Prev Sci DOI 10.1007/s11121-017-0758-4

History of Maltreatment in Childhood and Subsequent Parenting Stress in At-Risk, First-Time Mothers: Identifying Points of Intervention During Home Visiting Chad E. Shenk 1,2 & Robert T. Ammerman 3 & Angelique R. Teeters 3 & Heather E. Bensman 3 & Elizabeth K. Allen 1 & Frank W. Putnam 4 & Judith B. Van Ginkel 3

# Society for Prevention Research 2017

Abstract Home visiting is an effective preventive intervention that can improve parenting outcomes for at-risk, new mothers, thereby optimizing subsequent child development. A history of maltreatment in childhood is common in mothers participating in home visiting, yet the extent to which such a history is related to parenting outcomes during home visiting is unknown. The current study evaluated whether mothers with a history of maltreatment in childhood respond less favorably to home visiting by examining the direct and indirect pathways to subsequent parenting stress, a key parenting outcome affecting child development. First-time mothers (N = 220; age range = 16–42) participating in one of two home visiting programs, Healthy Families America or Nurse Family Partnership, were evaluated at enrollment and again at 9-and 18-month post-enrollment assessments. Researchers administered measures of maternal history of maltreatment in childhood, depressive symptoms, social support, and parenting stress. Maternal history of maltreatment in childhood predicted worsening parenting stress at the 18-month assessment. Mediation modeling identified two indirect pathways, one

* Chad E. Shenk [email protected]

1

Department of Human Development and Family Studies, The Pennsylvania State University, 115 Health and Human Development Building, University Park, PA 16802, USA

2

Department of Pediatrics, College of Medicine, The Pennsylvania State University, State College, PA, USA

3

Department of Pediatrics, College of Medicine, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, OH, USA

4

Department of Psychiatry, School of Medicine, University of North Carolina, Chapel Hill, NC, USA

involving social support at enrollment and one involving persistent depressive symptoms during home visiting, that explained the relation between a history of maltreatment in childhood and parenting stress at the 18-month assessment. Ways to improve the preventive effects of home visiting for mothers with a history of maltreatment in childhood through the identification of relevant intervention targets and their ideal time of administration are discussed. Keywords Child maltreatment . Home visiting . Depression . Social support . Parenting stress Child maltreatment, including sexual abuse, physical abuse, emotional abuse, and neglect, affects 12.5% of all children in the USA under the age of 18 (Wildeman et al. 2014). One important consequence of experiencing maltreatment in childhood is an increased risk for becoming a mother during adolescence and young adulthood (Garwood et al. 2015; Noll and Shenk 2013), a time when the demands of parenting can outweigh the developmental abilities for appropriately caring for a newborn child. Findings from extant research demonstrate that a maternal history of maltreatment in childhood increases the risk and severity of subsequent parenting stress (Bailey et al. 2012; Steele et al. 2016), the gap between the demands of parenting and available personal resources (Abidin 1995). Parenting stress undermines child development by interfering with the required attention and sensitivity to a child’s needs, disrupting goal-directed behavior, and contributing to parental maladjustment in overall functioning (Chang and Fine 2007; Pereira et al. 2012). Parenting stress is also one of the primary risk factors for the subsequent maltreatment of offspring (Gonzalez and MacMillan 2008), providing a potential explanation for the intergenerational transmission of child maltreatment from parent to child (Noll et al. 2009). Addressing the

