This Web site is a component of the SAMHSA Health Information Network
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This Web site is a component of the SAMHSA Health Information Network. |
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Clinical Preventive Services in Substance Abuse and Mental Health Update: From Science to ServicesVI. High-Risk Pregnant Women and Children to Age 5Preventive services during pregnancy, infancy, and early childhood can reduce the prevalence and severity of future medical, behavioral, and social problems. Risk is highest in low-income and socially disadvantaged family units. The term “high risk” in the literature refers to those low-income, first-time mothers at risk for poverty, welfare dependency, and involvement with the criminal justice system. The term also refers to babies with low birthweight, prematurity, or mental deficits such as retardation. Medicaid and public sector health care systems see large numbers of such families. As poverty is not the only determinant of risk, there are likely to be small numbers of high-risk individuals in every health care system, whether public or private. Two sets of services are presented. The first is a program of home visitation for family units characterized by social and economic vulnerability. The second is the need for supplemental educational services for the infants and preschool children from these families, plus selective low-birthweight infants; those exposed to substance use disorder during pregnancy; and those born to mothers with mental retardation. Although the provision of the supplemental educational services might not be the role of the health care delivery system, if pediatric staff does not identify the infants in need of service, it is unlikely that the infants will receive the needed services. A. Social and Economic Dependency Family units at highest risk of social and economic dependency are those with one or more of the following risk characteristics: low-income, adolescent pregnant woman or mother, unemployed, fewer than 12 years of education, or membership in a socially vulnerable ethnic, racial, or non-Englishspeaking group. Individuals with these risk factors tend to depend on Medicaid-oriented managed care plans, public systems of care, or do without routine care altogether. Two sets of services and benefits may be best for these high-risk family units. The first set, focusing on early and comprehensive prenatal care, can reduce prematurity and infant mortality, and by reducing the need for intensive hospital services during the first 30 days of life, reduce health care costs. The second set—addressed here—is primarily nonmedical. This second set, for families that could benefit from these interventions, can yield substantial social, educational, economic, and behavioral benefits—but is unlikely to generate immediate reductions in health care costs. Prenatal and infant home visitation to reduce family dependence on welfare is classified as “targeted” in this report. This is an intervention with a strong evidence base, but with social, economic, educational, and other nonmedical goals. The home visit intervention involves nurses visiting homes to deliver education and emotional coaching to low-income, first-time, disadvantaged pregnant women. The intervention consists of prenatal and infancy home visits by nurses every 2 weeks for an average of nine prenatal visits lasting over an hour each. The nurses also screen infants for sensory and developmental problems. There is provision of free transportation to prenatal and well child visits to local clinics, and in some cases, continued home visits for up to 2 years after the birth of the child. While in the home, nurses promote health-related behaviors during pregnancy, appropriate care for infants by parents, and maternal life-course family planning and educational achievement (Olds et al., 1993; 1997). Home visitation primarily relates to health care organizations that serve socially and economically vulnerable populations. As noted above, however, every health care system is likely to have small numbers of family units that could benefit from such services. Since the benefits are substantial, these services might be implemented by health care systems serving high-risk populations. Other health care systems may choose to be aware of such services and develop the capacity to connect selected families to these outreach and educational programs. The literature, reviewed below, attests to the benefits of home visitation in the context of a comprehensive program of preventive services in preventing future mother and child illness, handicap, social dependency, and behavioral problems. Issues and problems addressed include the following:
Women who may benefit from the addition of home visitation services—in addition to already comprehensive medical, financial, and social-support services—are women with multiple sociodemographic risk factors such as being an adolescent, being unmarried, having fewer than 12 years of education, and/or being unemployed. The primary benefits relate to welfare dependency. Other benefits included a wide range of health, social, and financial domains. The concept of offsetting savings in other health care costs was not pursued. These services are not inexpensive. The benefits are unlikely to include substantial short-term reductions in health care costs. This creates a situation where supplemental funding might be pursued to cover the costs of these services. One would expect such funding to be tied to supplemental guidelines and standardized reporting procedures to document the efficacy and efficiency of these services. Intervention To be effective and cost-efficient, these services might be best delivered by specially trained staff and in accordance with strictly defined protocols. Training requirements and protocols can be accessed at the Internet site of the National Center for Children Families and Communities (NCCFC) at the University of Colorado Health Sciences Center, www.nccfc.org. Review of Literature Olds and Kitzman published six papers between 1986 and 1994 on their Elmira study, dealing with parental care-giving at 25 to 40 months of age (Olds, 1994); effect of the nurse visitation program on government spending (AFDC, food stamps, Medicaid and Child Protective minus tax revenues from maternal employment (Olds et al., 1993) (AFDC is Aid for Families with Dependent Children, since renamed TANF, Temporary Aid to Needy Families); adverse maternal health behavior, dysfunctional infant care and stressful environmental conditions (Olds, 1992); maternal life course vis-a-vis completion of high school and employment (Olds et al., 1988); prenatal