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OBJECTIVES Limited evidence is available on mechanisms linking integrated, multisector interventions with early childhood development. The Integrated Early Childhood Development program aims to improve children’s development by promoting targeted caregiving behaviors beginning prenatally through age 5 years, in partnership with the Royal Government of Cambodia. METHODS This cluster stepped-wedge trial is being conducted in Cambodia among 3 cohorts, encompassing 339 villages and 1790 caregivers who are pregnant or caring for a child aged CONCLUSIONS This protocol article describes the plans for a cluster randomized controlled trial to measure the impact of an integrated, multisector intervention on children’s development. By partnering with the Royal Government of Cambodia and addressing intervention pathways and moderators, this trial will provide guidance for policies and programs to promote early childhood development using principles of implementation science and equity, including increased investment for vulnerable families.

OBJECTIVES: Prenatal homelessness is associated with elevated risks of adverse neonatal outcomes. How the timing and duration of homelessness during pregnancy and/or a child’s early life relate to postnatal child health is unclear. METHODS: We interviewed 20 571 low-income caregivers of children 6 months or RESULTS: After controlling for birth outcomes and other potential confounders, compared with never-homeless children, children who were homeless both pre- and postnatally were at the highest risk of the following: postneonatal hospitalizations (adjusted odds ratio [aOR] 1.41; confidence interval [CI] 1.18–1.69), fair or poor child health (aOR 1.97; CI 1.58–2.47), and developmental delays (aOR 1.48; CI 1.16–1.89). There was no significant association with risk of underweight (aOR 0.95; CI 0.76–1.18) or overweight status (aOR 1.07; CI 0.84–1.37). Children 6 months of homelessness versus those who were never homeless had high risks of fair or poor health (aOR 3.13; CI 2.05–4.79); children 1 to 4 years old who were homeless for >6 months were at risk for fair or poor health (aOR 1.89; CI 1.38–2.58). CONCLUSIONS: After controlling for birth outcomes, the stress of prenatal and postnatal homelessness was found to be associated with an increased risk of adverse pediatric health outcomes relative to those who were never homeless. Interventions to stabilize young families as quickly as possible in adequate and affordable housing may result in improved pediatric health outcomes.

OBJECTIVE: To ascertain measures of health status among 6- to 24-month-old children classified as below normal weight-for-age (underweight) by the Centers for Disease Control and Prevention (CDC) 2000 growth reference but as normal weight-for-age by the World Health Organization (WHO) 2006 standard. METHODS: Data were gathered from children and primary caregivers at emergency departments and primary care clinics in 7 US cities. Outcome measures included caregiver rating of child health, parental evaluation of developmental status, history of hospitalizations, and admission to hospital at the time of visit. Children were classified as (1) not underweight by either CDC 2000 or WHO 2006 criteria, (2) underweight by CDC 2000 but not by WHO 2006 criteria, or (3) underweight by both criteria. Associations between these categories and health outcome measures were assessed by using multiple logistic regression analysis. RESULTS: Data were available for 18 420 children. For each health outcome measure, children classified as underweight by CDC 2000 but normal by WHO 2006 had higher adjusted odds ratios (aORs) of adverse health outcomes than children not classified as underweight by either; children classified as underweight by both had the highest aORs of adverse outcomes. For example, compared with children not underweight by either criteria, the aORs for fair/poor health rating were 2.54 (95% confidence interval: 2.20–2.93) among children underweight by CDC but not WHO and 3.76 (3.13–4.51) among children underweight by both. CONCLUSIONS: Children who are reclassified from underweight to normal weight in changing from CDC 2000 to WHO 2006 growth charts may still be affected by morbidities associated with underweight.