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impact of a mother’s history of maltreatment in childhood on subsequent parenting stress can have significant benefits on parenting outcomes that directly improve the health, safety, and development of offspring. Home visiting can be an effective prevention approach where trained professionals provide education, support, and parenting services to new mothers in the home before or shortly after birth and extending though the first years of the child’s life to promote optimal health, safety, and development (Adirim and Supplee 2013; Olds 2010). Home visiting is particularly beneficial when delivered in a selective prevention format where young mothers with specific demographic risk factors common to poor child outcomes (e.g. unmarried, low income) are identified and provided services to improve parent functioning, parent-child interactions, and promote child development (Astuto and Allen 2009). A history of maltreatment in childhood often co-occurs with the other risk factors used to identify and select mothers into home visiting (Sedlak et al. 2010). Indeed, a history of maltreatment in childhood is common in new and young mothers receiving home visiting (Ammerman et al. 2012; Smith et al. 2006). However, existing home visiting programs generally do not target the impact of this history on parenting outcomes, specifically parenting stress. Thus, it remains unknown whether home visiting provides equal benefit to mothers with a history of maltreatment in childhood. Examining the mechanisms of action during home visiting for new mothers with a history of maltreatment in childhood would provide a better understanding of the effectiveness of home visiting as well as identify newly specified targets for intervention for these women. One mechanism of action that can potentially explain the relationship between a mother’s history of maltreatment in childhood and subsequent parenting stress is the severity of depressive symptoms experienced at enrollment to and during participation in home visiting. A history of maltreatment in childhood increases the risk for depressive symptoms during late adolescence and young adulthood (Scott et al. 2010). Indeed, major depressive disorder is common among new mothers where prevalence rates range from 12.0 to 23.1% (Bennett et al. 2004; Mayberry et al. 2007; Wisner et al. 2013). A history of maltreatment in childhood is also a reliable predictor of postpartum depression and a chronic course of depressive symptoms throughout home visiting (Teeters et al. 2016; Vliegen et al. 2014). Depressive symptoms are also consistently associated with more severe parenting stress and are a strong predictor of its persistence (Lee et al. 2009; Webster-Stratton and Hammond 1988). Thus, depressive symptom severity may serve as a key risk mechanism explaining the relationship between a history of maltreatment in childhood and subsequent parenting stress in home visiting. In contrast, the identification of resilience mechanisms, processes that lead to successful adaptation and outcomes for individuals exposed to maltreatment in childhood, has

received less attention yet holds considerable promise for informing novel areas of intervention in home visiting (Luthar and Cicchetti 2000). Subsequent access to social support is one potential resilience mechanism that could explain variation in parenting stress across new mothers with a history of maltreatment in childhood. For example, caregivers are the most common perpetrators of child maltreatment (National Children’s National Children’s Alliance 2014), and having a caregiver removed from the home or placing the child in kinship or foster care can affect the child’s ability to establish or maintain social support provided by family, peers, schools, and community agencies (Schonbucher et al. 2014). A history of maltreatment in childhood can also affect the degree to which a developing child trusts others enough to share or describe the experience of maltreatment (Murphy et al. 2014), as well as painful thoughts and emotions in general (Shenk et al. 2014), further limiting one’s ability to access support. Difficulty establishing or maintaining social support after maltreatment in childhood can in turn increase the risk of subjective distress experienced at sensitive times in development, such as the stress experienced during the first few years of becoming a parent (Balaji et al. 2007; Lakey and Orehek 2011; Stith et al. 2009). Varying degrees of social support can therefore be viewed as a potential mechanism that explains how a history of maltreatment in childhood does or does not lead to subsequent adverse outcomes, specifically parenting stress. Results from previous research have demonstrated that depressive symptom severity and the degree of available social support each appear to play a critical role in explaining the relation between a maternal history of maltreatment in childhood and parenting stress during home visiting (Ammerman et al. 2013b). This is in line with recent recommendations that pregnant women and new mothers be screened for depression (O’Connor et al. 2016) and suggests that reducing the severity of depression pre- or postpartum, while increasing the degree of social support for these mothers, may promote resilience in the context of subsequent parenting stress. However, it remains unknown whether depressive symptoms or access to social support during home visiting influence one another bi-directionally or whether one process is more influential in the reduction of subsequent parenting stress. Determining whether depressive symptoms or social support is most influential on parenting stress would also identify which of these factors is the most useful intervention target during home visiting when mothers have a history of maltreatment in childhood. Doing so has the potential to optimize preventive effects for this subpopulation, promote subsequent child development, and disrupt the intergenerational transmission of child maltreatment. The current study adopted two primary goals to advance research in the area of home visiting for new mothers with a history of maltreatment in childhood: (1) to determine whether

