflective parenting), stress coping, and mental health, but that these results were most pronounced for women who entered the program with histories of interpersonal trauma and/or mental health diagnoses—precisely the families the program was designed to reach (LePlatte et al., 2012; Muzik et al., in press). In addition, our pilot data also confirmed our clinical intuition that participants’ engagement and satisfaction with the intervention was high; in fact, treatment engagement with Mom Power was in the 65-73% range across race/ethnicity groups of Caucasian and African-American mothers (Muzik et al., 2014). However, the initial pilot study compared mothers who graduated from the Mom Power program (i.e., attended at least 7 of the 10 group sessions) against those who dropped out prematurely. In order to evaluate more rigorously, we therefore, together with our community partners in the southeastern Michigan region, undertook a more stringent evaluation, conducting what is referred to as a “randomized clinical trial”, that is, we recruited women from the community and assigned them randomly to either the Mom Power program or to a waitlist condition.  In the waitlist condition women received weekly mailings that conveyed the content without the “warm overlay” of active group involvement; these families were eligible to participate in the Mom Power program in the “next round” of delivery, after we finished the assessments that allowed us to observe whether women in Mom Power or the waitlist group differed on key outcomes.  Importantly, for ethical reasons, all women were eligible for any referral indicated and provided including home based IMH services; that is, no family was ever denied access to treatment, but only some were assigned immediately to the Mom Power preventive intervention.  As with our initial pilot study we observed that, compared to the waitlist control condition, participation in Mom Power was associated with significant reductions in mental health symptoms and parenting stress and improvement in mother-infant bonding.  In addition, mothers assigned to Mom Power were more likely to receive additional referrals for services (approximately half of all mothers in Mom Power, but only 9% of women in the waitlist condition were referred to additional services including IMH).

This type of randomized controlled study represents a strong test for the efficacy of the intervention.  Just as importantly, the “real world” applicability of this approach was strengthened by the fact that Mom Power was delivered by trained community IMH providers in their agency settings.  This allowed us to learn from providers about what makes this work, as well as what barriers exist to community-based implementation, so that we can strengthen these facilitators and reduce barriers in subsequent implementations.  This also contributes to the likelihood that the model can be sustainably delivered beyond the duration of the research study, an important goal for us as researchers and clinicians.  Indeed, we are very pleased that Mom Power is now offered at multiple sites as a billable program service, independent of our research collaborations.

A Unique Adaptation of the Mom Power Model:  Strong Military Families

Military parents make a dual commitment to protect their children and protect our nation. Yet these families face special challenges in balancing military and family life.  Military children and families sacrifice and serve alongside service members, and the need for support and a strong community continues during the period of reintegration after the service member returns.  As one father shared: “He was born and I was deployed before he was walking. And when I came back, he was standing, gripping onto (his mother’s) leg –- looking at me like, ‘That’s who?’ She had to tell him, ‘That’s Daddy.’” Another father commented, “When I came back, it was difficult … trying to find that closeness and trying to find that reconnect.”

Indeed, more than 12,000 Michigan National Guard troops have been deployed since 9/11.  Michigan’s military community is vast – recently ranking ninth of all states in the number who have served in Iraq and Afghanistan — and underserved – ranking last among states in providing services to veterans and their families. The steep rise in rates of child abuse, divorce, depression, PTSD, and suicide during and following deployment highlights the need for support, yet due to geographic dispersion in civilian communities National Guard families often lack access to mental health services. Separation from one parent, coupled with heightened distress in the at-home parent, places young children at particular risk.  Although often eagerly anticipated, reunification also poses challenges, including adjusting to the parent-soldier’s return, reestablishing roles and routines, and, if necessary, accommodating to combat-related injuries.

Despite overwhelming need, tailored interventions for military families with young children are rare; thus, promising practices that incorporate evidence-based strategies can fill a critical void.  We therefore developed the Strong Military Families model, an adaptation of the 10-week multi-family Mom Power group intervention, tailored for military families with young children and to include both mothers and fathers (Rosenblum & Muzik, 2014).  The intervention incorporates evidence-based strategies to reduce parental stress and social isolation, enhance parenting, and connect families with resources, thereby improving mental health outcomes.