BACKGROUND AND OBJECTIVE: Previous research found that prenatal cocaine exposure (PCE) may increase children's vulnerability to behavior and cognition problems. Maturational changes in brain and social development make adolescence an ideal time to reexamine associations. The objective was to conduct a systematic review of published studies examining associations between PCE and adolescent development (behavior, cognition/school outcomes, physiologic responses, and brain morphology/functioning). METHODS: Articles were obtained from PubMed, PsycInfo, Web of Science, and CINAHL databases through July 2012 with search terms: prenatal drug, substance, or cocaine exposure; adolescence/adolescent; and in utero substance/drug exposure. Criteria for inclusion were nonexposed comparison group, human adolescents aged 11 to 19, peer-reviewed, English-language, and adolescent outcomes. RESULTS: Twenty-seven studies representing 9 cohorts met the criteria. Four outcome categories were identified: behavior, cognition/school performance, brain structure/function, and physiologic responses. Eleven examined behavior; 7 found small but significant differences favoring nonexposed adolescents, with small effect sizes. Eight examined cognition/school performance; 6 reported significantly lower scores on language and memory tasks among adolescents with PCE, with varying effect sizes varied. Eight examined brain structure/function and reported morphologic differences with few functional differences. Three examined physiologic responses with discordant findings. Most studies controlled for other prenatal exposures, caregiving environment, and violence exposure; few examined mechanisms. CONCLUSIONS: Consistent with findings among younger children, PCE increases the risk for small but significantly less favorable adolescent functioning. Although the clinical importance of differences is often unknown, the caregiving environment and violence exposure pose additional threats. Future research should investigate mechanisms linking PCE with adolescent functioning.

OBJECTIVES: The objective of this study was to evaluate a 12-session home/community-based health promotion/obesity prevention program (Challenge!) on changes in BMI status, body composition, physical activity, and diet. METHODS: A total of 235 black adolescents (aged 11–16 years; 38% overweight/obese) were recruited from low-income urban communities. Baseline measures included weight, height, body composition, physical activity (PA), and diet. PA was measured by 7-day play-equivalent physical activity (≥1800 activity counts per minute). Participants were randomly assigned to health promotion/obesity prevention that is anchored in social cognitive theory and motivational interviewing and was delivered by college-aged black mentors or to control. Postintervention (11 months) and delayed follow-up (24 months) evaluations were conducted. Longitudinal analyses used multilevel models with random intercepts and generalized estimating equations, controlling for baseline age/gender. Stratified analyses examined baseline BMI category. RESULTS: Retention was 76% over 2 years; overweight/obese status declined 5% among intervention adolescents and increased 11% among control adolescents. Among overweight/obese youth, the intervention reduced total percentage of body fat and fat mass and increased fat-free mass at delayed follow-up and increased play-equivalent physical activity at postintervention but not at delayed follow-up. Intervention adolescents declined significantly more in snack/dessert consumption than control adolescents at both follow-up evaluations. CONCLUSIONS: At postintervention, there were intervention effects on diet and PA but not BMI category or body composition. At delayed follow-up, dietary changes were sustained and the intervention prevented an increase in BMI category. Body composition was improved for overweight/obese youth. Changes in body composition follow changes in diet and PA and may not be detected immediately after intervention.

OBJECTIVES:To develop a brief screen to identify families at risk for food insecurity (FI) and to evaluate the sensitivity, specificity, and convergent validity of the screen.PATIENTS AND METHODS:Caregivers of children (age: birth through 3 years) from 7 urban medical centers completed the US Department of Agriculture 18-item Household Food Security Survey (HFSS), reports of child health, hospitalizations in their lifetime, and developmental risk. Children were weighed and measured. An FI screen was developed on the basis of affirmative HFSS responses among food-insecure families. Sensitivity and specificity were evaluated. Convergent validity (the correspondence between the FI screen and theoretically related variables) was assessed with logistic regression, adjusted for covariates including study site; the caregivers' race/ethnicity, US-born versus immigrant status, marital status, education, and employment; history of breastfeeding; child's gender; and the child's low birth weight status.RESULTS:The sample included 30 098 families, 23% of which were food insecure. HFSS questions 1 and 2 were most frequently endorsed among food-insecure families (92.5% and 81.9%, respectively). An affirmative response to either question 1 or 2 had a sensitivity of 97% and specificity of 83% and was associated with increased risk of reported poor/fair child health (adjusted odds ratio [aOR]: 1.56; P < .001), hospitalizations in their lifetime (aOR: 1.17; P < .001), and developmental risk (aOR: 1.60; P < .001).CONCLUSIONS:A 2-item FI screen was sensitive, specific, and valid among low-income families with young children. The FI screen rapidly identifies households at risk for FI, enabling providers to target services that ameliorate the health and developmental consequences associated with FI.

