412316 maternal depression
TRANSCRIPT
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HomeVisitingandMaternalDepression
SeizingtheOpportunitiestoHelpMothersandYoungChildren
OliviaGolden,AmeliaHawkins,andWilliamBeardslee
March2011
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CopyrightMarch2011.TheUrbanInstitute.Allrightsreserved.Permissionisgrantedforreproduction
ofthisfile,withattributiontotheUrbanInstitute.
Theauthorswanttothank,aboveall,thedozensofparents, localserviceproviders,andstateofficials
whotooktimetotalkwithusabouttheirexperiences,insights,andhopesforthefuture.Wealsothank
JenniferMacomber
for
her
conceptual
leadership
in
the
project
from
the
beginning
and
her
deeply
thoughtfulcomments;SerenaLeiforherextremelyhelpfuleditorialassistance;FrancieZimmermanfor
herinsightthroughouttheprojectandherthoughtfulreview;MonicaRohacekforhertirelesseffortson
sitevisitsandcommentsonthisguide;RosaMariaCastanedaandRobinHarwoodfortheircontribution
to this project in its initial stage; Embry Howell, Janice Cooper, Jeanne Miranda, Carl Bell, Jennifer
Oppenheim,DeborahSaunders,andPaulDworkin fortheir thoughtfulcommentsandadvice;and the
DorisDukeCharitableFoundationforitsgeneroussupportofthisproject.
The Urban Institute is a nonprofit, nonpartisan policy research and educational organizations that
examines the social,economic,andgovernanceproblems facing thenation.Theviewsexpressedare
thoseoftheauthorsandshouldnotbeattributedtotheUrbanInstitute,itstrustees,oritsfunders.
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Contents
ExecutiveSummary v
HomeVisiting
and
Maternal
Depression
1
MaternalDepression:Prevalence,Treatment,andEffectonChildren 3
HomeVisiting:TheOpportunity 4
MothersPerspectivesonDepressionandTreatment 5
HomeVisiting:WhatItTakestoServeDepressedMothersofYoungChildren 9
ConclusionandNextSteps 20
Notes
22
References 23
AbouttheAuthors 24
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v
ExecutiveSummary
Undetectedanduntreatedparentaldepressionplacesmillionsofchildren in theUnitedStatesat risk
eachday.Parentaldepressioncanbeespeciallydamaging forthegrowthandhealthydevelopmentof
veryyoung
children,
who
depend
heavily
on
their
parents
for
nurture
and
care.
Treating
parental
depression and addressing its negative effects early in a childs life could improve that childs
development.Severalsafeandeffectivedepressiontreatmentsareavailable,butthedeliveryofthese
services,especiallytolowincomefamilies,requiresnewandinnovativeapproaches.
Thisguidelooksatonepromisingapproach:usinghomevisitingprogramstoidentifydepressed
mothers and connect them and their families to services. Home visiting programs generally involve
regularvisitstopregnantwomenandmothersofyoungchildrenoverseveralmonthstoseveralyearsby
a paraprofessional or professional (such as a nurse or social worker), with goals that may include
enhancedparenting skills,bettermaternal and childhealth,achievementofmaternal educationand
employmentgoals,
postponement
of
subsequent
births,
and
enhanced
child
development.
Researchers
haveidentifieddifferenthomevisitingprogramsthatarebackedbysolidevidenceofimprovedresults,
andnewfundingtoexpandtheprograms isincludedinthePatientProtectionandAffordableCareAct
(orACA).
However,despitetheseprogramspromise,theevidenceabouttheircurrentsuccessspecifically
fordepressedmothersand their children ismixed, leading researchers to call forbetter information
abouthowtoredesignorsupplementservices.Thisguidehelpsfillthatinformationgap.Bydrawingon
researchaswellasnewinterviewswithlowincomemothers,homevisitors,andotherserviceproviders,
thisguideofferspractical insightsabouthowhomevisitingprogramscanenhancetheirownworkand
theirlinks
to
other
programs
in
the
communitysuch
as
mental
health
treatmentto
better
serve
depressedmothersandtheiryoungchildren.
Lowincomemothersofyoungchildren,aswellashomevisitorsthemselvesandotherservice
providers, agree with researchers on the tremendous potential of home visiting services to reach
mothers, build a trusting relationship, and enable moms to get help with depression. The mothers
interviewed believe that depression is widespread in their communities among mothers of young
children,andmanywouldadviseadepressedfriendtoseekhelpsomewhere.Whiletheydonotagree
on a single institution or person to go to for help with depression, they do articulate the kind of
relationshipthey lookfor:onewheretheotherpersonwhetherneighbor,familymember,orservice
providerhasearnedtheirtrustthroughconsistencyovertime.
Yet,interviewsandresearchevidencealsomakeclearthelargechallengesthatfacehomevisit
programsinrespondingtomaternaldepressionandthepracticaloptionsthatexistforaddressingeach
challenge.
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vi
1. Reaching the mothers who most need help. As programs expand with new ACA funding,communities should seize the opportunity to use data to learn about and target services to
depressedmothersofyoungchildren,developeffectivereferralandrecruitmentpathsthatconnect
depressedmotherswithhomevisiting,andoffermanysuchpathsformotherswithyoungchildren
ofdifferentages.
2. Helping home visitors identify depression and talk to mothers about its implications andtreatment. Home visiting programs should consider depression screening as part of a more
comprehensiveapproachtoengagingandhelpingdepressedmothers.Programsshouldexplain to
staffhowidentifyingandtreatingamothersdepressionconnectstothecorehomevisitingmission,
consider training home visitors to speak honestly to a mothers concerns about child protective
services,complementoneononeattentionduringhomevisitswithgrouporcommunitystrategies
that are not stigmatized, and seek out resources to overcome some of the mothers practical
barrierswhilealsoconnectingmotherstodepressiontreatment.
3. Connecting to, supporting, and providing highquality treatment. Researchers are studying twopromisingapproachestothischallenge:developinghomebasedmentalhealthservicesthatpartner
with home visit programs, and providing skilled mental health consultation and supervision.
Programsshouldconsidercombiningthetwoapproachestoreachthemostfamilies.
4. Attending to young childrens development aswell asmothers treatment. Keeping a genuinefocusonboththechildsandthemothersneedsisnoteasyorautomatic.Programsshouldconsider
partnering(forexample,betweenNurseFamilyPartnershipandEarlyHeadStart),multidisciplinary
collaborativeteams,andcrosstrainingaspotentialstrategies.
5. Offeringongoinghelpafterhomevisiting.Programsshouldconsideranexplicittransitionplanformotherswithdepressionleavinghomevisitingprograms.
Researchershaveclearlydemonstratedthewidespreadprevalenceofmaternaldepressionand
the risks to young childrenwhogrowupwithmotherswithuntreateddepression. Studieshavealso
shown the clinical effectiveness of treatment once depression is identified. The challenge for
policymakers and program leaders is to translate this clear research evidence into service delivery
approaches that make a difference. Today, the visibility of home visiting and the opportunity for
additional resources offer an opportunity to build on innovations from the field and significantly
improveyoungchildrenslifechances.
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HomeVisitingandMaternalDepression
SeizingtheOpportunitiestoHelpMothersandYoungChildren
Undetectedanduntreatedparentaldepressionplacesmillionsofchildren in theUnitedStatesat risk
eachday.Parentaldepressioncanbeespeciallydamaging forthegrowthandhealthydevelopmentof
very young children, who depend heavily on their parents for nurture and care. Treating parental
depression and addressing its negative effects early in a childs life could improve that childs
development.Severalsafeandeffectivedepressiontreatmentsareavailable,butthedeliveryofthese
services,especiallytolowincomefamilies,requiresnewandinnovativeapproaches(NationalResearch
CouncilandInstituteofMedicine[NRCandIOM]2009).
In this guide, we look at one promising approach: using home visiting programs to identify
depressedmothersandconnectthemandtheirfamiliestoservices.Wefocusonmothersbecausethey
areoftentheprimarycaregivers,butwealsorecognizetheseriousnessofpaternaldepression.
WhatAreHomeVisitingPrograms?
In theUnited States, an estimated 400publicly and privately fundedhome visitationprogramsnow
reach 500,000 children (Ammerman et al. 2010). These programs generally involve regular visits to
pregnant
women
and
mothers
of
young
children
over
several
months
to
several
years
by
a
paraprofessional or professional (such as a nurse or social worker), with goals that may include
enhancedparenting skills,bettermaternal and childhealth,achievementofmaternal educationand
employment goals, postponement of subsequent births, and enhanced child development. Some
programs, such as NurseFamily Partnership and Healthy Families America, are built on nationally
designedcurriculaandapproaches,whileothersarelocallydesignedorrepresentuniquelocalvariants
ofanationalapproach.Someprograms,suchasEarlyHeadStartandHeadStart,offerhomevisitingin
conjunctionwithotherservices(suchascenterbasedearlychildhoodclasses)eitherasanoptionoras
oneelementofaprogram.
