412316 Maternal Depression

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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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1

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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3

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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4

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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9

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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10

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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11

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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12

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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13

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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15

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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16

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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17

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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23

References

Ammerman,RobertT.,FrankW.Putnam,NicoleB.Bosse,AngeliqueR.Teeters,andJudithB.Van

Ginkel.2010.MaternalDepressioninHomeVisitation:ASystematicReview.Aggressionand

ViolentBehavior15:191200.

Ammerman,RobertT.,AmyL.Bodley,FrankW.Putnam,WendiL.Lopez,LaurenJ.Holleb,JackStevens,

andJudithB.VanGinkel.2007.InHomeCognitiveBehaviorTherapyforaDepressedMotherin

aHomeVisitationProgram.ClinicalCaseStudies6:16180.

Boris,N.W.,Larrieu,J.A.,Zeanah,P.D.,Nagle,G.A.,Steier,A.andP.McNeill.2006.TheProcessand

PromiseofMentalHealthAugmentationofNurseHomeVisitingPrograms:Datafromthe

LouisianaNurseFamilyPartnership.InfantMentalHealthJournal27:2640.

Chau,Michelle,KalyaniThampi,andVanessaR.Wight.2010.BasicFactsaboutLowIncomeChildren,

2009ChildrenunderAge3.NewYork:NationalCenterforChildreninPoverty.

Golden,Olivia,andKarinaFortuny.2011.ImprovingtheLivesofYoungChildren:TwoGenerational

ServicesandInterventions.Washington,DC:TheUrbanInstitute.

Kenney,GenevieveM.,andJenniferPelletier.2010.ImprovingtheLivesofYoungChildren:TheRoleof

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Miranda,Jeanne,JoyceY.Chung,BonnieL.Green,JaniceKrupnick,JunedSiddique,DennisA.Revicki,

andTomBelin.2003.TreatingDepressioninPredominantlyLowIncomeYoungMinority

Women:ARandomizedControlledTrial.JournaloftheAmericanMedicalAssociation290(1):

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and

Institute

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Medicine.

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Depression,

Parenting

Practices,

and

theHealthyDevelopmentofChildren,BoardonChildren,Youth,andFamilies,Divisionon

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Children:OpportunitiestoImproveIdentification,Treatment,andPrevention.Washington,DC:

NationalAcademiesPress.

Paulsell,Diane,SarahAvellar,EmilySamaMartin,andPatriciaDelGrosso.2010.HomeVisiting

EvidenceofEffectivenessReview:ExecutiveSummary.Washington,DC:U.S.Departmentof

HealthandHumanServices,AdministrationforChildrenandFamilies,OfficeofPlanning,

ResearchandEvaluation.

Pelletier,Jennifer,andGenevieveM.Kenney.2010.ImprovingtheLivesofYoungChildren:Increasing

Referralsand

Follow

Up

Treatment

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Medicaid

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CHIP.

Washington,

DC:

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U.S.DepartmentofHealthandHumanServices.2005.NationalSurveyofChildandAdolescentWell

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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.

Documents

412316 Maternal Depression