OBJECTIVES:The goals were to generate a cumulative hardship index and to evaluate its association with the well-being of children 4 to 36 months of age without private health insurance.METHODS:Cross-sectional surveys were linked to anthropometric measures and medical record review at 5 urban medical centers (July 1, 2004, to December 31, 2007). Cumulative hardship index scores ranged from 0 to 6, with food, housing, and energy each contributing a possible score of 0 (secure), 1 (moderately insecure), or 2 (severely insecure) to generate scores indicating no hardship (score of 0), moderate hardship (scores of 1–3), or severe hardship (scores of 4–6). The outcome was a composite indicator of child wellness, including caregivers' reports of children's good/excellent heath, no hospitalizations, not being developmentally at risk, and anthropometric measurements within normal limits. Covariates were selected a priori and through association with predictors and outcomes.RESULTS:Of 7141 participants, 37% reported no material hardship, 57% moderate hardship, and 6% severe hardship. Multivariate logistic regression analyses showed ordinal association between the cumulative hardship index and children's adjusted odds of wellness (severe versus no hardship, adjusted odds ratio [AOR]: 0.65 [95% confidence interval [CI]: 0.51–0.83]; severe versus moderate hardship, AOR: 0.73 [95% CI: 0.58–0.92]; moderate versus no hardship, AOR: 0.89 [95% CI: 0.79–0.99]).CONCLUSION:Increasing levels of a composite measure of remediable adverse material conditions correlated with decreasing adjusted odds of wellness among young US children.

CONTEXT: Studies through 6 years have shown no long-term direct effects of prenatal cocaine exposure (PCE) on children's physical growth, developmental test scores, or language outcomes. Little is known about the effects of PCE among school-aged children aged 6 years and older. OBJECTIVE: We reviewed articles from studies that examined the effects of PCE on growth, cognitive ability, academic functioning, and brain structure and function among school-aged children. METHODS: Articles were obtained by searching PubMed, Medline, TOXNET, and PsycInfo databases from January 1980 to December 2008 with the terms “prenatal cocaine exposure,” “cocaine,” “drug exposure,” “substance exposure,” “maternal drug use,” “polysubstance,” “children,” “adolescent,” “in utero,” “pregnancy,” “development,” and “behavior.” Criteria for inclusion were (1) empirical research on children aged 6 years and older prenatally exposed to cocaine, (2) peer-reviewed English-language journal, (3) comparison group, (4) longitudinal follow-up or historical prospective design, (5) masked assessment, (6) exclusion of subjects with serious medical disabilities, and (7) studies that reported nonredundant findings for samples used in multiple investigations. Thirty-two unique studies met the criteria. Each article was independently abstracted by 2 authors to obtain sample composition, methods of PCE assessment, study design, comparison groups, dependent variables, covariates, and results. RESULTS: Associations between PCE and growth, cognitive ability, academic achievement, and language functioning were small and attenuated by environmental variables. PCE had significant negative associations with sustained attention and behavioral self-regulation, even with covariate control. Although emerging evidence suggests PCE-related alterations in brain structure and function, interpretation is limited by methodologic inconsistencies. CONCLUSIONS: Consistent with findings among preschool-aged children, environmental variables play a key role in moderating and explaining the effects of PCE on school-aged children's functioning. After controlling for these effects, PCE-related impairments are reliably reported in sustained attention and behavioral self-regulation among school-aged children.

OBJECTIVE. Household energy security has not been measured empirically or related to child health and development but is an emerging concern for clinicians and researchers as energy costs increase. The objectives of this study were to develop a clinical indicator of household energy security and assess associations with food security, health, and developmental risk in children METHODS. A cross-sectional study that used household survey and surveillance data was conducted. Caregivers were interviewed in emergency departments and primary care clinics form January 2001 through December 2006 on demographics, public assistance, food security, experience with heating/cooling and utilities, Parents Evaluation of Developmental Status, and child health. The household energy security indicator includes energy-secure, no energy problems; moderate energy insecurity, utility shutoff threatened in past year; and severe energy insecurity, heated with cooking stove, utility shutoff, or ≥1 day without heat/cooling in past year. The main outcome measures were household and child food security, child reported health status, Parents Evaluation of Developmental Status concerns, and hospitalizations.RESULTS. Of 9721 children, 11% (n = 1043) and 23% (n = 2293) experienced moderate and severe energy insecurity, respectively. Versus children with energy security, children with moderate energy insecurity had greater odds of household food insecurity, child food insecurity, hospitalization since birth, and caregiver report of child fair/poor health, adjusted for research site and mother, child, and household characteristics. Children with severe energy insecurity had greater adjusted odds of household food insecurity, child food insecurity, caregivers reporting significant developmental concerns on the Parents Evaluation of Developmental Status scale, and report of child fair/poor health. No significant association was found between energy security and child weight for age or weight for length.CONCLUSIONS. As household energy insecurity increases, infants and toddlers experienced increased odds of household and child food insecurity and of reported poor health, hospitalizations, and developmental risks.