Researchershave
found
solid
evidence
that
several
approaches
to
home
visiting
can
produce
results formothersandyoung children in suchareasaspreventionof childabuseandneglect, child
health,maternalhealth,childdevelopmentandschoolreadiness,familyeconomicselfsufficiency,and
positiveparentingpractices.Arecentreview identifiedsevenprogramsasevidencebased:EarlyHead
Start, Family Check Up, Healthy Families America, Healthy Steps, Home Instruction for Parents of
PreschoolYoungsters,NurseFamilyPartnership,andParentsasTeachers(Paulselletal.2010).
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Thinkingaboutmaternaldepression in thecontextofhomevisitationprograms isparticularly
timely.ThePatientProtectionandAffordableCareAct(ACA)of2010provides$1.5billionoverthenext
five years through the Maternal, Infant and Early ChildhoodHome Visiting Program to improve the
healthofmothersandchildren.ThesefundswillbeadministeredbytheHealthResourcesandServices
AdministrationinpartnershipwiththeAdministrationforChildrenandFamiliesasasectionoftheTitle
V Maternal and Child Health block grant. Prompted by this new initiative, states are planning their
approachestoexpandingandstrengtheninghomevisitation.
However,despitetheseprogramspromise,theevidenceabouttheircurrentsuccessspecifically
fordepressedmothersand their children ismixed, leading researchers to call forbetter information
about how to redesign or supplement services (Ammerman et al. 2010). This guide helps fill that
informationgap.Bydrawingonexistingresearchaswellasnew interviewswith lowincomemothers,
homevisitors,andotherserviceproviders,thisguideofferspractical insightsabouthowhomevisiting
programs canenhance theirownworkand their links tootherprograms in the communitysuchas
mental
health
treatmentto
better
serve
depressed
mothers
and
their
young
children.
Aftersummarizingbasicinformationaboutmaternaldepressionanditseffectsonchildren,the
threemainsectionsoftheguideexplore
1. whyhomevisitingoffersanopportunity to reachdepressedmotherswith treatmentandsupportservices;
2. whatmothersreportarethebiggestneedsandchallengesoffamiliescopingwithdepressioninlowincomecommunities;and
3. whatitwilltaketorevamphomevisitingprogramsandtheirlinkstootherservicestoaddressthoseneeds.
Throughout,theguideincludesnewevidenceaboutparentandserviceproviderperspectiveson
maternaldepressiondrawn fromweeklong site visits to three cities:Chicago, IL;Cleveland,OH;and
Greensboro,NC.1Eachvisitincludedfocusgroupswithlowincomeparents(twogroupsineachcity)and
interviewswithserviceproviders.Most focusgroupparticipantswereAfricanAmericanandabout10
percentwereHispanic,withonefocusgroupconductedentirelyinSpanish.2Weaskedseveraldifferent
organizationstoinvitemotherswithachildundertheageof4toattendthefocusgroups;someparents
had participated in home visiting programs, while many others had not. In the three cities, we
conducted54
interviews
with
service
providers
who
worked
with
low
income
mothers
and
their
young
children,includinghomevisitors,earlychildhoodteachers,familyadvocates,SpecialNutritionProgram
forWomen,Infants,andChildren(WIC)nutritionists,pediatricians,familypractitioners,nurses,mental
healthcounselors,andsocialworkersinhealthandmentalhealthclinicsandpractices.
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MaternalDepression:Prevalence,Treatment,andEffectonChildren
Depression iswidespread,particularlyamong lowincomemothers.Asmanyas15millionchildren,or
oneoutofeveryfive,livewithanadultwhohadmajordepressioninthepastyear(NRCandIOM2009).
Ourcompanionstudy,which for the first timeusesanationaldataset to lookatmaternaldepression
(theEarly
Childhood
Longitudinal
Study
Birth
Cohort
or
ECLS
B),
shows
astrikingly
high
rate
of
depression.Amonginfantsinfamilieslivingbelowthepovertylevel,oneinninehasamotherreporting
severedepressionsymptoms.Andmorethanhalf(55percent)ofallinfantsinpovertyarebeingraised
byamother reporting some formofdepression, includingmild andmoderatedepression symptoms
(Verickeretal.2010).
Maternaldepression frequently coincideswithother risks, includingothermentalhealthand
substanceabusediagnoses,chronicmedicalconditions,andsuchsocialdisadvantagesaspovertyand
domesticviolence (NRCand IOM2009).AccordingtotheECLSBstudy,among infants inpovertywith
severelydepressedmothers,16percentofmothersreportrecentphysicalabuse,and14percentreport
bingedrinkinginthepreviousmonth(Verickeretal.2010).
Maternal depression affects childrens development. Untreated depression interferes with a
parentsabilitytobepositiveandnurturingandcanimpedeaparentsabilitytoensureconsistentcare
in a safe environment. Depression in parents is associated with poor social development and poor
physical,psychological,behavioral,andmentalhealthforchildren (NRCand IOM2009).Researchalso
documentsdepressions link to childabuseandneglect.The incidenceofdepressionamong families
involvedwithchildwelfaresystemsishigh.Anationalstudyrevealsthatoneinfourparentswhowere
investigated by childwelfare systems,butwhose childrenwerenot removed, reported experiencing
majordepression
in
the
past
year
(DHHS
2005).
Fortunately, maternal depression can be treated. Medication, psychotherapy, behavioral
therapy, and alternative medical approaches can be used to treat depression in adults safely and
effectively.However,theimpactofthesetreatmentinterventionsonparentaldepressionhasnotbeen
rigorouslystudiedamongvulnerablepopulations,suchaslowincomewomen(NRCandIOM2009).For
these particularly vulnerable populations, researchers find that supplementing the usual depression
interventions may be necessary. For example, one study finds evidence that for young, lowincome
minoritywomen,anapproachwith intensiveoutreach,childcare,transportation,andencouragement
tocomplywithevidencebasedmedicationorpsychotherapyworksbetterthanusualcareonitsown
(Mirandaet
al.
2003).
Further,
the
National
Research
Council
and
Institute
of
Medicines
2009
report
recommendsthatafocusonpositiveparentingandchilddevelopmentshouldbepairedwithtreatment
ofparentaldepressiontopreventthechildsadverseoutcomes,enhancetheparentsinteractionswith
thechild,andhelpengagetheparentintreatment.
Despite theprevalenceofmaternaldepressionamong lowincomemothersand itseffectson
children,manymothersstilldonot receivehelp.Forover twothirdsof infantswithmothers living in
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poverty and reporting severedepression symptoms, theirmothersdidnot speakwith apsychiatrist,
psychologist, doctor, or counselor in the past year about an emotional or psychological problem
(Vericker et al. 2010). Getting help to depressed parents, especially those with young children, is
therefore a major opportunity to enhance childrens development, ensure their safety, and prevent
abuseandneglect.
HomeVisiting:TheOpportunity
Researchers,practitioners,andparentsagreethathomevisitingofferspromiseforreachingandhelping
vulnerablemothers,specificallythosewithdepression.Ratherthanaskingadepressedmothertofind
the energy to persist on the phone until she reaches a doctor or counselor, find child care and
transportation,andkeeptheappointmentasplanned,thehomevisitorseeksheroutandcanhelpher
navigatetheseobstacles.Homevisitorsareoftenskilledatandtrainedforbuildingwarmandsupportive
relationships,whichoughttohelpengagemotherswithdepression.Andsincehomevisitingprograms
aregenerally
designed
to
reach
mothers
during
pregnancy
or
shortly
after
the
baby
is
born,
they
offer
oneoftheearliestportalsthroughwhichsizablenumbersofhighriskmotherscometotheattentionof
serviceproviders(Ammermanetal.2010).
Manyparentsinourfocusgroupstoldustheywouldsuggesthomevisitingasasourceofhelpif
theyknewadepressedmotherofyoungchildren.3Theyemphasizednotonlytheconvenienceofhaving
someonecometotheirhome,butalsothecomfort:homeiswheretheparentfeels incontrol.Asone
parentsaid:
Theycometoyourhomewhereyouarecomfortable.BecauseIlltellyourightnow,they
dontcome
out
in
suits.
They
come
out
dressed
like
whoever.
They
dont
make
you
feel
uncomfortableIf you smoke, smoke,whatever. Itsnotgoing into somebodysoffice.
Itsalmostlikesittingdowntalkingtoafriend.
However, one parent wasnt convinced that any service provider could make her feel
comfortable:Ijustreallydontlikeit.Icantdealwiththem.Theyretooscary.