care and outcomes of pregnancy (Olds, et al., 1986); and prevention of child abuse during infancy (Olds et al., 1986). In 1995, Olds et al. (1995) reported interim strongly favorable results relative to child abuse and neglect in Elmira. In 1997, Kitzman et al. (1997) published the results of their Memphis trial on a number of maternal and infant health measures. Dramatic and highly statistically significant benefits were shown for pregnancy-induced hypertension, visits and hospitalizations for infant injuries and ingestions, and second pregnancies. There were no program effects on preterm delivery, low birthweight, children’s immunization rates, mental development, or behavioral problems or mother’s education and employment. In 1997, Olds et al. (1997) also published a 15-year follow-up on the Elmira study, showing dramatic and highly statistically significant benefits in areas of welfare dependency, child abuse and neglect, arrests, and behavioral impairments related to alcohol and other drugs. In 1998, Olds et al. (1998) published another 15-year follow-up of the Elmira study. The case families showed substantial clinical benefits and statistically significant differences from the control families in the incidence of running away, arrests, convictions, number of lifetime sex partners, tobacco use, alcohol use, and problems related to alcohol and drugs. In 2000, Kitzman et al. (2000) published a 3-year follow-up of their trial of home visits to a cohort of 743 mainly African American women in Memphis, Tennessee. These women had no previous live births and at least two of three sociodemographic risk factors (unmarried, fewer than 12 years of education, or unemployed). Modest but strongly statistically significant outcomes were noted, all in favor of the intervention group, for intervals between pregnancies and months of dependence on AFDC and food stamps. This study showed persistence of benefit over the 3-year period with findings consistent with their prior studies of White women in a rural area. In 2000, the Olds/Kitzman group—this time with Eckenrode as prime author (Eckenrode et al., 2000)—published yet another 15-year follow-up of the Elmira study. The group successfully reached 315 of the 400 families visited during pregnancy and up to 2 years postpartum. The women had been adolescent, unmarried, and/or low-income at the time of initial enrollment. This publication showed a substantial and highly statistically significant reduction in a number of measures of child abuse and neglect, but only among the families that had received postnatal visits, and only among family units with 28 or fewer incidents of domestic violence. Other Investigators In 1996, Margolis et al. did a randomized trial involving 93 Medicaid eligible pregnant women in two North Carolina counties to see whether home visitation would do a better job of accessing prenatal care. Results were strongly positive (Margolis et al., 1996). In 1998, Ramey et al. published the combined results from three trials intended to demonstrate prevention of intellectual disability in low-birthweight and economically vulnerable newborns (Ramey & Ramey, 1998). These early intervention programs were multidisciplinary in that they included early childhood education, family counseling and home visits, health services, medical services, nursing services, nutrition services, service coordination, special instruction, speech-language services, and transportation. The study relative to the lowbirthweight infants (Ramey et al., 1992) is reported in the next section of this report. The Abecedarian and Carolina Approach to Responsive Education (Project CARE) studies were randomized controlled trials of an educational intervention using a 36- month program known as Partners for Learning. These two trials showed consistent and substantial improvements in IQ, as measured in cognitive assessments at 6, 12, 18, 24, and 36 months of age. In 1999, Armstrong et al. published results of a randomized controlled trial of nurse home visits to “vulnerable” families with newborns to see whether they could reduce maternal depression and improve maternalinfant bonding. This study, conducted in Australia with 180 participants and 6 weeks of follow-up measurement, showed strong and highly significant improvement in measures of emotion and maternal-child inter- action. In 2001, Margolis et al. in North Carolina reported on the results of a validation study expanding this approach to a systematic community-wide intervention involving teams of nursing staff working with both private practitioners and community health centers. Levels of participation by both physician offices and eligible women were very high. Multiple outcome measures very strongly favored the intervention women in this randomized trial (Margolis et al., 2001). In October of 2003, an independent, nonfederal task force with support from CDC—the task force developing the Guide to Community Preventive Services—issued a report recommending early childhood home visitation for the prevention of child abuse and neglect (Task Force on Community Preventive Services, 2003). This was based on a highly structured review of the literature. Program Implementation Issues: Data Needs Specific to Home Visitation
B. Educational Services To Improve the Intelligence of Selective Infants and Preschool Children The following groups of infants and preschool children are at high risk of subnormal intellectual development—a risk that can be identified by the health care provider, and then addressed through the delivery of specialized educational services:
Research indicates that health care delivery systems should be alerted to the need for supplemental educational services for these infants. Although it may not be incumbent upon the health care system to provide the needed education, these infants are likely to be missed unless detected and brought to the attention of social service agencies by pediatric staff. The need for supplemental educational services will be most apparent to the pediatric medical and nursing staff if they have been alerted to this problem. Awareness of the problem through in-service education would seem reasonable for all health plans, especially those serving large numbers of atrisk families. Whether or not the needed supplemental educational services are paid for by the health plan or provided by the health care delivery systems will depend on plan-specific scope-of-contract decisions, and plan and health-care-delivery-system definition as to whether such services are considered medical, rather than social or nonmedical (Rosenbaum et al., 2003). If deemed outside the scope-of-contract or nonmedical, research would indicate it