OBJECTIVES. We sought to examine the impact of a randomized, controlled trial of home visiting among infants with failure to thrive on growth, academic/cognitive performance, and home/classroom behavior at age 8.METHODS. Infants with failure to thrive (N = 130) or adequate growth (N = 119) were recruited from pediatric primary care clinics serving low-income, urban communities. Eligibility criteria included age 36 weeks, birth weight >2500 g, and no significant medical conditions. Evaluation included anthropometries, Bayley scales, maternal anthropometries, demographics, negative affect, IQ, and the Home Observation for Measurement of the Environment scale. Infants with failure to thrive were treated in an interdisciplinary growth and nutrition clinic and randomized into clinical-intervention-plus-home-intervention or clinical-care-only groups. The home-visiting curriculum promoted maternal sensitivity, parent-infant relationships, and child development. Follow-up visits were conducted by evaluators who were unaware of the children's growth or intervention history. At age 8, the evaluation included anthropometries, the Wechsler Intelligence Scale for Children III, and the Wide Range Achievement Test, Revised. Mothers completed the Child Behavior Checklist and teachers completed the Teacher Report Form.ANALYSIS. Multivariate analyses of variance were used to examine differences in growth, cognitive/academic performance, and home/school behavior, adjusted by maternal education, public assistance, and, when appropriate, infant Bayley score, maternal BMI, height, negative affect, IQ, and Home Observation for Measurement of the Environment scores.RESULTS. Retention was 74% to 78%. Children in the adequate-growth group were significantly taller, heavier, and had better arithmetic scores than the clinical-intervention-only group, with the clinical-intervention-plus-home-intervention group intermediate. There were no group differences in IQ, reading, or mother-reported behavior problems. Children in the clinical-intervention-plus-home-intervention group had fewer teacher-reported internalizing problems and better work habits than the clinical-intervention-only group.CONCLUSIONS. Early failure to thrive increased children's vulnerability to short stature, poor arithmetic performance, and poor work habits. Home visiting attenuated some of the negative effects of early failure to thrive, possibly by promoting maternal sensitivity and helping children build strong work habits that enabled them to benefit from school. Findings provide evidence for early intervention programs for vulnerable infants.