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mothers with a history of maltreatment in childhood experience a worsening of parenting stress after 18 months of home visiting and (2) to identify relevant mechanisms of action that explain this relation and can potentially optimize the preventive effects of home visiting for mothers with a history of maltreatment in childhood. A sample of first time mothers receiving one of two home visiting programs, The Nurse Family Partnership (NFP; Olds 2010) and Healthy Families America (HFA; Holton and Harding 2007), completed measures of prior exposure to maltreatment in childhood, depressive symptoms, access to social support, and subsequent parenting stress during the first 18 months of participation in one of these programs. These home visiting programs were selected because each target depressive symptoms and access to social support in at-risk, first time mothers by promoting relationships with family and peers, building parenting knowledge and efficacy, and connecting individual mothers with needed ancillary services that ultimately can reduce parenting stress (Barnes et al. 2013; Green et al. 2014; Olds 2006). NFP has a much more extensive history in controlled trials research (Macmillan et al. 2009), although both NFP and HFA are considered evidence-based programs according to the US Department of Health and Human Services standards (Avellar et al. 2016). Investigators examined the relations between a history of maltreatment in childhood, bidirectional influences of depressive symptoms, and social support from enrollment in home visiting to 9 months post-enrollment and a worsening of parenting stress 18 months post-enrollment. In addition to obtaining individual parameter estimates among key, study-related variables over these assessments, the indirect effects of depression and social support were tested as mediators of the relation between a history of maltreatment in childhood and subsequent parenting stress to identify potential targets for future intervention.

Method Sample The participants were 220 first-time mothers enrolled in Every Child Succeeds (ECS), a regional home visiting program for new mothers and their infants that delivers both NFP and HFA. ECS is a voluntary program that operates with both state and private funding sources. Enrolled mothers met at least one of four criteria: low income ($40,000 Unknown

21 (9.5%) 6 (2.7%)

scores reflecting mothers’ cumulative exposure to one or more forms of maltreatment experienced in childhood and prior to enrollment. Internal consistency of the items used to create the CTQ total score for this study was Cronbach’s α = .95. Mean CTQ scores at enrollment were 41.11 (SD = 18.43).

Interpersonal Support Evaluation List (ISEL; Cohen and Hoberman 1983) The ISEL is a widely used 40-item measure of social support in clinical and non-clinical populations. Each item on the ISEL evaluates the availability and use of tangible and emotional support from others. Participants endorse items using a 4-point scale reflecting the degree to which each item is true. Sample items include: BIf I were sick, I could easily find someone to help me with my daily chores^ and BThere is at least one person I know whose advice I really trust.^ The ISEL has excellent reliability and validity (Cohen and Hoberman 1983). Internal consistencies of the ISEL administered at the enrollment and 9-month post-enrollment assessments were Cronbach’s α = .93 and α = .95, respectively. Mean ISEL total scores were 95.14 (SD = 15.92) at enrollment and 92.72 (SD = 19.61) at the 9-month assessment.

Parenting Stress Index–Short-Form (PSI-SF; Abidin 1995) The PSI-SF is a 36-item, parent-report measure of child and parent functioning. The PSI-SF has excellent psychometric properties and is widely used in parenting research (Barroso et al. 2015). The PSI-SF generates a standardized score on Total Stress, reflecting the overall degree of parenting stress that a caregiver has experienced. Internal consistencies of the PSI-SF administered at the 9 and 18-month post-enrollment assessments were Cronbach’s α = .91 at each measurement occasion. Mean PSI-SF scores were 65.18 (SD = 17.41) at the 9-month and 65.86 (SD = 16.59) at the 18-month assessment.