Otherparentsemphasized the relationshipwith thehome visitor. Theyhave therapists that
comeouttoyourhouseaswellassomebodythatcomesouttoseeyourchild,oneparentsaid.There
is also somebody who comesjust for you, and I still have a relationshipwith them. Some parents
believedit
was
advantageous
for
ahome
visitor
to
see
amother
in
her
real
life
context.
They
thought
a
homevisitorwouldbelesslikelythanaprofessionalinanofficetothinkadepressedmotherwasgoing
tohurtherselforherchildrenandneeded tobereported tochildprotectiveservices.Othermothers
trustedtheirhomevisitorbecause,unlikeamedicaldoctor,thehomevisitorhastimetositandlisten,
allowingthemtogointomoredetail.
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Thehomevisitorsweinterviewedagreedthatgoingtothehomeandgettingacloseupviewof
afamilywerebothkeyadvantagesofthemodel:
Wecometotheirhouse,which isahugebenefit.Tryingtogetanyplaceforhalfthese
women[costs]$2.50forabusticketonadailybasis.Beingabletogointhehomeand
seethe
conditions,
how
they
are
living,
whether
they
keep
the
blinds
closed,
whether
theygetdressed,andwhethertheykeeptheappointment[isabenefit].
Sometimes,thatcloseviewcanleadtoidentifyingchallengesearly:
Thehomeeducatoristhefirsttoidentifytheseissues[maternalandfamilystressesofall
kinds]becausetheyrethereMondaytoThursday.Sometimesthemomdoesntsay,but
the home educator observes. Sometimes they see themom hasmarks or bruises, or
therearemarksonthebaby,ortheyfindthemomcrying.
Butwhile researchers,practitioners,andparentsall seeagreatpotential forhomevisiting to
reachdepressedmothers,theyalsoseeplentyofpitfalls.Homevisitorsnotspeciallytrainedtoaddress
mothersdepressioncanfacemanychallengesinrespondingeffectively.Theresearchevidencetakenas
a whole indicates that home visitation services alone are insufficient to bring about substantial
improvementindepression(Ammermanetal.2010,197and199).Andthebestcombinationofmental
health services, needed to treat depression in at least some mothers, with the alternative kind of
supportofferedbyhomevisitorsisntobviousoreasytodo.
Therefore, the question addressed in the remainder of this guide is how to confront these
challenges and build on the promising start that home visiting offers. To ground the discussion of
challengesand
solutions,
we
begin
with
amore
detailed
look
at
the
perspectives
of
mothers.
MothersPerspectivesonDepressionandTreatment
Lowincomemothersofyoungchildrenviewdepressionasaseriousproblemfortheirpeers,andthey
havemanyideasaboutwhatworksandwhatdoesntworktoaddressit.
MothersBelieveThatDepressionIsWidespread
Ineachofoursixfocusgroups,mothersreportedthattheybelievedepression,stress,andsadnessare
widespread
among
mothers
of
young
children
in
their
communities.
Mothers
reported
that,
among
the
women theyknow, feelingdepressed iscommonorpretty typical.Some focusgroupparticipants
thought thatasmanyas80percentof themoms in theircommunity feeldepressed.Severalwomen
attributedthisestimatedincidenceinparttohighlevelsofcommunityviolence,domesticviolence,and
financialstress,aswellastheabsenceoffamilysupport.
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ManyMothersWouldAdviseaDepressedFriendtoSeekHelp
While their perspectives on seeking help are complex,many mothers in the focus groups said they
would advise a depressed friend to seek help somewhere, especially because depression affects
children. Somemothers said the negative effectson childrenmakematernal depression particularly
graveandserveasamotivationforseekinghelp.Asonemothersaid,
Ifsomeonestaysaloneintheirhouse,intheirworld,andtheydontreflectontheirkids
andtheydontlookforhelp,itisaproblem.Thesituationdoesntgetbetter,andithurts
the kids and other people. It is a big problem when you dont look for help or
information.
Thesewomenwould encourage a depressed friend to think about the childor tell her Your kids
shouldntsufferbecauseofwhatyouregoingthroughtomotivatetheirfriendtoseekhelp.
MothersHaveNoConsensusonaSingleSourceofFormalorInformalHelp
Mothersdifferedonwheretogoorwhomtoaskabouthelpfordepression.Nosinglesourceofhelp,
formalorinformal,istrusteduniversally.
Instead,focusgroupparticipantsagreedonthecharacteristicsofthepersontheywouldcount
ontohelpthem:someonewithwhomtheyhavehadacaringandtrustingrelationshipoveraperiodof
time.Participantsappliedthesecriteriatoboth formalserviceprovidersand informalsourcesofhelp,
suchasfamilyorchurchmembers.Alongtermrelationshipisimportantbecausethepersonknowsthe
motherwell,understandsherrelationshipwithherchildren,andwontjumptoconclusions fromone
disclosure.Asonewomanexplained,
IhavefoundagoodpediatricianIdprobablyfeelcomfortabletalkingtohimabout it
[depression],andheknowsmebetterandseeshowIinteractwithmychild.SoifItell
him Iwasfeeling really shitty the other day., he knows not to assume thatmeans
Imgoingtotakemyselfandmykidout.
Anothermotherexplainedthatseeingthesameprovidermanytimesallowstheprovidertosee
changesinhermoodfromoneappointmenttothenext.
Mothers also trustproviderswho go above andbeyond theirduties,who really care and
wanttohelpyou insteadofbeingreallyjustthereforthepaycheck.Onemothercametotrusther
doctorwhen
he
followed
up
on
the
referral
calls
he
had
asked
her
to
make:
He
was
calling
to
check
up
onme.Didyougotosuchandsuch?IthoughtthatwassomebodyIcouldturnto.Inaddition,several
motherssaidtheydidntwanttobejudgedforbeingyoungor inexperiencedparentsaconcernthat
woulddiscouragethemfromseekinghelp.Professionalpeopleareveryscarytotalktowhenyouare
young,onemothersaid,becausetheyarealready lookingatyou like,Oh,youareyoung.Youdont
evenknowwhatyouaredoing.
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Motherssoughtouttrustworthinessandnonjudgmentalattitudesininformalhelpersaswellas
professionals.Theyappreciatesomeonewhotakestheirconcernsseriouslyandlistenscarefully.Asone
mothersaid,
Theresa lady inmyneighborhoodwhoeverybodyseemstogotobecausesheisolder,
andshe
has
been
there
awhile,
and
she
just
listens
to
you.
She
doesnt
talk
down
or
judgeyou.Itdoesntseemlikesheistellingyouwhattodowithyourlife.
Somemotherssaidtheywouldnotseekhelpfromneighborsorfamilymembersbecausethey
wouldbenegativeandunsupportive.Familymembersmightgetdownonyou,think itsall inyour
head,orthatyourefullofit.
ManyMothersWorryaboutChildProtectiveServices,Confidentiality,and
Medication
Mothers identifiedseveralspecificworriesthatcouldkeepsomeonefromseekinghelpfordepression:
forexample,
that
their
children
will
be
removed
by
child
protective
services,
or
that
the
person
they
seekhelp fromwillviolate theirconfidentiality.Somemothersalsodistrustmedicationprescribed for
depression.
Many mothers in our focus groups have friends or family members involved with child
protectiveservices(CPS)orwhohavelostcustodyoftheirchildren.Asimplephonecall[toCPS]iswhy
mostwomen are scared to seekhelpoutsideof thehome, especiallywithpeople youdont know.
Mothers fear that revealing their depression, sadness, or frustrationswillmake them seem unfit as
parents.Ifyoutelladoctororsomebodyinpower,somebodyinacertainposition,theyhavetoturnit
overtosocialservicesortheyhavetotelltheauthorities,onemothersaid.Shecontinued:
TherehavebeentimeswhereIliterallyfelt likeputtingmychildonthesideoftheroad
while Im driving down the street and theyre crying. I just want to stop on the
highway,pulltheircarseatoutthecar,andputthemonthesideoftheroadanddrive
on. Ifelt like that. Ihavenotdone it.But if I say that tomydoctoror if Isay that to
anybodyinsocialservices,CPSisgonnaberightthereatmydoor.
Mothersworryabouttheconfidentialityoftheirstatementsforotherreasonsaswell,including
the fearofdomestic violence.Depressionexacerbatedbydomesticabuse canprevent somewomen
fromseekinghelp.Onefocusgroupparticipantsaidthatafriendofhers
justbrokedownandtoldthedoctoreverythingandwheneverherhusbandfoundout,he
madeherswitchdoctors.Whenshewenttogethermedicalreports,whatevershesaid
wasinhermedicalreports.Soitsgoingtobewithherforever.Soshethoughtwhatshe
toldthemwasconfidential.Nowshesscaredtotellanybodybecauseshesscaredof
whatmighthappen[asaresultofherhusbandknowing].
