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The goal of creating evidence-based programs is to scale them at sufficient breadth to support population-level improvements in critical outcomes. However, this promise is challenging to fulfill. One of the biggest issues for the field is the reduction in effect sizes seen when a program is taken to scale. This paper discusses an economic perspective that identifies the underlying incentives in the research process that lead to scale up problems and to deliver potential solutions to strengthen outcomes at scale. The principles of open science are well aligned with this goal. One prevention program that has begun to scale across the USA is early childhood home visiting. While there is substantial impact research on home visiting, overall average effect size is 0.10 and a recent national randomized trial found attenuated effect sizes in programs implemented under real-world conditions. The paper concludes with a case study of the relevance of the economic model and open science in developing and scaling evidence-based home visiting. The case study considers how the traditional approach for testing interventions has influenced home visiting's evolution to date and how open science practices could have supported efforts to maintain impacts while scaling home visiting. It concludes by considering how open science can accelerate the refinement and scaling of home visiting interventions going forward, through accelerated translation of research into policy and practice.

The variation in childhood social-emotional development within at-risk populations may be attributed in part to epigenetic mechanisms such as DNA methylation (DNAm) that respond to environmental stressors. These mechanisms may partially underlie the degree of vulnerability (and resilience) to negative social-emotional development within adverse psychosocial environments. Extensive research supports an association between maternal adversity and offspring DNAm of the NR3C1 gene, which encodes the glucocorticoid receptor (GR). A gap in knowledge remains regarding the relationship between NR3C1 DNAm, measured in neonatal (1-month of age) buccal cells, and subsequent social-emotional development during infancy and early childhood. We conducted a longitudinal cohort study of n = 53 mother-child dyads (n = 30 with developmental outcomes formed the basis of current study) who were enrolled in a home visiting (HV) program. Higher mean DNAm of the NR3C1 exon 1F promoter was significantly associated with lower 6-month Ages and Stages Questionnaire: Social-Emotional (ASQ:SE) scores-more positive infant social-emotional functioning. A similar trend was observed at 18-months of age in a smaller sample (n = 12). The findings of this pilot study indicate that in a diverse and disadvantaged population, the level of neonatal NR3C1 DNAm is related to later social-emotional development. Limitations and implications for future research are discussed.

Caregiver trust in medical providers and the healthcare system is essential to pediatric primary care. Relatively little research has been conducted on contributors to caregivers’ trust, or lack thereof, in aspects of pediatric primary care, especially for those who have experienced adversity. To examine the relationship between caregiver trust and adverse childhood experiences (ACEs) in pediatric primary care, we measured four aspects of trust in 76 caregivers (74 mothers, 2 aunts) of children at an urban primary care clinic. We ran correlation and regression analyses to examine the relationship between the Philadelphia ACEs and caregiver trust. Results indicated that specific ACEs (e.g. experiencing abuse) were associated with caregiver mistrust in the healthcare system and lower trust in the child’s pediatrician. Some ACEs (e.g. community discrimination) were associated with only general trust. Thus, the relationship between trust and trauma varied based on the levels of trust and types of ACEs. [ABSTRACT FROM AUTHOR]

The increasing acuity of mental health needs amongst youth coupled with a dwindling and lesser trained workforce (e.g., bachelor level and dependently licensed, early career providers) means that those with less experience and training in the delivery of evidence-based treatments (EBTs) are more likely to provide services to youth with the highest level of needs. EBTs for common pediatric mental health conditions are well documented in the literature. However, standardized and consistent implementation of EBTs do not exist at a systems level. Psychologists have expertise in the theory and clinical application of EBTs, developed through years of coursework and clinical rotations supervised by licensed doctoral level psychologists. Therefore, it is fruitful for psychologists to take leadership roles to ensure that the workforce is appropriately prepared to deliver and maintain the fidelity of EBTs. This paper will provide an overview of the six levels of mental health care delivered across our system (Levels 0–5), as well as outline five core components of an effective training and case consultation model designed to scale and spread EBTs across the system. These five core components include: (1) content experts as leaders, (2) institutional commitment, (3) intentionality in hiring and onboarding providers receptive to the model, (4) data driven approach, and (5) ongoing training and case consultation that includes modeling, role-playing and/or direct observation. Application of the model to multidisciplinary teams and sustainability at each level of care is addressed, as well as plans for further spread in scale and scope of this model. [ABSTRACT FROM AUTHOR]