Fig. 1 Study flow diagram for mothers enrolled in home visiting services. All study drop-out (n = 10) due to loss of participant contact

231 - Mothers enrolled

11 - Administratively withdrawn 7 - due to miscarriage 4 - due to loss of custody

98 - Nurse Family Partnership 96 - Completed

122 - Healthy Families America 114 - Completed

1 - Dropped out by 9-months

6 - Dropped out by 9-months

1 - Dropped out by 18-months

2 - Dropped out by 18-months

98 - Included in analyses

122 - Included in analyses

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Data Analytic Strategy The current study examined whether mothers with a history of maltreatment in childhood experienced a worsening of parenting stress 18 months after enrolling in home visiting by examining potential mechanisms of action that explain this relation. Investigators tested a three-path mediation model where the autoregressive and cross-lagged indirect effects for depressive symptoms and social support were estimated within the path analytic framework using maximum likelihood estimation in Mplus 7.0 (Muthén and Muthén 1998-2012). Model fit was evaluated using Tucker Lewis Index (TLI) ≥ .95, root mean square error of approximation (RMSEA) ≤ .06, and standardized root mean square residual (SRMR) < .08 guidelines (Hu and Bentler 1999). All specific indirect effects of the relation between child maltreatment and subsequent parenting stress were estimated using the IND command. Estimates of the total, direct, and specific indirect effects and their corresponding confidence intervals were obtained using the bootstrapping procedure in Mplus based on k = 5000 bootstrap samples with bias-corrected 95% confidence intervals (95% CI). Because participants enrolled in two different home visiting programs, NFP and HFA, were combined for the present analyses, an invariance test was performed using the GROUPING command in Mplus to assess whether the results from the three-path mediation analysis differed significantly based on the type of home visiting program received, NFP or HFA. To do so, a baseline model for each home visiting program was performed where each constituent pathway of the three-term mediation model was allowed to vary across the Table 2

two programs. Then, a nested model was estimated where the pathways in the three-term mediation model were now constrained to be equal across the two programs. A significant degradation in model fit from the baseline to nested model was evaluated through the change in χ2 fit values, along with the change in degrees of freedom (Δdf), and comparing it to the respective critical value to determine the statistical significance (p < .05) of the change. The null hypothesis in this case is that the magnitude differences in parameter estimates making up the mediation model do not differ significantly across NFP and HFA programs. Alternatively, if the nested model produces a significant change in χ2 fit, it can be interpreted as home visiting program exerting a moderating effect on one or more of the pathways in the mediation model.

Results Data Screening and Identification of Covariates Because mothers enrolling in home visiting services in this study were not randomly assigned to a home visiting program, zero-order correlations among demographic and study-related variables were examined to identify potential covariates. M at er na l r a ce w as r ec o de d i n t o m i n or i t y s t a t u s (0 = Caucasian, 1 = Minority) due to limited representation of multiple, diverse racial groups in this sample. Similarly, marital status was recoded into single status (0 = Other, 1 = Single) given the preponderance of single, never married mothers in this sample. Program type was coded to reflect participation in NFP (0 = HFA, 1 = NFP). As shown in Table 2,

Correlations among demographic and study-related variables

Variable

1

2

3

4

5

6

7

1. Maternal age 2. Years of education 3. Household income 4. Single 5. Minority status 6. Program type 7. Number of visits

– .54*** .13 −.33*** −.10 .04 .17*

– .14* −.20** −.04 .01 .16*

−.20** −.13 .05 .16*

– .21** .02 −.11

– .16* −.12

– .00

–

8. CTQ

−.06

−.20**

9. BDI-II (Enrollment) 10. BDI-II (9 months) 11. ISEL (Enrollment) 12. ISEL (9 months) 13. PSI-SF (9 months) 14. PSI-SF (18 month)