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Some mothers believe medicine can help treat depression, but others are skeptical or
concernedaboutsideeffects.Somethinkprovidersprescribemedicationasaquickfix.Adoctorhears
acomplaintandthefirstthingtheywant[is]tofillyouupwithantidepressants,oneparticipantsaid.
Someparentsworryabout sideeffects thatmedicationwilldamage theirheartor causedrowsiness
compromisingtheirparenting,orcauseamiscarriage.Otherssaidtheycouldnotaffordmedication.
PartnersandFamilyMembersMayBeSupportiveorMayHoldMothersBackfrom
SeekingHelp
Mothers in our focus groups had complex feelings about their family members roles regarding
depressionandtreatment.Somemotherssaidtheirpartners,parents,andotherfamilymemberswere
supportive,whileotherssaidtheywereaburdenorabarriertotreatment.Someyoungmothers felt
that familymemberscaused themstressby interfering in theirparentingor telling themwhat todo.
Otherssaidfamilymembersgavethemwelcomeandusefuladvice.
Whilesomemothersfeeltheoverbearingpresenceoftheirfamily,othersstrugglewithisolation
and theabsenceofa supportive family.Manymothers,especially singleparents, feel theyhave few
options forhelpwhenoverwhelmedby childrearing. Some live far away from familymembers (e.g.,
haveapartnerservinginthearmedforcesoverseas),andotherslivenearfamilybutcannotrelyontheir
support.Onemothersaid,
My sonsfather ismarried, so there is only somuch that he can doforme. I know
absolutelynothingabout raisingbabies.When Ibroughtmy sonhome thefirst three
nights, Iwas reallypullingmyhairoutbecause Ihadno cluewhat todo [andhad]
nobodytocalltosayMybabyiscrying,whatdoIdo?Ihadtocallthepoliceandask
thepolice.Theycametomyhouseandstayedwithmeforaboutanhourtofigureout
whatsgoingon.
Evenwhen familymembersand spousesare supportiveonpractical issues,mothersdisagree
aboutwhether familymembersandspousesare therightpeople to turnto forhelpwithdepression.
[Husbands] will not listen to you, one mother said, and they dont know about or understand
depression.Othermothersfeartheywillbephysicallyorverballyabusediftheytalktotheirspousesor
familymembersaboutseekingdepressiontreatment.Ontheotherhand,somemotherswouldlookto
their familyexclusively forhelpwithdepression:Your familybusiness is familybusiness.Yougo toa
grandparentforwisdomoraproblem.
Trauma,Loss,andStressArePartoftheContextforMothersDepressioninLow
IncomeCommunities
Manymotherswe interviewed talked about the trauma and stress theyorpeople they knew faced.
Domesticandcommunityviolencecameupas soonasweaskedaboutdepression.Ihada sadand
depressingpregnancy,onemothersaid.Ihadan11montholdandthefathergotkilledonthestreet
andIwascarryingachild.Iwasdepressedandclosedin.Itwashard.Thefinancialpressuretheselow
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incomemothersexperiencealsocameupasasourceofstress.Inaddition,alackofresourcessuchas
money,childcare,andtransportationcanhindertreatment,forcingsomemotherstochoose,asone
participantsaid,betweenfoodandmedicaltreatment.
HomeVisiting:
What
It
Takes
to
Serve
Depressed
Mothers
of
Young
Children
Basedoninsightsfromourparentfocusgroupsandinterviewswithhomevisitors,aswellasresearchon
depressionandchilddevelopment,we identifiedsixchallengeshomevisitingprogramsface inhelping
depressedmothers.Wealsoidentifiedpromisingapproachestoovercomeeachchallenge.Policymakers
andpractitionersshouldviewthesestrategiesasearlyeffortstoapplyexperienceandevidencetosolve
problems,butnotasprovenoruniversal solutions, sinceno rigorous researchhas tested themona
largescale.
1.Reaching
the
Mothers
Who
Most
Need
Help
Homevisitingprogramsservemanymotherswithdepressionbetween28and61percentofmothers
inprogramsscreenedpositiveasdepressed,accordingtoonesynthesisofavailablestudies(Ammerman
etal.2010).Butmanyotherdepressedmothers likelyarenotenrolled forahostofreasons.Roughly
500,000familiesareservedbyhomevisitingprogramsintheUnitedStates,whichcorrespondstoabout
1in6ofallyoungchildren(underage3)livinginpovertyandabout1in12ofthoselivinginlowincome
families (below twice the federalpoverty level).4Sinceweestimate thatmore thanhalfof infants in
povertylivewithmotherswhohavemild,moderate,orseveredepressionsymptoms(about1.5million
families),aconsiderablenumberofdepressedmothersarenotservedbyhomevisitingprograms.
Inthecommunitieswevisited,serviceproviderstoldus,sometimeswithgreatemotion,about
missedopportunities toservedepressedmomsand theirbelief thatmorehomebasedservicescould
drawinthosemothers.TwomentalhealthcliniciansinChicagopointedoutthatmotherswhoneedthe
mosthelpoftengowithoutbecausetheycantkeepappointmentsregularly.Mostofthepeoplewho
needhelpdontget it,one clinician said. If thereweremorehomebasedservices toaddress their
needs[theseindividualswoulddobetter].Theirsupervisorsaidshewouldliketorefermoreclientsto
alocalparentingandhomevisitingprogram,butitiswoefullyunderfunded.
Bothhome visitorsand staff inotherprograms that serve lowincomemothers thought that
budgetcuts
made
reaching
high
risk
mothers
of
young
children,
including
depressed
mothers,
hard
for
home visiting programs. In Illinois, case management staff for several small programs for highrisk
motherssaid thatastatebudgetcut forced them todropnearly twothirdsoftheirhomevisitcases,
going from64to24totalfamilies.Whilethe fundswere laterrestored,staffworriedthattheywould
notbeableto findthe families.AWICnutritionist inNorthCarolinaworriedwhenshewenthomeat
nightaboutwhetherthemothersandbabiesshesawwouldevergethelp fordeeprootedproblems,
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suchasdepression.SheknewofoneMedicaidfundedhomevisitingandcasemanagementprogram,
butshethoughttheprogramwaslimitedtoservingasmallgroupoffamilies.
TheadditionalresourcesavailabletostatesthroughtheACAofferanopportunitytostrengthen
homevisitingprogramsandtoexpand,potentiallytargetingtheenrollmentofdepressedmothers.We
discussthree
promising
approaches
below.
Usecommunitydatatolearnaboutandtargetservicestodepressedmothersofyoungchildren.StatesandcommunitiesdecidinghowtousethenewACAhomevisitingresourcesshouldconsider
bringingtogetherlocalpartnersanddatasourcestoassesstheneedsandservicegapsfordepressed
mothersofyoungchildren.Localdataabout thenumberandshareof infantswhosemothersare
depressedcanbeestimatedfromnationaldataandbydrawingoninformationfromlocalhospitals,
existinghomevisitingandmaternalcasemanagementprograms,earlycareandeducationandearly
intervention programs, doctors and clinics that see pregnant women, pediatricians, community
mental health and family support programs, WIC clinics, and parents themselves. With this
information,stateswillbeabletobettertargetACAresources.
Wecameacrosstwoexamplesofcommunitiesusingdatatotargetresourcestodepressedmothers.
Inonesitevisit,we learnedaboutanetworkofserviceproviderscommitted tohelpingpregnant
women andnewmothers and its strategy for targeting services todepressedmothers.Nearly a
decadeago,theperinatalnetworkdecidedto focusonhelpingpregnantwomenwithdepression.
The leadersgathereddatafromhealthcareandotherprogramsthatservedpregnantwomen(for
example, by asking a small number of providers to administer the Edinburg screening tool for
depressionduringastudyperiod).Thenetworkalsosurveyedalargernumberofsocialservicesand
healthproviderstofindoutaboutrelevantpractices,suchaswhethertheyscreen fordepression,
andexisting services.Over the years, that initialassessmenthashelped shapea communitywide
approachtomaternaldepressionthathasledto,amongotherthings,commonscreeningtoolsand
acommonreferralform.
In a smallerscale example, an early childhood programdirector in another city told us thather
agencys own needs assessment led the staff to implement a homebased (rather than center
based)programinoneneighborhoodtoincreaseinvolvementamongthemothersofyoungchildren
there.Manymothers in thatcommunitywereundocumented immigrantsandafraid to take their
children toa centerbasedprogram.Once thehomebased servicesbegan,homevisitors learned
thatthesemothersalsoexperiencedhighlevelsofdepressionandisolation.