The increase in behavioral health problems presenting in pediatric primary care (PPC) has led to a greater focus on the prevention and treatment of mental health concerns. As a result, care has shifted from colocation to integrated PPC models. However, the literature provides limited guidance on the development and implementation of integrated PPC models that aim to transform both PPC and the larger health care system. We developed an integrated behavioral health (IBH) approach modeled with fidelity to the Integrated Practice Assessment Tool to fully integrate behavioral health into PPC. Over the 4 years since the application of our model, we have been successful in the development of an integration process and model for practice transformation of an urban PPC center and the spread and scale of IBH services to 2 additional clinics. Four elements combine to make our integrated behavioral health program novel: (a) clear mission and vision, (b) provision of universal prevention services, (c) continuous quality improvement, and (d) emphasis on practice and systems transformation. Trends in practice and scholarly inquiry indicate the need for robust pediatric IBH models, with a clear mission and vision; articulation of how research informs the development and implementation of the model; and infrastructure to meaningfully examine the model's impact. Cognizant of these needs, Cincinnati Children's Hospital Medical Center developed an IBH program. We provide key learnings for IBH program development, PPC transformation, and innovative systems redesign. We describe these elements and make recommendations for future research and practice. Public Significance Statement Integrated Behavioral Health is a key strategy to address behavioral health programs in primary care. We share learnings about how four innovations have made our program novel and successful in scaling and spreading. Keywords: integrated behavioral health, pediatric primary care, prevention, quality improvement, practice transformation, The incidence of mental health concerns in children and adolescents has risen dramatically in the last decade (Houtrow, Larson, Olson, Newacheck, & Halfon, 2014). It is estimated that in children [...]

Introduction Pediatric primary care and home visiting programs seek to reduce health disparities and promote coordinated health care use. It is unclear whether these services impact high-cost, emergency department (ED) utilization. We evaluated the association of well-child care (WCC) and home visiting with ED visit frequency for children < 1 year with an established medical home. Methods Retrospective cohort study using linked administrative data for infants [greater than or equal to] 34 weeks' gestation from 2010 to 2014, within a multisite, academic primary care system. Latent class analysis characterized longitudinal patterns of WCC. Multivariable negative binomial regression models tested the independent association between WCC patterns and home visiting enrollment with ED visits. Results Among 10,363 infants, three WCC latent classes were identified: 'Adherent' (83.4% of the cohort), 'Intermediate' (9.7%), and 'Decreasing adherence' (7.0%). Sixty-one percent of the sample had [greater than or equal to] 1 ED visit in the first 12 months of life, and 73% of all ED visits were triaged as non-urgent. There was a significant interaction effect between WCC pattern and insurance status. Among Medicaid-insured infants, 'Intermediate' and 'Decreasing adherence' WCC patterns were associated with a lower incident rate of ED visits compared with the 'Adherent' pattern (incident rate ratios (IRR) 0.88, p = 0.03 and 0.79, p < 0.001 respectively); this effect was not observed among privately-insured infants. Home visiting enrollment was independently associated with a higher rate of ED visits (IRR 1.24, p < 0.001). Discussion Among infants with an established medical home, adherence to recommended WCC and home visiting enrollment was associated with greater ED use for non-urgent conditions., Author(s): Neera K. Goyal [sup.1] [sup.2] [sup.9] , Courtney M. Brown [sup.3] [sup.4] , Alonzo T. Folger [sup.5] [sup.6] , Eric S. Hall [sup.5] [sup.7] , Judith B. Van Ginkel [...]