.03 −.01 .04 .01 −.06 −.07

.05 −.04 .13 .12 −.10 −.07

−.05 .02 −.10 .16* .20** −.10 −.12

−.05 .02 .06 .01 −.03 .13 .17*

.06 .03 .05 −.05 −.09 .13 .13

.02 .02 −.03 −.07 .04 .06 .03

−.01 −.08 −.09 .08 .11 −.11 −.15*

8

9

10

11

12

13

– .35*** .24** −.36*** −.30*** .18* .21**

– .46*** −.46*** −.33*** .35*** .33***

– −.37*** −.49*** .54*** .50***

– .68*** –.40*** −.37***

– −.56*** −.43***

– .70***

–

CTQ Childhood Trauma Questionnaire, BDI-II Beck Depression Inventory-II, ISEL Interpersonal Support Evaluation List, PSI-SF Parenting Stress Index-Short Form *p < .05; **p < .01; ***p < .001

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minority status was significantly associated with enrollment in NFP (r = .16). Maternal age (r = .17), years of education (r = .16), and annual household income (r = .16) were significantly and positively correlated with the number of home visits received by the 18-month assessment. Years of education were also significantly and negatively associated with scores on the CTQ (r = −.20). Annual household income was significantly and positively related to ISEL scores at both enrollment (r = .16) and at the 9-month assessment (r = .20). Being a single mother (r = .17) and receiving fewer home visits (r = −.15) were both significantly associated with higher PSI-SF scores at 18 months. Because age, annual income, single mother status, minority status, years of education, program type, and number of home visits received correlated with each other or with key study variables, they were all included as covariates in the mediation model. Parenting stress measured at the 9-month post-enrollment assessment was also included as a covariate to assess a worsening of parenting stress from the 9-month to the 18-month assessment. Rates of missing data were low in this study and affected only BDI-II scores at the 9-month assessment (6.4%), ISEL scores at the 9-month assessment (6.4%), PSI-SF at the 9-month assessment (6.8%), and PSISF at the 18-month assessment (5.0%). The path analytic model shown in Fig. 2 provided a good fit to the observed data, TLI = .97, RMSEA = .04, and SRMR = .03. The total, direct, and specific indirect effects for depressive symptoms and social support during home visiting were then examined to determine whether they explained the relation between a mother’s history of maltreatment in childhood and a worsening of parenting stress 18 months after enrolling in home visiting. The confidence interval for the total effect estimate of the relation between CTQ and PSI-SF scores did not include zero, Point Estimate = .19, 95% CI = 0.06–0.32, demonstrating a statistically significant relation between a history of maltreatment in childhood and worsening parenting stress 18 months after enrollment in home visiting. Specific indirect effects for depressive symptoms and social support were then examined. First, a cross-lagged ISEL pathway, consisting of CTQ scores, to ISEL scores at enrollment, to BDI-II scores at 9-month assessment, and to PSI-SF scores at 18-month assessment, was statistically significant, Point Estimate = .01, 95% CI = 0.00–0.03. Second, Enrollment