Developeffectivereferralandrecruitmentpaths,andkeepfinetuningthem.NationaldatafromtheECLSB studyoffer somehintsabout likely sources for reachingdepressedmothersof young
children.Thesedatasuggest that clinicsproviding servicesunderWICandpediatricianspractices
offerparticularlygoodopportunitiestoreachdepressedmothersofinfants.Ninetyfourpercentof
infants inpovertywith severely depressedmothers lived in a familyusingWIC services and, on
average,theseinfantshadsixvisitstothepediatricianbythetimetheywere9monthsold(Vericker
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etal.2010).Cliniciansthattreatpregnantwomenorseemothersandinfantsrightafterbirthcould
alsobegoodscreeningsitesandreferralsources.
Inoursitevisits,wesawrecruitmenteffortsforhomevisitingthatdrewonthesesourcesandthat
aimed to reachmotherswithmental health vulnerabilities. In Chicago, casemanagers forhome
visitingprograms
had
an
office
at
the
WIC
clinic
and
were
able
to
recruit
high
risk
pregnant
women
andmothersof infants intotheirprogramswhentheycame in forWIC.Doctors inNorthCarolina
whosawwomenforprenatalcarereferredthemtoNurseFamilyPartnership,givingpreferenceto
thosewithgreatermentalhealthneeds.Other referrals to thatNFPcame froma familyplanning
clinicthatsawwomenduringpregnancyandafterdelivery.
However, referrals only work if service providers who see depressed mothers know the right
organizationstoreferthemto,andourinterviewssuggestedthatisnotalwaysthecase.Whilethis
gapmayhavebeenpartlybecausenotenoughprogramswereavailabletomeettheneed,wealso
heardthatforbusyprofessionals,rememberingwhomightbeavailabletohelpisdifficult.Forthat
reason,the
leaders
of
the
perinatal
network
emphasized
the
need
for
an
ongoing
process
that
keeps
everyone in the community who cares about maternal depression abreast of available services,
trainingopportunities,andemergingpartnershipsandcollaborations.Theperinatalnetworkstarted
aquarterlytaskforcemeetingwherehealthandsocialservicesproviderscandiscussproblemsthey
encountertryingto identifymotherswithdepressionandreferthemtootherpartnersforservices
andtreatment.Anotherapproach to thesamecommunicationand feedbackproblem is todesign
andimplementacentralizedreferralsystemsuchastheChildDevelopmentInfolineinConnecticut.5
Offermanypathstohomevisitingfordepressedmotherswithyoungchildren,enablingreferralformothersindifferentcircumstancesandwithchildrenofdifferentages.Multiplepathstohome
visitingwill
likely
reach
alarger
number
of
families
that
need
help.
First
onset
of
depression
can
occur at any age, and formany the condition is chronicor reoccurring. States and communities
shouldconsiderpairinganintensefocusonpregnancyanidealtimetoidentifymotherswithorat
risk for depressionwith homebased services for depressed mothers of slightly older children,
including infants,toddlers,andpreschoolers.Forsomemothers,theirdiscoverythatachildneeds
help could be what motivates their ownwillingness to seek treatment. Ideally,multiple referral
opportunities and home visiting programs would allow services to be available for depressed
mothers of young children whenever depression is identified and the parent is ready to seek
treatment.
2.Helping
Home
Visitors
Identify
Depression
and
Talk
to
Mothers
about
Its
ImplicationsandTreatment
Inoursitevisits,homevisitorsoftentoldusthattheywereuncomfortablediscussingdepressionwitha
motherunlessshe raised the issueherselforalreadyhadamentalhealth referralordiagnosis.Some
werenotsureidentifyingdepressionwastheirjob.Wedontdoscreensformaternaldepression,one
homevisitingprogramsupervisorsaid,sotherecouldbemoremomswithdepressionthanweknow
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butwefocusonchilddevelopmentWedontnecessarilytouchonthoseissues.Othersworriedthat
focusingondepressionwoulddetractfromtheircoremission,definedashelpingmothersachievegoals
they themselves identified. The multiple overwhelming issues in mothers lives made prioritizing
depression treatment difficult for both mothers and home visitors. If [mothers] score high [on a
depression screen], they may refuse the referral because they think their situation is causing the
problem,thingstheyaredealingwithallthetime,onehomevisitorsaid.Theydontthinkitsrelated
totheirpregnancyorpostpartumdepression.Theycantsleepbecausetheyreworriedabouthowthey
willfeedtheirchildrenthenextdayandpayingbillsontime,dealingwithdisconnectionnotices.Theyre
thusreluctanttoseekhelp.Amotherinonefocusgroupconfirmedthischallenge:
My thing is that sometimes you dont have time to be depressed; you dont have a
choice.Youhavetogetup.Youhavetotakecareofthebaby.Youhavetogotoschool.
Youhavetogotowork.
Otherhomevisitors,though,toldusthattheydonotknowhowtoidentifydepression,andthey
worryabout
failing
to
help
mothers
because
they
do
not
recognize
its
signs.
In
Illinois,
ahome
educator
fromanearlychildhoodprogramechoed theconcernsofotherswe interviewedwhen shedescribed
howoverwhelmingbeingtheonly lifeline foradepressedandperhapsabusedmother is.Shewanted
trainingtorecognizedepressionandrefermotherstotreatment.
Whatarethesigns?Howtoconvincethefamilytogethelpandnotjustthechild?Allof
ourtrainingsareaboutthechild. Ifwecangetthemomemotionallyhealthy,thenthe
childwillbehealthier.
InNorthCarolina,homevisitorstoldusoftheirworryofpossiblyhavingmissedamentalhealth
diagnosisand
being
unable
to
engage
amother
whose
lack
of
interest
perhaps
masked
underlying
depression.Onehomevisitorsaidshetriedtoconvinceamothertoseekmentalhealthtreatmentbut
wasrebuffedseveraltimes.Thenursefinallyencouragedthemothertoseeadoctorforapapsmear,
hopingatleasttoinvolveanotherprofessionalwhomightkeepaneyeonher.
Otherresearchhasconfirmedthathomevisitorsmayhavetrouble identifyingdepressionand
othermentalhealthproblemsandmaygetcaughtupinamothersimmediate,tangibleneedswithout
alsoprioritizingtreatment(Ammermanetal.2010).Onestudyfindsthatinthethirdyearoffollowup,
homevisitors stillonly recognize14percentof thecasesofpoormentalhealth inmothers identified
throughadepression screen (Ammermanetal.2010).Aproject inLouisiana thatprovidedenhanced
mentalhealthconsultationtonursehomevisitorswasmotivatedinpartbythedifficultiesnursesreport
increatingrelationshipswithhighriskclients.Theresearcherswonderedwhetherdepressionwasone
reason theparents,who appeared unmotivatedorevendisinterested to thenurses,werehard to
connect with (Boris et al. 2006, 29). And an experienced clinician pointed out that people with
depressionhaveanauraofhopelessnessthat inexperienced,untrainedserviceprovidersmayeasily
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buy into,comingtosharethedepressedpersonsviewthatallotherproblems(e.g.,povertyor lackof
housing)mustbesolvedbeforeaddressingdepression.6
The home visiting programs we visited varied considerably in how much identifying and
respondingtodepressionwaspartoftheireverydaypractices,mission,andtraining.Thefollowingare
amongthe
lessons
we
learned:
Considerdepressionscreeningaspartofamorecomprehensiveapproachtoengagingandhelpingdepressedmothers. Perhaps thebroadest lesson learnedwas that addingdepression screens to
homevisitingisnotasimple,standalonefix,butneedstobepartofabroaderapproach.
Accordingtoa leaderwiththeperinatalnetwork, implementingadepressionscreen inthedayto
dayworkofserviceproviderswhosawnewmotherstookseveralsteps.Atfirst,shesaid,program
stafftoldherthatmotherswouldntwanttobescreened,butasurveyconductedbythenetwork
suggested thatmothersdid cooperateand found the screenings valuable.Theperinatalnetwork
thenextensively
trained
staff.
We
did
role
play,
group
work,
heard
concerns
and
addressed
concerns,andslowlygot[theserviceproviders]onboard,thenetworkleadersaid.Thefirstgroup,
wewereshockedabouttheresistance,anditwassoopen.Iwillnotbreakmyclientsconfidence.
Wedonttalktomedicaldoctors.Theytakeawaykids....Wesaidthatonceyoustart,wearehere
foryoutohelpyouwithissues.And loandbeholdthey[serviceprovidersdoingthescreen]are
the biggest proponents of it now. In our interviews with programs that dont regularly screen
mothers,weheardthesameworriesaboutconfidentiality,CPS,and linkingtootherservicesfrom
home visitors as well as requests for training that would go beyond identifying depression to
engagingadepressedmother,seeingtheworldfromherperspective,andfindingwaystoconvince
hertogettreatment.