is incumbent upon the health care system to refer such cases to appropriate educational and social service programs, and to assist the family in securing the needed service. For these reasons, the provision of the supplemental educational services are classified as “targeted/social and educational” in this report. These interventions have a moderate evidence base, as reviewed below, and are fully consistent with the larger and more definitive studies presented in the prior section that demonstrate the value of intensified services to economically and socially vulnerable mother/infant dyads. The benefits to be secured from these services are primarily social rather than medical in nature. The literature demonstrating the value of such services for improving infant and child intelligence does not address the possibility that such services might reduce health care costs. As a result, these services are not expected to generate a health care cost-related return on investment. Intervention Such services could be dismissed easily as social and educational in nature and not the concern of health care delivery systems. However, if they are not addressed by pediatric staff, it is unlikely that the families in need of such services will connect with them, regardless of who pays for them. Provision of such supplemental educational services can be seen as having three distinct stages. The first is detection of the need for such services. The second is delivery of the services. The third is follow-up to determine if the services were provided and whether they were effective in enhancing infant and child intelligence. The decision to pay for or provide the educational service is one to be made by each health care delivery system on the basis of its scope of coverage and conceptualization of whether such services are medical in nature. However, the research indicates that a good case can be made for all health care systems having the capacity to identify the need for such services and to follow up to help assure that they have been provided effectively. At the health care system level, the following will be beneficial, based on the literature:
Review of Literature The results showed statistically significant increases in mean Stanford-Binet IQ scores, comparing cases to controls, and a doseresponse relationship within the case population showing increases in IQ with increasing participation in the program, with the low participation group showing a mean IQ about five points higher than controls, and the highest participation group showing a mean IQ almost 15 points higher. Although the factors determining levels of program participation among the cases were not randomly distributed and probably reflected important confounding variables, it seems reasonable to conclude that the threepart intervention did have a significant impact on the child’s IQ score at age 36 months (Ramey et al., 1992). In 1997, McCarton et al. published an 8- year follow-up on a randomized controlled trial of educational services, home-based family support, and pediatric follow-up to low-birthweight infants. The results showed small, but favorable differences, comparing the intervention to control groups, with most of the benefit in the heavier infants (McCarton et al., 1997). In 1999, Bao et al. published the results of a randomized controlled trial conducted in Beijing, China (Bao, Sun, & Wei, 1999). Enrollees were all low-birthweight infants. The intervention consisted of an educational program that taught mothers techniques of infant stimulation to be used in the home. At the end of the 2-year intervention, the Mental Development Index scores for the intervention infants were approximately 14 points higher than for the low-birthweight controls, and approximately six points higher than the small group of normal birthweight control infants. Services to Economically and Socially Vulnerable Families To Improve Infant/Child Intelligence In 1998, Ramey and Ramey published the combined results from three trials intended to demonstrate prevention of intellectual disability in low-birthweight and economically vulnerable newborns (Ramey & Ramey, 1998). The study relative to the low-birthweight infants (Ramey et al., 1992) is reported in the next section of this monograph. The Abecedarian and CARE studies were randomized controlled trials of an educational intervention of a 36-month program known as Partners for Learning. These two trials showed consistent and substantial improvements in IQ, as measured in cognitive assessments at 6, 12, 18, 24, and 36 months of age. Based on this research, it appears that generalized home visitation programs are likely to have a minimal impact on infant/child intelligence, but intensive educational programs can have a significant effect. Services to Infants Born to Mentally Retarded or Otherwise Challenged Mothers Securing the participation of enough infants of mentally retarded mothers to do reasonably rigorous randomized controlled trials is a difficult task. Given the magnitude of the benefit documented in this study, and the consistency of these results with the results of other studies of intensive support services provided to vulnerable mother/infant dyads, it seems reasonable to accept the results of these studies as strong evidence that intensive educational support services provided as a supplement to reasonably comprehensive medical care can be effective in dramatically improving the intellectual performance of infants born to mentally retarded mothers. Other In 1994, Black et al. (1994) published results of a small randomized clinical trial, including 31 cases and 29 controls, of home visitation for newborn infants of drugabusing women. This program of generalized support through biweekly home visits by nurses during the first 18 months of life showed modest improvements in maternal drug-related behavior, improvements in parenting, and improvements in child development. Although this study is weak and far from definitive (it is the only one covering this issue from the perspective of drug-abusing pregnant women), its findings suggest that these women and their infants respond to infant visitation programs offering comprehensive maternal and pediatric care in a manner similar to other vulnerable women and their infants. Program Implementation Issues: Data To Be Gathered Summary: High-Risk Women and Children Targeted interventions, including home visits to at-risk, low-income, pregnant women and developmental/sensory screening of their infants, may yield short-term benefits to the health plan of healthier babies wih fewer problems, and long-term benefits to the mother and child. |
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