9 Month

ISEL

ISEL

an autoregressive BDI-II pathway, consisting of CTQ scores, to BDI-II scores at enrollment, to BDI-II scores at the 9-month assessment, and to PSI-SF scores at the 18-month assessment, was also statistically significant, Point Estimate = 0.02, 95% CI = 0.00–0.04. Of note, the confidence interval for the direct effect of a maternal history of maltreatment in childhood on parenting stress at the 18-month assessment did include zero, Point Estimate = .07, 95% CI = −0.04 to 0.18, providing evidence of mediation of this relation when all indirect pathways from a history of maltreatment in childhood to parenting stress at 18-months are estimated. The stability of the mediation model across NFP and HFA programs was then assessed in an invariance test comparing the difference in χ2 fit from a freely estimated baseline model to a nested model that constrained the pathways making up the mediation model to be equal across the programs. The baseline model produced a fit of χ2(20) = 19.83 where the nested model fit was χ2(29) = 28.26, a difference of 8.43. The critical χ2 value at p < .05 for Δdf = 9 is 16.92, suggesting that the nested model did not result in a significant degradation in model fit when compared to the freely estimated baseline model. This suggests that the results of the mediational model were invariant across the two home visiting programs. Examination of the individual path coefficients indicates that the CTQ significantly predicted scores on the ISEL, b = −.31, p < .001, and BDI-II, b = .14, p < .001, at enrollment. The cross-lagged relations between ISEL and BDI-II scores from enrollment to the 9-month assessment were also examined while accounting for the autoregressive relations between these variables. After adjusting for BDI-II scores at enrollment, ISEL scores at enrollment significantly predicted BDIII scores at the 9-month assessment, b = −.11, p = .034, demonstrating a cross-lagged relationship on subsequent depressive symptoms. The autoregressive relation between ISEL scores at enrollment and 9-month assessment was significant, b = .78, p < .001, as was the relation between BDI-II scores at enrollment and the 9-month assessment, b = .45, p < .001. After adjusting for prior levels of parenting stress and all other model parameters, BDI-II scores at the 9-month assessment were the only predictor of PSI-SF scores at the 18-month assessment, b = .26, p < .040. All other paths for depressive symptoms and social support were non-significant.

18 Month

Discussion PSI

CTQ BDI-II

BDI-II

Fig. 2 Mediation model for depressive symptoms and social support during home visiting. Covariates and direct paths are estimated but not shown

This study examined the degree to which a first-time mother’s history of maltreatment in childhood predicted a worsening of parenting stress after 18 months of home visiting delivered within an implementation-as-usual community setting, identifying relevant targets for intervention that explain this relation and can therefore optimize the effects of home visiting for these mothers and their children. This approach supports prior

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research (Ammerman et al. 2013b) and follows calls from the developers of home visiting programs to examine the mechanisms of action during home visiting to identify important targets for reducing parenting stress and promoting optimal child development (Olds 2010). While randomized clinical trials are the ideal method for generating causal inferences about mechanisms of action in intervention research, translation of findings into community settings to maximize dissemination of effective services is always the ultimate goal of this research. Capitalizing on the dissemination of two established home visiting programs, NFP and HFA, investigators undertook a community-based approach to accomplish this goal so that appropriate modifications to service delivery can be made in the settings where most at-risk mothers will receive services. Findings from the present study point to specific directions for the improvement of home visiting services for new mothers with a history of maltreatment in childhood. Home visiting can be an effective prevention approach that provides first-time mothers with the resources and skills they need to ensure the optimal development and safety of their newborn child over the first few years of life. When applied as a selective prevention program, identified risk factors of suboptimal child development in new mothers are used to target a smaller yet highest risk segment of this larger population. Maternal history of maltreatment in childhood co-occurs with many of these identified risk factors (Sedlak et al. 2010), yet itself is not used as an eligibility criterion to select new mothers into home visiting. Results from this study suggest that a history of maltreatment in childhood, after adjusting estimates due to other risk factors used to select into home visiting, led to a worsening of parenting stress and therefore a poorer response to home visiting, after the first 18 months of services. This finding is in line with prior research demonstrating a persistent course of more severe parenting stress for those mothers with a history of maltreatment in childhood (Bailey et al. 2012; Steele et al. 2016). Results from this study extend this phenomenon to the context of response to home visiting and suggest that a history of maltreatment in childhood is a unique risk factor that warrants consideration in the delivery of home visiting. In line with recent recommendations for the screening of depressive symptoms for all pregnant and new mothers to promote mother and child health and development (O’Connor et al. 2016), screening for a history of maltreatment in childhood can be an effective way to identify a subpopulation of mothers that are less likely to benefit from home visiting than mothers without such a history. Because of the added risk for worsening parenting stress, identification of relevant intervention targets to be augmented in home visiting for mothers with a history of maltreatment in childhood is an important step forward to facilitate the effectiveness of home visiting. Results from the current study identify two indirect pathways involving depressive symptoms and social support that contribute to the worsening of