A qualitative, community-engaged assessment was conducted to identify needs and priorities for infant obesity prevention programs among mothers participating in home visiting programs. Thirty-two stakeholders (i.e., community partners, mothers, home visitors) affiliated with a home visiting program serving low-income families during the prenatal to age three period participated in group level assessment sessions or individual qualitative interviews. Results indicated families face many challenges to obesity prevention particularly in terms of healthy eating. An obesity prevention program can address these challenges by offering realistic feeding options and non-judgmental peer support, improving access to resources, and tailoring program content to individual family needs and preferences. Informational needs, family factors in healthy eating outcomes, and the importance of access and awareness of programs were also noted. To ensure the cultural- and contextual-relevance of infant obesity prevention programs for underserved populations, needs and preferences among community stakeholders and the focal population should be used as a roadmap for intervention development. [ABSTRACT FROM AUTHOR]

Objective To pilot test a statewide quality improvement (QI) collaborative learning network of home visiting agencies. Methods Project timeline was June 2014-May 2015. Overall objectives of this 8-month initiative were to assess the use of collaborative QI to engage local home visiting agencies and to test the use of statewide home visiting data for QI. Outcome measures were mean time from referral to first home visit, percentage of families with at least three home visits per month, mean duration of participation, and exit rate among infants, Author(s): Neera K. Goyal [sup.1] [sup.2] [sup.3] , Martha G. Rome [sup.4] , Julie A. Massie [sup.4] , Colleen Mangeot [sup.5] , Robert T. Ammerman [sup.3] [sup.6] , Jye Breckenridge [...]

Research indicates that up to half of mothers in home visiting experience clinically significant levels of depression during their participation in services. Depression alters maternal life course, negatively impacts child development, and contributes to poorer home visiting outcomes. This article describes the Moving Beyond Depression (MBD) program, an innovative and evidence-based approach to treating depressed mothers in home visiting. MBD uses In-Home Cognitive Behavioral Therapy, an empirically validated and collaborative intervention that overcomes barriers to treatment and contributes to recovery from depression and prevention of relapse. MBD has been successfully disseminated to other home visiting programs nationally.

Research has documented the deleterious effects of maternal depression and childhood trauma on parenting and child development. There are high rates of both depression and childhood trauma in new mothers participating in home visitation programs, a prevention approach designed to optimize mother and child outcomes. Little is known about the impacts of maternal depression and childhood trauma on parenting in the context of home visitation. This study contrasted depressed and non-depressed mothers enrolled in the first year of a home visitation program on parenting stress, quality of home environment, social network, and psychiatric symptoms. Mothers were young, low income, and predominantly unmarried. Results indicated that depressed mothers displayed impairments in parenting, smaller and less robust social networks, and increased psychiatric symptoms relative to their non-depressed counterparts. Path analyses for the full sample revealed a path linking childhood trauma, depression, and parenting stress. Path analyses by group revealed several differential relationships between dimensions of social network and parenting. Number of embedded networks, namely the number of different domains in which the mother is actively interacting with others, was associated with lowered parenting stress among non-depressed mothers and increased parenting stress in their depressed counterparts with childhood trauma histories. In depressed mothers, social network size was associated with lower levels of parenting stress but decreased quality of the home environment, whereas number of embedded networks was positively related to quality of the home environment. Implications of findings for home visitation programs are discussed.

Home visiting is a child abuse prevention strategy that seeks to optimize child development by providing mothers with support, training, and parenting information. Research has consistently found high rates of depression in mothers participating in home visiting programs and low levels of obtaining mental health treatment in the community. Successful treatment of depressed mothers in home visiting programs holds the potential to improve maternal and child outcomes. In-Home Cognitive-Behavioral Therapy (IH-CBT) is an adapted treatment for depressed mothers, which is provided alongside home visiting and seeks to optimize engagement and impact through delivery in the home setting; a focus on issues important to young, low-income mothers; and a strong collaborative relationship between therapists and home visitors. This study examined predictors of depression status at posttreatment in 60 mothers who received IH-CBT and concurrent home visiting. Variables considered included demographics, illness history, severity, and numbers of treatment sessions and home visits. Results indicated that young maternal age, fewer episodes of major depressive disorder, lower depression severity at pretreatment, lower levels of symptoms of personality disorders, and more treatment sessions and home visits predicted asymptomatic status at posttreatment. (Contains 3 tables and 1 figure.)