Make explicit how identifying and treating amothers depression connects to the core homevisitingmission, and train home visitors to talkwithmothers about the connections. To feel
comfortable screening and engaging mothers, home visitors need to see how identifying and
treatingdepression canhelp thembe true to theprogramsmission.Especially inprograms that
prioritize meeting the mothers own goals, home visitors need to understand and be able to
communicate to a mother how depression can make achieving those goals more of a struggle,
despiteherbesteffortssotreatingdepressionandreducingthesymptomswillhelphergetwhere
she wants to go. Mental health training, supervision, and consultation can help home visitors
understandand communicate tomothers thatnomatterhowmanypracticalbarriers theyhave,
untreateddepressionmakesall theothersharder to solve.Forexample,depressions symptoms,
suchas sleeping toomuchor too littleandbeing irritableorwithdrawn,may inhibitadepressed
motherfromachievingothergoalslikeobtainingaGED,holdingajob,orbeinganengagedparent.
Depression can also hinder a mothers ability to find housing, apply for social services, follow
referrals,orevenpickupbabyformulafromtheWICoffice.
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Inhomevisitingprogramswhosemissioncenteredon thechildsdevelopmentmore thanon the
mothersgoals,homevisitorswereparticularlyreceptive to informationaboutdepressionseffect
onbabiesandyoungchildren.Oncetheyhadthatinformation,theysawopportunitiesforengaging
themotherinaconversationarounddepression.
Becauseso
many
mothers
cope
with
multiple
challenges,
home
visiting
programs
would
probably
alsobenefit fromaguidingphilosophy, informedbymentalhealthclinicalknowledge,abouthow
home visitors should prioritize families needs. For example, in one successful depression
intervention for lowincomewomen, theprogramsdesignerdistinguishedbetweentimesensitive
crisesandongoingbarriers.Forcrises,suchasachildsupcomingdeportationhearing,programstaff
delayed themotherstreatmentwhileshewenttothehearing,whileemphasizingthat treatment
would give her something in her life she could control. For ongoing barriers, the program
encouragedmotherstoseehowreducingdepressionsymptomsthrougheffectivetreatmentwould
help themmanage theirproblems.7Thisparticularphilosophymightnotbe right foranongoing
home visiting program, but some coherent philosophy thought through in advance would help
homevisitorshandleconstantprioritychoices.
Seekoutresources tohelpmotherssolvesomeof theirotherchallengeswhilealsoworkingondepression. Mothers may be able to address some of their multiple challenges as they seek
treatment fordepression, rather thanhaving tojustworkononepriorityata time. Inparticular,
homevisitingprogramsoftenincludeconnectionstocommunityresources,someofwhichcanhelp
motherscopewithorovercometheirproblems.Homevisitorshadmixed feelingsabout theright
balance, with some seeing such material help (e.g., clothing, baby supplies, and formula) as a
distraction;othersseeitaswelcomerelieffor immediateneeds.Somefeltdonationshelpedthem
buildarapportwithmothersthatcanleadtodeeperengagementovertime:Alotofparentswant
todo theprogram forstuff,onehomevisitor toldus.Wecanusestuffasprops tohelpusget
through,and itallowsyou tobuildup rapportand then [the clients]warmup.TheOhiohome
visitingmentalhealthcliniciansalsosawthebenefitsofcombiningtherapywithcasemanagement
services,buttheythoughtthatdoingbothslowedtheprogressoftherapy.Tomakegainingaccess
toother serviceseasier forhomevisitors,some stateshavedevelopedanautomatedcommunity
resourceinventory.8
Considertraininghomevisitors tospeakhonestlytoamothersconcernsaboutchildprotectiveservices.Giventheextentofsomemothersfearsthatevenraisingamentalhealthissuemightlead
to
their
childrens
removal,
home
visitors
may
need
to
be
prepared
with
accurate
information
about
childprotectiveservicesandanhonestapproachtotheseconcerns.Homevisitorsnodoubtalready
havetodealwiththis issueasmandatedreportersofchildabuseandneglect.Theymaybemost
effectivewithmothersbybeingupfrontaboutwhatwould require reporting,butmaintaininga
warmrelationshipsothemotherfeelsunderstoodanddoesnotbelievethatherstatementsabout
mentalhealthconcernsorneedswillbemisunderstood.
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Onesuccessful intervention trial to treatdepressionamong lowincomewomen trainednurses to
addressthetopicofchildprotectiveservicesinearlymeetingswithmothers.Thenurseswentover
thecriteriaforreportingchildabuseorneglectandmadeclearthathavingdepressionandbeingon
medicationswerenotreasonsforcontactingCPS.Thenursessaiddirectlythatcircumstancescould
come up where they saw a child was in danger, in which case they would have to report that
danger.9Thistrial,whilenotastudyofahomevisitingprogram,providesanexampleofhandling
mothersconcernsaboutCPSreporting.
Complement oneonone attention during home visits with group or community strategies.Serviceprovidersandmothers recommended fighting the stigmaofdepressionbydiscussing it in
manydifferentpublicsettingswheremothersdonthavetocomeforward individually,thenusing
these settings to send the message that depression is common and treatable and that seeking
treatment is good for themothers children.The serviceprovidersandmothers suggestedmany
waystosharethismessage,suchasthroughpresentationsordiscussionsatparentsupportgroups,
buttheyallhadacommontheme:givingmothers information inagroupenvironmentthat isnot
stigmatized, followingup rightat the sessionoratanotheropportunity,andperhaps choosinga
setting that could include partners or other family members. Depending on the home visiting
program, such a mixed strategy might be possible within the program itself (for example, at
socializations, group activities that are part of homebased Head Start and Early Head Start
programs) or through community partnerships. These group or community strategies can
complement the oneonone relationship with the home visitor, increasing the likelihood that
parentswouldbereceptivetoscreeningandtreatment.Inaddition,thereisexcellentevidencethat
somegroupexperiencesarequitevaluablefortreatingdepressionandthatcertaingroupscanhave
importantpreventiveeffectsby supportingorhelpingdepressedparentsexerciseorgetoutwith
theirchildren
(NRC
and
IOM
2009).
3.Connectingto,Supporting,andProvidingHighQualityTreatment
Homevisitorshavemanyconcernsaboutwhatmighthappenonceamotherstarts talkingabouther
depression and looks to them for help. First, they see challenges in linking depressed parents to
treatment.Theymayknoworassumethataffordablementalhealthservicesarehardtocomeby,have
waitinglists,orrequireexpensivebusorcabridestootherpartsoftown.Onehomevisitorsaid:
We do have afamily crisis centerbut in the suburbs. Financial and transportation
[obstacles]arebig.Iknowthereisaservicethatwouldgotothehouse,butIdontknow
aboutfunding
and
how
that
would
work.
[A
person
might
have]
awaitlist
of
at
least
six
weeks to go through,or togo through emergency because theyfelt theywould hurt
themselvesorsomebody.
Eveniftheyseehowamothercouldgettreatment,homevisitorsalsowonderabouttheirrole
inhelpingonceamother isdiagnosedwithdepression.My [client]momwasafraidofbeingputon
drugs,ahomevisitor said.Shedidntwantmedication. I respect thatbutkeepaneyeon this. It
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couldbedangerous. I gaveher vitaminalternatives,but shedidnotwantdrugs.Home visitors are
sometimesfrustratedthattheycannotworkwiththetreatingclinician.Wehavesomeclientsalready
receivingtreatmentfordepression,but itstill isachallengebecauseunlesstheclientgivespermission
forthecliniciantotalktothecaseworker,wehavenoideawhatsgoingon,ahomevisitingsupervisor
said.Thishurtsusbecauseifaclientisincrisis,wemighthaveabetterideaofwhattodo.
Researchershave recentlywritten about two promisingways to get treatment todepressed
mothers inhomevisitingprogramsandaddressthechallenges listedabove.One istocreateahome
basedmentalhealthservicetopartnerwiththehomevisitingprogram;theother istoprovideskilled
mental health consultation and supervision to the home visitors so they can deliver some services
themselves.Thesetwoapproachesalsocouldbecombinedtobuildontheadvantagesofeach.
Inadditiontotheseapproachesspecificallytargetedtohomevisiting,otherrelatedapproaches
aimtoenhancethecapacityofcaregiverswithsimilarbackgroundstohomevisitors,suchasHeadStart
andEarlyHeadStart teachers, tobeable todealeffectivelywithdepression.Thegeneralprinciple is
both toprovide the basic service (home visitingor EarlyHead Start) and then enrich itwith special
outreachtoparentswithdepression(NRCandIOM2009).
Develop homebasedmental health services. Ammerman and colleagues have developed andimplemented amodelofhome visiting fordepressedmothers that includeshomebasedmental
healthclinicianswhoprovidetreatmentafterahomevisitorhasmadeareferral.Thehomevisitor
introducesthementalhealthclinicianonajointvisit,afterwhichtheclinicianmakes independent
visits(Ammermanetal.2007).Thispivotalpreestablishedrelationshipwithmentalhealthproviders
helpsfacilitatereferrals,followthrough,andmothersactiveengagementwithservices.