parenting stress observed 18 months after enrollment to home visiting. One, the indirect pathway from a history of maltreatment in childhood, to fewer social supports at enrollment, to more depressive symptoms 9-months later, and to a worsening of parenting stress achieved statistical significance. This pathway suggests that targeting social supports immediately upon enrollment to home visiting for mothers with a history of maltreatment in childhood will likely have the earliest and most influential effects on subsequent processes affecting parenting stress, namely depressive symptom severity. Prior research findings indicate that both maltreatment in childhood and lower levels of social support at enrollment predict a more severe course of depressive symptoms throughout home visiting (Teeters et al. 2016). One option to build social support for these mothers could be to promote social interactions among home visiting participants with histories of maltreatment in childhood given that survivors of child maltreatment often experience support and cohesion with other individuals who have had similar experiences (Schonbucher et al. 2014). Another option could be to identify members of the mother’s existing social support network, including family members, peers, neighbors, and church members, to increase engagement in pleasurable and valued activities that can exert a protective effect against subsequent depressive symptoms (Kanter et al. 2006). In any case, promoting the tangible and emotional support that new mothers receive is likely to play an important role in improving the effects of home visiting on subsequent parenting stress for mothers with a history of maltreatment in childhood. The second indirect pathway involved a history of maltreatment in childhood to depressive symptoms at enrollment that persisted over the first 9 months of home visiting and ultimately predicted a worsening of parenting stress at the 18-month assessment. A mother’s history of maltreatment in childhood increases the risk for subsequent depressive symptoms (Scott et al. 2010), and results from this study demonstrate that mothers with such a history who continue to struggle with depressive symptoms in young adulthood and throughout home visiting should receive services directly targeting depression by the 9-month assessment to reduce current depressive symptoms and protect against worsening parenting stress. Thus, if there are elevated depressive symptoms even after targeting social supports at enrollment, interventions must be implemented to address these persistent symptoms in order to have the greatest impact on subsequent parenting stress. To this end, treatment specifically designed for depressed mothers in home visiting may be warranted (Ammerman et al. 2013a). Both of the indirect pathways identified in this study demonstrate the risk for worsening parenting stress posed by depressive symptom severity at the 9-month assessment. Increased social supports at enrollment or direct intervention by 9 months post-enrollment are necessary to address more severe

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depressive symptoms in order to exert the greatest protective effect against worsening parenting stress for mothers with a history of maltreatment in childhood. These intervention targets for mothers with a history of maltreatment in childhood contribute unique information to the theoretical underpinnings of both NFP and HFA. NFP draws upon three theoretically complementary perspectives: human ecology, self-efficacy, and attachment (Olds 2010). In standard administration, these theoretical perspectives drive the selection of intervention strategies that emphasize providing information to new mothers, building interpersonal and coping skills, strengthening ties to individuals and communities, enhancing the parent-infant relationship, and establishing a strong working alliance between mothers and home visitors. HFA also relies upon human ecological theory (Holton and Harding 2007), where factors present across multiple systems, such as a mother’s history of maltreatment in childhood and currently available microsystemic interpersonal relationships, influence subsequent parenting outcomes, such as severity of parenting stress. Results from this study suggest that the theoretical bases guiding the standard delivery of NFP and HFA, particularly human ecological theory, require advancement to maximize the applicability for mothers with a history of child maltreatment when the primary outcome of interest is parenting stress. Specifically, identifying intervention targets unique to this subpopulation at the most relevant times during home visiting highlights the ecological, developmental, and contextual nature of issues facing these mothers so that more tailored and effective services can be delivered. There are several limitations to this study. First, all information was obtained through maternal self-report, including the retrospective assessment of a mother’s history of maltreatment in childhood, which may impact results due to mono-method bias. Future research should employ a multi-method strategy, including case records from child protective services, clinician ratings, and observational assessments, to strengthen conclusions that the results are accurate and not subject to method variance. Second, random assignment to home visiting program was not used in this study, thereby raising concerns about the impact of selection bias and spuriousness on parent outcomes. These concerns are mitigated in that the results of the mediation model were invariant across these two programs. Furthermore, demographic variables, type and dose of home visiting program received, and prior levels of parenting stress were included as covariates to adjust risk estimates and limit potential bias. Even with these additional controls, claims regarding the identification of causal processes or the generation of causal inferences are not appropriate. Third, findings from this study are not necessarily generalizable to other home visiting programs. HFA and NFP are home visiting programs that seek to improve parent and child outcomes. Both models, directly and indirectly, contain program elements