Strong Military Families is a program of the University of Michigan Department of Psychiatry and Depression Center’s Military Support Programs and Networks (M-SPAN), which has a successful track record of developing and implementing mental health programs for military families, and is well-connected with military service providers across the state.  However, in order to reach families with young children and sustain services across the state it was clear that we needed to again implement an evaluation approach that involved collaboration with community partners who serve families with young children.  We therefore established a collaboration with the Michigan Department of Community Health and with a number of regional collaborators, which include but are not limited to Easter Seals in Oakland County, the Judson Center in Macomb, and the Community Action Agency in Jackson County.  Funding to support the development and initial evaluation of Strong Military Families included support from the national Welcome Back Veterans initiative as well as the National Institutes of Health, while the regional Flinn Foundation and Great Start Collaborative Macomb provided support for disseminating the model and building capacity to deliver this service at specific sites in Southeastern Michigan.   Consistent with the Mom Power evaluation, our pilot data are very encouraging and indicate improvements in parent mental health, parenting, and child outcomes.  We are now finishing up collection of data in a larger clinical trial contrasting waitlist families from those who complete the multifamily group.  While this is underway we are simultaneously working to identify new and innovative ways to reach families in geographically diverse regions.  For example, with recent support from the Justin Verlander “Wins for Warriors” Foundation we will be launching a pilot adaptation of a weekend “Wins for Warriors Strong Military Families Weekend Retreat,” which will allow us to engage and support families from diverse geographic regions via delivery of a weekend version of the Strong Military Families in northern Michigan.

One of the many important “take home” messages from the work we have done with Strong Military Families is that fathers and couples express a desire for and can benefit from involvement in this type of a multifamily group model approach.  We are therefore currently working with collaborators at UM and Wayne State to identify ways of adapting this model to meet the needs of civilian community, urban fathers of young children as well.

Ultimately, we believe that the Mom Power and Strong Military Families models hold promise not only as solid, evidence-based practices for engaging vulnerable families and for improving parenting, parent mental health, and child outcomes, but also as models for partnership between researchers and providers to ensure that best practice models are not only “evidence-based” but also reflect real world “practice-informed” approaches to this important work.

 

References:

LePlatte, D., Rosenblum, K., Stanton, E., Miller, N., Muzik, M. (2012).  Mental Health in Primary Care for Adolescent Patients.  Mental Health in Family Medicine, 9, 39-45.

Muzik, M. , Rosenblum, K., Schuster, M. & Ribaudo, J. (2013). Mom Power Curriculum (Unpublished Manual). [Note: Training in the model is available; contact muzik@med.umich.edu or katier@med.umich.edu with questions or for more information.]

Muzik, M., Schmicker, M., Alfafara, E, Dayton, C, Schuster, M, & Rosenblum, KL. (2014).  Predictors of Treatment Engagement to a Parenting Intervention among Caucasian and African-American Mothers. Journal of Social Service Research,40 (5); 662-680.

Muzik, M. , Rosenblum, K., Alfafara, E., Schuster, M., Miller, N., Waddell, R. & Kohler, E. (in press). Mom Power: An Intervention to Enhance Parenting and Mental Health in High-Risk Mothers. Archives of Women’s Mental Health.

Rosenblum, K. & Muzik, M. (2014).  STRoNG Military Families: A multifamily group intervention for military families with young children.  Psychiatric Services, 65, 399.

Over the past decade advances in developmental biology have provided considerable evidence linking early adversity to negative outcomes.  Children living in poverty face substantially increased risk of early adversity. Stressful environments characterized by elevated levels of chronic environmental and caregiving stressors in the context of poverty can disrupt brain architecture and exacerbate underlying genetic vulnerabilities to affect psychological functioning. Shonkoff and colleagues (2009) define toxic stress as the prolonged exposure to cumulative stressors that disrupt regulation via chronic reactivity of physical stress-response systems. Guided largely by attachment theory and research, supportive caregiving is recognized as a crucial buffer against toxic stressors, reducing the harmful physiological effects of high stress (Shonkoff, 2010). Recent evidence demonstrates the long term positive effects of early attachment-based intervention programs on children’s development in high-risk community samples, enhancing the importance of early community-based intervention implementation to vulnerable populations.

Early Head Start: The Need for Support

Early Head Start (EHS) and other publicly funded programs were designed to promote early parenting and child development among families living in poverty. The prominent goal of EHS is to provide high-quality, comprehensive support services to promote child development and positive, child-parent relationships. Longitudinal data from the Early Head Start Research and Evaluation Project (EHSREP) has demonstrated numerous, consistent, modest program effects on observed parenting for the sample as a whole (Administration for Children and Families, 2002; Love et al., 2005). For example, mothers who received EHS displayed more supportive parenting behaviors towards their children and children who engaged more with their mothers compared to those randomly assigned to the control group. However, recent work has begun to highlight what works for whom in EHS programming effects across the diverse population groups (Raikes, Vogel, & Love, 2013). For example, smaller program effects were found for children with mothers identified as high-risk, according to the EHSREP cumulative demographic risk protocol (Administration for Children and Families, 2002; Raikes, Vogel, & Love, 2013). Furthermore, Berlin and colleagues (2011) found fewer effects of program participation on supportive parenting behaviors for mothers with higher levels of attachment avoidance at baseline compared to mothers with lower levels of attachment avoidance. Researchers and practitioners have suggested that some EHS recipients would benefit from attachment-based parenting services (Raikes, Vogel, & Love, 2013).