Weinterviewed
home
visitors
in
North
Carolina
and
Ohio
who
had
some
access
to
such
home
based
mentalhealthservicesfortheirclients;inOhio,wealsointerviewedthementalhealthclinicians.In
bothsites,homevisitorsdescribedseveraladvantagesofhomebasedmentalhealthservices.With
homebasedmentalhealthservice,clientsdonthavetoworryaboutarrangingtransportationand
homevisitorsareableto introducethecliniciantotheclient,buildingontheirownrelationshipto
increasethelikelihoodthattheclientwillbewillingtoaccepttheservice.
InoneOhiohomevisitingprogram,wherementalhealthcliniciansandhomevisitorsworkforthe
sameagency, thetwocanworktogether, learning fromeachothersperspectivesonhowbestto
servethefamily.Inthatprogram,oncehomevisitorsreferaclientwithahighdepressionscreening
score,amental
health
clinician
contacts
the
client
within
24
to
48
hours,
allowing
home
visitors
to
feelconfidentthatamothertheyareworriedaboutwillreceivepromptattention.
Mentalhealthcliniciansalsoseebigadvantagestothehomebasedservices.Goingtothemothers
homegivescliniciansaclearerpictureofhersituation.Theyhavetomodifytherapyconductedat
home (for example,with familymembers coming in andout all the time),but they enjoy the
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creativityofdesigningapproachessuitableforahomesetting,forexamplebuiltaroundplayandart.
Onecliniciansaidthathomebasedservicesofferanopportunitytoengagepartnersandfamily.
Wedomorecouplescounseling than I thoughtweddo. Imsurprisedhowmanymen
want totalk tome.Theywant to telltheirsideandwanthelp.Theydontunderstand
whatis
going
on
with
the
woman.
She
is
changed,
mean,
irritable,
doesnt
want
sex.
We
getthemtohaveanunderstanding.
Provide skilledmental health consultation and supervision to enable home visitors to handledepressionandotherdifficultissues.Louisianahastakenthisapproachtoaddresstheconsiderable
mental health needs of their NurseFamily Partnership caseload. The state provides extensive
training fornursehomevisitorsandmentalhealth consultants,ensuring theydevelopacommon
language (Borisetal.2006).Nursesreceivea30hour intensivetrainingprogramon infantmental
health that includes information on caregiverinfant attachment, assessment of the infant and
mother, available interventions, when to make mental health referrals, and how to be more
consciousof
their
own
attitudes,
beliefs,
and
values
as
they
intervene.
The
mental
health
consultants,assignedonetoateamofnurses,aregenerallyexperienced intreatingolderchildren
butarenotexperts in infantsandyoungchildren.Theygothroughtwotrainingsessions:onea4
month, halftime session and one an 8month supervised field experience. The mental health
consultantsworkwiththeirteamofnursesinteamcaseconferencesandconsultationsonindividual
cases.
Whilewedidnotvisitanysettingswherehomevisitorshadthiskindof individualizedconsultation
available, themodelhas someclearappeal.Given the relationships thathomevisitorsbuildwith
families and the amount of time they are able to spendwith them (farmore time thanmental
healthprofessionals
could
likely
spend
with
mothers),
enhancing
their
skills
could
pay
off
greatly
for
families. With ongoing consultation and supervision by skilled mental health clinicians, it seems
possiblethatnursehomevisitorscouldoffersufficientservicesforsomefamiliesandlearnhowto
make targeted referrals for others, providing additional support to a more sophisticated clinical
intervention. The effectiveness of this model could depend considerably on the home visitors
education level, as nurses may be better prepared to learn from training followed by clinical
consultationsthanparaprofessionalhomevisitorswhodonothaveanursingeducation.
Considercombiningthetwomodels,withadded inhomeservicesforsomefamiliesplusmentalhealthsupervisionandconsultationforhomevisitors.Mentalhealthsupervision,consultation,and
trainingfor
home
visitors
seem
important,
even
with
in
home
help
from
clinicians,
if
only
because
homevisitorswillstillneedto learnhowtosupportclinicaltreatment.Homevisitorsmayneedto
support the clinicians instructions tomothers regarding theirmedication, forexample,or givea
motherfeedbackaboutthewayhertreatmentishelpingherparenting.Inaddition,giventhelikely
limits on the duration and caseloads of inhome services, home visitors may need to support
mothers in their program who have finished or are still waiting for treatment. Thus, in many
communities,thiscombinationofthetwoapproachesmightbestmeetfamiliesneeds.
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4.AttendingtoYoungChildrensDevelopmentaswellasMothersTreatment
As we have seen, maternal depression is associated with more hostile, negative, and disengaged
parenting practices and adverse child outcomes, including problems in childrens daily functioning,
physicalhealth,andwellbeing(NRCandIOM2009).Becausematernaldepressioncanbesodamaging
to thehealthydevelopmentofyoungchildren, it iscritical thathomevisitingprograms findaway to
addresstheneedsofbothmotherandchild.
Aswehaveseeninearlierexamples,though,thisfocusonbothmotherandchild,orthedyad,
canbehardtoaccomplishinpractice.Inmostprogramswevisited,homevisitorsdescribedtheirgoals
as focusingeitheron themotheras theprimaryclientoron thechild.Homevisitors inchildfocused
programsaresometimesfrustratedbyseeingmaternaldepressionsharmfuleffectsonchildrenandnot
knowingwhattodo.AHeadStartadministratorinChicagoworriesthatwhen[themoms]decidetodo
nothing[abouttheirdepression]andcontinuelivinginthesamecirclethehomeeducatorcanseethe
issuesareaffecting thechildren.Theyarebehind in the curriculumandhavedevelopmentaldelays.
Homeeducators
in
this
program
believe
that
training
could
help
them
convince
amother
that
addressingherdepressionmaybewhatthechildneeds.
In adultfocused programs, home visitors may find an emphasis on the child difficult or
distractinggivenalltheotherexpectationstheyface.InoneprogramwhereaNurseFamilyPartnership
addedanearlychildhoodcomponent,nursehomevisitorstrainedinmaternalhealthinitiallystruggled
withintegratingchilddevelopmentlessonsintotheirhomevisit.Onenursehomevisitorsaidabouther
earlyexperiences:
Doing the home basedpiece [for the early childhood component] is a different thing
altogether.That
piece
takes
away
from
the
other
stuff
mom
may
need
now.
We
have
to
address thechildandworkon thechilddevelopment.Wehave to teachmomhow to
teachherbaby.Thatwasdifferentformeasanurse. Idont think thatway.How to
teachachild,ittakesmoreenergy,effort,time.
Considerclosepartnerships,multidisciplinarycollaborativeteams,andcrosstraining.Inonesite,arecently implemented collaboration between NurseFamily Partnership and Early Head Start
appearstobeaverypromisingapproachtofocusingonbothmotherandchild.Inthisprogram,the
nursehomevisitorvisitsandcoachesthemotherthroughherpregnancyandbecomesthenurse
familyadvocatewhenthebabyisborn.ThenurseintroducesthefamilytohomebasedEarlyHead
Startand
then
helps
the
child
transition
to
acenter
based
Early
Head
Start
teacher.
The
programs
directordescribesthisteamworkandfeedbackloop:
Wewanttohavean inhouseconversationbetweenthe[nurse]advocateandteacher.
Thefamily advocatemight say, The child lost an uncle andmay have difficulty.
[Likewise] the teacher [can] say, I noticed this. Maybe you can check this in the
home.Thispartnership,alongwith trainingforbothparties,allows theproviders to
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19
betterunderstand thefamilys issues, includingmaternaldepression,andbetter serve
motherandchild.
Crosstraining appears crucial to create effective partnerships. Few service providers have equal
experienceworkingwithadultsandyoungchildren.Trainingneedstoconsiderwhattheseproviders
alreadyknow
and
then
fill
in
the
gaps.
In
augmenting
the
Louisiana
Nurse
Family
Partnership
with
mentalhealthconsultation,theproject leadersforesawthatnurseswouldneednotjustageneral
understanding of adult mental health, but a specific understanding of early childhood and the
infantcaregiverrelationship(Borisetal.2006).
These examples also illustrate thatprograms that effectively addressmultidimensionalproblems
likematernaldepressionand itseffectonchildrenprobablywontworkperfectly intheirveryfirst
incarnation.Rather,programsthatworkwellareabletolearnfromearlyexperiences,becausethey
haveclearlydefinedstrategicgoals,anexpectationthattrainingandotherkeyelementsofprogram
design need constant refinement and retooling, and an ongoing plan for gathering information
aboutwhat
elements
of
the
program
work
and
which
need
improvement.