OBJECTIVES. Public funding for the Low Income Home Energy Assistance Program has never been sufficient to serve more than a small minority of income-eligible households. Low Income Home Energy Assistance Program funding has not increased with recent rapidly rising energy costs, harsh winter conditions, or higher child poverty rates. Although a national performance goal for the Low Income Home Energy Assistance Program is to increase the percentage of recipient households having ≥1 member ≤5 years of age, the association of income-eligible households' receipt of the Low Income Home Energy Assistance Program with indicators of well-being in young children has not been evaluated previously. The goal of the current study was to evaluate the association between a family's participation or nonparticipation in the Low Income Home Energy Assistance Program and the anthropometric status and health of their young children.METHODS. In the ongoing Children's Sentinel Nutrition Assessment Project from June 1998 through December 2004, caregivers with children RESULTS. In this sample of 7074 caregivers, 16% of families received the Low Income Home Energy Assistance Program, similar to the national rate of 17%. Caregivers who received the Low Income Home Energy Assistance Program were more likely to be single (63% vs 54%), US born (77% vs 68%), and older (mother's mean age: 28.1 vs 26.7 years) but were less likely to be employed (44% vs 47%). Households who received the Low Income Home Energy Assistance Program were more likely to receive Supplemental Nutrition Program for Women, Infants, and Children (85% vs 80%), Supplemental Security Income (13% vs 9%), Temporary Assistance for Needy Families (38% vs 23%), and food stamps (59% vs 37%) and to live in subsidized housing (38% vs 19%) compared with nonrecipients. Children in families participating in the Low Income Home Energy Assistance Program were older than children in nonparticipating families (13.6 vs 12.5 months), were less likely to be uninsured (5% vs 9%), and were more likely to have had a low birth weight ≤2500 g (17% vs 14%). Families participating in the Low Income Home Energy Assistance Program reported more household food insecurity (24% vs 20%) There were no significant group differences between recipients and nonrecipients in caregiver's education or child's gender. After controlling for these potentially confounding variables, including receipt of other means-tested programs, compared with children in recipient households, those in nonrecipient households had greater adjusted odds of being at aggregate nutritional risk for growth problems, defined as children with weight-for-age below the 5th percentile or weight-for-height below the 10th percentile, with significantly lower mean weight-for-age z scores calculated from age- and gender-specific values from the Centers for Disease Control and Prevention 2000 reference data. However, in adjusted analyses, children aged 2 to 3 years in recipient households were not more likely to be overweight (BMI >95th percentile) than those in nonrecipient households. Rates of age-adjusted lifetime hospitalization excluding birth and the day of the interview did not differ between Low Income Home Energy Assistance Program recipient groups. Among the 4445 of 7074 children evaluated in the 2 emergency departments, children from eligible households not receiving the Low Income Home Energy Assistance Program had greater adjusted odds than those in recipient households of acute hospital admission on the day of the interview.CONCLUSIONS. Even within a low-income renter sample, Low Income Home Energy Assistance Program benefits seem to reach families at the highest social and medical risk with more food insecurity and higher rates of low birth-weight children. Nevertheless, after adjustment for differences in background risk, living in a household receiving the Low Income Home Energy Assistance Program is associated with less anthropometric evidence of undernutrition, no evidence of increased overweight, and lower odds of acute hospitalization from an emergency department visit among young children in low-income renter households compared with children in comparable households not receiving the Low Income Home Energy Assistance Program. The Low Income Home Energy Assistance Program in many states shuts down early each winter when their funding is exhausted. From a clinical perspective, pediatric health providers caring for children from impoverished families should consider encouraging families of these children to apply for the Low Income Home Energy Assistance Program early in the season before funding is depleted. From a public policy perspective, although this cross-sectional study design can only demonstrate associations and not causation, these findings suggest that, particularly as fuel costs and children's poverty rates increase, expanding the Low Income Home Energy Assistance Program funding and meeting the national Low Income Home Energy Assistance Program performance goal of increasing the percentage of recipient households with young children might potentially benefit such children's growth and health.

Background. Limited longitudinal re- search has been conducted on the impact of neglect on children's health and well-being. There is a need to con- sider the impact of specific subtypes of neglect on chil- dren's functioning. In addition, there is interest in exam- ining the cumulative effect of experiencing >1 subtype of neglect. Objective. To examine the individual and cumulative relationships among physical, psychological, and envi- ronmental neglect and children's behavior and develop- ment at age 3, and the impact on changes in children's behavior and development between ages 3 and 5. Methods. One hundred thirty-six children and their primary caregivers participating in a prospective longi- tudinal study of children's development and maltreat- ment were assessed when the children were aged 3 and 5 years. The children were recruited from primary care clinics because of failure to thrive, risk for human im- munodeficiency virus, or as a comparison group. Evalu- ations were conducted in laboratory and home settings using observations, maternal self-report, and standard- ized testing of the children. Scores on physical, psycho- logical, and environmental neglect were combined into a Cumulative Neglect Index. Regression analyses were run to examine the association of specific subtypes of neglect and of cumulative neglect with children's functioning at age 3, controlling for group, sociodemographic risk, and maternal depression. The analyses were repeated exam- ining the impact on child outcomes at age 5, controlling for the above 3 variables as well as the children's cogni- tive development and behavior at age 3. Results. Of the subtypes of neglect at age 3, only psychological neglect was significantly associated with increased internalizing and externalizing behavior prob- lems at age 3; the Cumulative Neglect Index was associ- ated with internalizing problems. None of the neglect subtypes or cumulative neglect were predictive of changes in children's behavior and development be- tween ages 3 and 5. Cognitive development of the entire sample was impaired at age 5, averaging 0.85 standard deviations below the norm, and their average externaliz- ing behavior score was significantly problematic with an average of 0.60 standard deviations above the norm. Conclusions. In the context of poverty where many preschool children have poor cognitive development and increased behavior problems, psychological neglect is significantly related to reported behavior problems. Chil- dren who experienced multiple types of neglect had in- creased internalizing problems. Neglect did not explain changes in children's behavior or development between ages 3 and 5. There is a need for pediatricians to identify and address child neglect, particularly psychological ne- glect, as early as possible. Pediatricians should also screen for maternal depression. Pediatrics 2002;109:1100 -1107; child neglect, behavior, development, poverty.