designed to reduce parenting stress. The evidence base for these models are not equivalent (Macmillan et al. 2009), and how findings from these studies can be used to enhance program outcomes must be considered in this context. Likewise, other home visiting programs exist, and the extent to which maltreatment in childhood, depressive symptom severity, and social support affect resulting parenting stress in those programs cannot be addressed in the current study. Finally, the sample consisted largely of Caucasian mothers; further research is needed to address the extent to which the risk posed by a history of maltreatment in childhood on subsequent parenting stress applies to racially and ethnically diverse mothers. Overall, these results bring together independent lines of inquiry on the long-term impact of maternal histories of maltreatment in childhood, the presence of such a history in home visiting, and the risk and protective functions of depressive symptom severity and social support in order to promote novel targets for intervention that can enhance response to home visiting for mothers with a history of maltreatment in childhood. This study offers several ways forward in advancing the benefits of established home visiting services delivered within community settings. First, results of this study warrant replication with a larger, more diverse sample that can be stratified based on a history of maltreatment in childhood and randomized to a home visiting program. This would allow for a more comprehensive examination of the effects of maltreatment experiences in childhood on program efficacy. It would also identify whether one home visiting program versus another is more effective in promoting services for the child maltreatment subpopulation in standard delivery. Second, evaluating the benefit of making adjustments to the standard delivery of home visiting programs, specifically to improve social supports at enrollment and reduce persistent depressive symptoms subsequently, for those mothers with a history of maltreatment in childhood is a promising approach to future research. Third, screening for a maternal history of maltreatment in childhood and using it as a selection factor for enrollment is a relatively efficient way to identify a subpopulation that does not appear to benefit as well from standard home visiting services. This information will allow researchers to evaluate the effectiveness of new services for this subpopulation, thereby demonstrating its added benefit. In the meantime, it is critical that mothers with a history of child maltreatment still receive standard home visiting services, as it is very likely that these mothers benefit from services when compared to those mothers with a history of maltreatment in childhood who do not receive home visiting services. Finally, any future evaluation of added services will need to be delivered and evaluated in community settings where efforts at dissemination are already taking place and where most mothers in need of such services will receive them. Dissemination efforts that more effectively reach this at-risk subpopulation are likely to make the biggest impact in the shortest amount of time.

Prev Sci Acknowledgments The authors express thanks to all the organizations contributing to Every Child Succeeds. We also wish to thank Alonzo T. Folger, Ph.D., for his assistance in preparing this manuscript. This study is supported by Grant R40 MC 06632-01 (Ammerman) from the Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human Services. Angelique R. Teeters is currently with TriHealth, Group Health Physicians, Cincinnati, Ohio. The authors acknowledge the participation and support of the United Way of Greater Cincinnati, Kentucky HANDS, and Ohio Help Me Grow. Compliance with Ethical Standards Conflict of Interest The authors declare that they have no conflict of interest. Human and Animal Rights and Informed Consent All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

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