ABC as a Supplement to EHS

The Attachment and Biobehavioral Catch-Up (ABC) developed by Dozier and colleagues, targets early parenting behaviors and attachment. The ABC program provides an evidence-based model consisting of structured intervention activities delivered in 10 home-based sessions by a trained parent coach. Specific attachment-related topics are addressed in each session, including demonstrations through video-recorded mother-infant interactions, with the presence of both mother and child. This brief, yet intense program provides parent coaching in reference to three specific behavioral targets for helping parents learn how to: (1) behave in nurturing ways when children are distressed; (2) follow the child’s lead in delighted ways; and (3) avoid behaving in frightening or intrusive ways. A key mechanism of the ABC program is for parent coaches to provide in the moment commenting related to the three target behaviors exhibited during the sessions. This immediate feedback reinforces and supports mothers’ use of target behaviors.

Partners for Parenting Study

As part of Administration for Children and Families Buffering Toxic Stress Research Consortium, the Partners for Parenting (P4P) study is an ongoing Early Head Start-University Partnership, addressing the prevention of toxic stress through attachment-based intervention (Co-Principal Investigators are Lisa Berlin and Brenda Jones Harden). The P4P study consists of a randomized controlled trial investigating the effects of home-based Early Head Start with a supplemental parenting intervention, the Attachment and Biobehavioral Catch-Up (ABC) program. Participants include primarily Spanish and English speaking Latino and African American mother-infant dyads in the Washington, DC metropolitan area receiving home-based Early Head Start services. The goal of the P4P project is to evaluate the effects on parenting behaviors and infant stress regulation via measuring the implementation and sustainability of the ABC program within the Early Head Start context. Initial analyses have reported robust feasibility and acceptance of this model by mothers and EHS staff (Berlin, Jones Harden, Raymond, & Denmark, 2012). Qualitative maternal interviews highlighted the unique benefits of receiving ABC in addition to Early Head Start home visits. Findings are expected to inform community-based intervention researchers, practitioners, and policymakers.

 

References

Administration for Children and Families. (2002). Making a difference in the lives of children and families: The impacts of Early Head Start programs on infants and toddlers and their families. Washington, DC: U. S. Department of Health and Human Services.

Berlin, L. J., Jones Harden, B., Raymond, M., & Denmark, N. (2012, June). Buffering children from toxic stress through attachment-based intervention: An Early Head Start-University Partnership. Poster presented at the Head Start National Research Conference, Washington.

Berlin, L. J., Whiteside-Mansell, L., Roggman, L. A., Green, B. L., Robinson, J., & Spieker, S. (2011). Testing maternal depression and attachment style as moderators of early head start’s effects on parenting. Attachment & Human Development, 13(1), 49-67.

Dozier, M., Lindheim, O., & Ackerman, J. (2008). Attachment and biobehavioral catch-up. In L. Berlin, Y. Ziv, L. Amaya-Jackson, & M. T. Greenberg (Eds.), Enhancing early attachments. New York: Guilford.

Love, J. M., Kisker, E. E., Ross, C., Raikes, H., Constantine, J., Boller, K., et al. (2005). The effectiveness of Early Head Start for 3-year-old children and their parents: Lessons for policy and programs. Developmental Psychology, 41(6), 885-901.

Raikes, H. H., Vogel, C., & Love, J. M. (2013). Family subgroups and impacts at ages 2, 3, and 5: Variability by race/ethnicity and demographic risk. Monographs of the Society for Research in Child Development, 78, 64-92.

Shonkoff, J. P. (2010). Building a new biodevelopmental framework to guide the future of early childhood policy. Child Development, 81(1), 357-367.

Shonkoff, J. P., Boyce, W. T., & McEwen, B. S. (2009). Neuroscience, molecular biology, and the childhood roots of health disparities: Building a new framework for health promotion and disease prevention. Journal of the American Medical Association, 301(21), 2252-2259.

Shonkoff, J., & Phillips, D. (Eds.). (2000). From neurons to neighborhoods: The science of early childhood development. Washington, DC: National Academy Press.