Objective. To investigate whether living in a 3-generation household (grandmother-mother-child) is associated with fewer behavior problems and better cognitive development among preschool children of mothers who gave birth during adolescence and whether it protects children from the behavior and developmental problems associated with maltreatment and maternal depression.Design. Cohort study.Setting. Participants included low-income families recruited from 4 sites: East, Northwest, Midwest, and South, who are part of LONGSCAN, a longitudinal study of children’s health, development, and maltreatment.Participants. One hundred ninety-four mothers who were adolescents (less than age 19) at delivery. Data were gathered when children were 4 to 5 years of age. Twenty-six percent of the children lived in 3-generation households, 39% had a history of maltreatment, and 32% of the mothers had depression scores in the clinical range.Main Outcome Measures. Child behavioral problems were measured with the Child Behavior Checklist, completed by the mother, and child developmental status was assessed with the Battelle Developmental Inventory Screening Test, administered by research assistants.Results. Multiple regression analyses revealed that children who had been reported for maltreatment and had mothers with depressive symptoms had more externalizing behavior problems, compared with children who experienced neither risk or only 1 risk. However, when residential status was considered, children with the greatest number of externalizing behavior problems were those who experienced both maltreatment and maternal depressive symptoms and lived in 3-generation households. Children who had been reported for maltreatment or had mothers with depressive symptoms were more likely to have internalizing problems, compared with children with neither risk. Residential status was not related to children’s internalizing behavior problems or cognitive development.Conclusions. Living in a 3-generation household did not protect preschool children from the behavior problems associated with maltreatment and depression. In contrast, living in a 3-generation household was associated with more behavior problems among the highest risk group of children—those who had been maltreated and had mothers with symptoms of depression. Although 3-generation families may provide an important source of support and stability for adolescent mothers and their infants early in the parenting process, it may not be advisable to rely on 3-generation households as young mothers enter adulthood, particularly among those with a history of maltreatment or depression. Children with the fewest number of behavior problems were living with their mothers in their own household (often with the father), had not been maltreated, and had mothers with few symptoms of depression.

To the Editor .— As pediatricians and psychologists who have conducted research involving children with failure to thrive (FTT) and/or treated literally thousands of children with FTT, we wish to share our concerns regarding the report “Failure to Thrive as a Manifestation of Child Neglect”1 from the American Academy of Pediatrics (AAP) Committee on Child Abuse and Neglect and Committee on Nutrition. Six aspects of the report are particularly troubling. First, the report does not make it sufficiently clear that FTT as a manifestation of child neglect represents a minority of children with FTT. We agree that, in some cases, FTT may be a marker of neglect and that the diagnosis of abuse and/or neglect should be considered if there is any history of “intentional withholding of food from the child; strong beliefs in health and/or nutrition regimens that jeopardize a child's well-being; and/or family that is resistant to recommended interventions despite multidisciplinary team approach.” Indeed, children with both FTT and neglect have lower cognitive skills initially and years after treatment …