5.OfferingOngoingHelpafterHomeVisiting
Whilesomeadultswithdepressionexperiencejustoneepisode, it ischronic forothers.For30 to50
percentofadultswithdepression,depressionbecomesachronicorrecurrentdisorder (NRCand IOM
2009).Thus,amothersneedforinterventionstotreatdepressionand/orstrengthenparentingthathas
beenaffectedbydepressionmaynotberesolvedwhenhomevisitingends.10 Inour interviews,home
visitorsdidworryaboutfamilieswholefthomevisitingearly:
Wecanrecognizetheclientsthatwontbe intheprogramvery long. [They]mayhave
issues,but
in
the
end,
we
cant
address
them,
because
we
cant
locate
[the
clients].
In
thosecases,wecall themorsend thema letter.But ifwecant reach themafter two
months,weexitthemout.
However,home visitorsdidnot typically thinkabouthow to transitionout familieswhohad
completed the home visiting program; such families represented a success to be celebrated. One
exception was home visitors in early childhood programs who regularlyworkedwith the local early
interventionprogramforchildrenbelowschoolage.Thesehomevisitorswereusedtohelpingchildren
andtheirparentstransitiontoschoolbasedservicesaschildrenreachedkindergarten,forexample,by
helpingtheparentensurethechildcontinuedreceivingspecializedservices.
Consideranexplicit transitionplan.Continuingsupport for familieswhereamothersuffers fromdepressionrequiresacommunitywidestrategy,involvingotherservicepartners.Formanyfamilies,
themost likelyongoing sourceofhelp isprimarymedical careeither amothersdoctororher
childsdoctor.11Otherpromising linksmightbetothechildsearlychildhoodprogramorschoolor
toearlyinterventionservices.InOhio,weinterviewedhomevisitorswhosawestablishingamedical
home12asacorepartoftheirjob.Onesupervisorsaid:
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20
Frommyperspective,thewaywepreventchildabuseandneglectistoconnectparents
to amedical home. When wefirst open the case,we connect [thefamily] with the
doctorvision,hearing, nutrition.We suggest getting immunizationsor something to
startthatprocesssotheygetamedicalhomeimmediately.
ConclusionandNextSteps
Aspolicyandprogram leadersatall levelsofgovernmentand in the community seek to takehome
visitingtothenext level, thispaperhighlightsthepromiseofhomevisitingasaplatformnotonly for
reachingand identifyingdepressedmothers,butalso for serving them.The relationshipsand service
approachesmothersarelookingfortofeelcomfortablereachingoutandtalkingabouttheirdepression
matchupwellwithwhathomevisitingcanprovide.
The suggestions in thispaperdrawon insights from researchers, clinicians,andpractitioners,
butthey
do
not
add
up
to
asingle
clear
answer
that
can
be
applied
in
every
setting.
This
lack
of
definitivesolutionsispartlybecauseofknowledgegaps.Weknowagreatdealabouttheimportanceof
depression,aconsiderableamountaboutclinicaltreatments,and far lessabouthowbest toorganize
service deliverylet alone the policy, financial systems, staff recruitment, supervision, training, and
otheradministrativesystemsthatundergirdeffectivehomevisiting.
Evenifweknewmore,however,asingleapproachwouldprobablynotberightforeveryhome
visiting program, given programs different missions, service delivery and policy environments, and
targetpopulations.Asa result,weurgepolicyandprogram leaders tobuildon thestrengthsof their
existing programs while honestly assessing gaps and weaknesses standing in the way of meeting
familiesneeds.
We
also
encourage
leaders
to
anticipate
ongoing
development
and
quality
improvement
of these initiatives and to commit to learning along theway,by collecting data about familyneeds,
experiences,andresultsandfinetuninginitiativesbasedonthosedata.
Anotherthemethatcutsacrosstheindividualrecommendations inthispaper isthatnosingle,
onetimefix,oreventwoorthreefixesinisolation,islikelytobeenoughforhomevisitingprogramsto
fullyrespondtotheneedsofdepressedmothersandtheiryoungchildren.Instead,programsaremore
likely to overcome the connected challenges of mission, training, service availability, links among
providers,andmoreiftheyhaveanunderlyingstrategybuiltonathoughtfulassessmentofhowfamilies
with a depressed parent fit into the programs mission, or possibly how the mission needs to be
expandedormodified.Thisclarifyingstrategywillhelptheprogrambuild itsnewapproachesstepby
step, learningeach time from trialanderror. Itmayalsohelp staff feelmore comfortablewithnew
expectationsaboutscreening,engagement,orservicedelivery.
Finally, changes substantialenough tomakea realdifference tomothersmentalhealthand
young childrens development will need to extend beyond the boundaries of a single home visiting
program.Whether thechanges start fromacommunitywidecommitmentor strategicassessment,or
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21
whether they begin within one program and ripple outward from there, several features of good
practice for these familiesconverge inacrossprogramstrategyforexample, theneed to linkhome
visiting to mental health and medical treatment, build referral networks into home visiting and
transitionsout,andtapintooneonone,group,andcommunityinterventions.
Researchershave
clearly
demonstrated
the
widespread
prevalence
of
maternal
depression
and
the risks to young childrenwhogrowupwithmotherswithuntreateddepression. Studieshavealso
shown the clinical effectiveness of treatment once depression is identified. The challenge for
policymakers and program leaders is to translate this clear research evidence into service delivery
approachesthatmakeadifference.Today,thevisibilityofhomevisitingandadditionalresourcesoffers
an opportunity tobuildon innovations from the field and significantly improve young childrens life
chances.
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22
Notes
1ThesitevisitswereconductedinChicagoinDecember2009,inGreensboroinApril2010,andinClevelandinJune
2010.
All
focus
group
and
interview
quotations
or
paraphrases
in
this
guide
are
from
these
site
visits
unless
otherwisenoted.Weprovidethecityinthetextexceptinafewinstanceswhereconfidentialityrequiredleaving
outthelocation.
2Weaskedthefocusgroupparticipantstodescribeorimagineafriendsdepression,notnecessarilyspeaktotheir
ownexperienceswithdepression.
3Onecautionininterpretingtheseperspectivesisthatwerecruitedsomefocusgroupparticipantsfromhome
visitingprograms,thoughmostwererecruitedfromothersources.Thoseprogramsmighthavechosenparents
whowereparticularlypleasedwiththeirservices.
4WeusedtheNationalCenteronChildreninPovertyfactsheet(Chau,ThampiandWight2010)onyoungchildren
in2009toget3.1millionpoorinfantsandtoddlers(outofabout12milliontotalinfantsandtoddlers)and5.9
millionlivinginlowincomefamilies.
5Paul
Dworkin,
University
of
Connecticut,
email
with
the
authors,
February
15,
2011.
6JeanneMiranda,UniversityofCaliforniaLosAngeles,discussionwiththeauthors,November22,2010.
7Miranda,November22,2010.
8Forexample,theUnitedWayofConnecticutChildDevelopmentInfolinehelpsconnectserviceprovidersto
communityresources(http://www.ctunitedway.org/cdi.html ).Theserviceprovidersweinterviewedemphasized
theimportancethatsuchaninventorybeuptodateontheavailablecommunityresourcesandhaveinformed
staff.
9Miranda,November22,2010.
10Inaddition,treatmentandinterventionsmayeffectivelyreducedepressivesymptomsbutnotresolveunderlying
circumstancesthaterodementalhealth.TheNationalResearchCouncilandInstituteofMedicine(2009)report
notesthat
different
people
will
need
different
treatments.
11Foranaccountofopportunitiesandbarrierstoserviceslinkagesforyoungchildrenandtheirparentsin
Medicaid/CHIPpolicy,alsoseeKenneyandPelletier(2010),PelletierandKenney(2010),andGoldenandFortuny
(2011).
12Afamilycenteredmedicalhomeisatrustingpartnershipbetweenachild,achild'sfamily,andthepediatric
primarycareteamwhooverseesthechild'shealthandwellbeingwithinacommunitybasedsystemthatprovides
uninterruptedcarewithappropriatepaymentstosupportandsustainoptimalhealthoutcomes(American
AcademyofPediatrics,ChildrensHealthTopics:MedicalHome,
http://www.aap.org/healthtopics/medicalhome.cfm).
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AbouttheAuthors
OliviaGoldenisanInstitutefellowattheUrbanInstitute.
AmeliaHawkins
is
aresearch
assistant
in
the
Center
on
Labor,
Human
Resources,
and
Population
at
the
UrbanInstitute.
William Beardslee is director of the Baer Prevention Initiatives and chairman emeritus atChildrens
Hospital in Boston, and Gardner/Monks Professor of Child Psychiatry at Harvard University Medical
School.