Objective. To evaluate the efficacy of home intervention with drug-abusing women on parenting behavior and attitudes, and on children's development. Design. A randomized, clinical trial of 60 drug-abusing women recruited prenatally and randomized into an intervention (n = 31) or comparison (n = 29) group. There were no group differences in gestational age, 1-minute Apgar scores, duration of hospital stay, or neonatal abstinence score. Intervention infants were slightly heavier (P = .098) and had slightly lower 5-minute Apgar scores (P = .089). Most mothers were single, African-American, multiparous, and non-high school graduates from low income families. Approximately 40% of the women were human immunodeficiency virus (HIV)-positive, all admitted to either cocaine and/or heroin use, and 62% had a history of incarceration. Intervention and comparison group women did not differ on any background variables. Interventions. All children received primary care in a multidisciplinary clinic. Biweekly home visits were provided by a nurse beginning before delivery and extending through 18 months of life. The intervention was designed to provide maternal support and to promote parenting, child development, the utilization of informal and formal resources, and advocacy. Measurements. Behavioral measures included self-reported ongoing drug abuse, compliance with primary care appointments, and an observation of the child-centered quality of the home (HOME Scale). Parenting attitudes were measured by the Child Abuse Potential Inventory (CAPI) and the Parenting Stress Index. The CAPI was administered before initiating the intervention and the Parenting Stress Index was administered when the children were 3 months of age. Both scales were repeated when the children were 18 months of age. Developmental status was measured with the Bayley Scales of Infant Development administered at 6, 12, and 18 months. Analyses. Repeated measures multivariate analyses of variance were used to examine changes in parenting attitudes and children's development. Analyses of covariance were used to examine compliance with primary care appointments and the quality of the home. Logistic regression was used to examine ongoing drug abuse. Birth weight and maternal education were used as covariates in all analyses. To control for social desirability, the faking-good index of the CAPI was included as a covariate in analyses involving self-report measures. Main results. Women in the intervention group were marginally more likely to report being drug-free (P = .059) and were compliant with primary care appointments for their children (P = .069). Based on the HOME Scale, women in the intervention group were more emotionally responsive (P = .033) and provided marginally more opportunities for stimulation (P = .065). At 18 months parents reported more normative attitudes regarding parenting and more child-related stress than they had initially, but the differences were not related to intervention status. At 6 months infants in the intervention group obtained marginally higher cognitive scores (P = .099); at 12 and 18 months there were no differences. Conclusions. The findings suggest a cautious optimism regarding the efficacy of early home intervention among drug-abusing women in promoting positive behaviors. Subsequent investigations of home intervention should include larger sample sizes and more intensive options.

Objective. To examine relationships involving three extremely high-risk behaviors (drug use, drug trafficking, and weapon carrying) among low-income, urban, African-American early adolescent boys using both quantitative and qualitative methods. Method. The quantitative phase included 192 African-American boys from 9 through 15 years of age recruited from recreation centers located in low-income communities. Youth completed a survey addressing personal risk practices; intentions to engage in risk practices; risk taking among family, friends and community; and values toward risk practices. They also completed standardized assessments of sensation seeking, perceived peer pressure, and parent-child communication. All questionnaires were self-administered through MacIntosh computers programmed to present questions aurally and visually. The qualitative phase included 12 African-American youth from low-income, urban families. The youth participated in 60- to 90-minute interviews regarding drug activities and violence. Results. Most boys (73%) were not involved in either drug activities or weapon carrying. Boys who were involved in drug activities or weapon carrying were often involved in other high-risk activities (cigarette and alcohol use, school failure and expulsion) and had low rates of adaptive communication with their parents. The boys reported high rates of drug involvement by their family, friends, and community. However, psychological and interpersonal factors were better predictors of individual risk activities than community or family variables. Personal values regarding economics predicted drug trafficking. More than 56% of the boys who reported past involvement in drug activities did not anticipate future involvement. Conclusions. Multilevel strategies are necessary to prevent involvement in drug activities and weapon carrying. Intervention programs should begin early and should promote communication between parents and children, adaptive behavior in school, and avoidance of cigarette and alcohol use. Community-level interventions are needed to alter the myth that drug involvement and weapon carrying are normative and to promote images that are less materialistic and more supportive of education and future-oriented activities.

The recent report by Melchior et al1 on food insecurity raised concerns about the effectiveness of nutritional-assistance programs and highlighted the role played by maternal mental health and domestic violence. Evidence from Children's HealthWatch (www.childrenshealthwatch.org) provides additional information on the link between nutritional-assistance programs and children's health and well-being. …