Age-17 Follow-up of Home Visiting Intervention
Condition: Antisocial Behavior; Psychopathology; Substance Use; HIV Infections
MeSH terms: Substance-Related Disorders; Antisocial Personality Disorder
Study type: Observational

Summary: 
      This study is a longitudinal follow-up of 670 primarily African-American women and their
      17-year-old firstborn children enrolled since 1990 in a highly significant randomized
      controlled trial (RCT) of prenatal and infancy home visiting by nurses. Nurses in this
      program are charged with improving pregnancy outcomes, child health and development, and
      maternal economic self-sufficiency. This follow-up examines whether earlier program effects
      on maternal and child functioning lead to less violent antisocial behavior, psychopathology,
      substance use and use-disorders, and risk for HIV; whether these effects are greater for
      those at both genetic and environmental risk; and whether program effects replicate those
      found with whites in an earlier trial.
    

Detailed description: 
      This study is a longitudinal follow-up of 670 primarily African-American women and their
      18-year-old firstborn children enrolled since 1990 in a randomized controlled trial (RCT) of
      prenatal and infancy home visiting by nurses. Nurses in this program are charged with
      improving pregnancy outcomes, child health and development, and maternal economic
      self-sufficiency.1 This follow-up examines whether earlier program effects on maternal and
      child functioning 2-7 lead to less violent antisocial behavior, psychopathology, substance
      use and use-disorders, and risk for HIV; whether these effects are greater for those who
      carry genetic susceptibility to the environment and are at environmental risk; and whether
      program effects replicate those found with whites in an earlier trial.8-10 Results from
      earlier phases of follow-up from this trial found that the Memphis program affected women's
      prenatal health, fertility, partner relations, and use of welfare; children's injuries,
      cognition, language, achievement, conduct, depression/anxiety, and use of substances through
      child age 12.2-7 Program effects on maternal life-course were concentrated among mothers with
      higher psychological resources (better intellectual functioning, mental health, and sense of
      mastery), probably because higher-resource mothers could envision their success in the world
      of work, leading to better pregnancy planning and employment. Program effects on children
      were greater for those born to mothers with low psychological resources, because without
      help, low-resource mothers are especially challenged in the care of their children and their
      children function less well. Given the damaging effects of early stressors on developing
      neural circuitry, and given that many early neural developmental insults do not become fully
      evident until synaptic pruning is complete in late adolescence and early adulthood, there was
      reason to expect this early intervention would have enduring effects at youth age 18.

      Hypotheses for Primary Grant

      We specified hypotheses based upon the pattern of results found through child age 12, and
      separated them into primary and secondary hypotheses. Following the original formulation of
      hypotheses, we edited them to take into account results from the earlier Elmira trial10 that
      were analyzed following the submission of the proposal for the current phase of follow-up in
      Memphis. We had originally hypothesized that program effects would be more pronounced for
      mothers and children living in the most disadvantaged neighborhoods in Memphis, but realized
      as these data were being gathered that virtually all of the participants in the Memphis trial
      lived in neighborhoods that were so disadvantaged that there was little meaningful variation
      among neighborhoods, and therefore removed this aspect of our hypotheses. We also found that
      it was impossible to consistently gather information from children's school records on
      outcomes like conduct grades from hundreds of schools, so substituted high school graduation
      as a secondary outcome. These refined hypotheses were specified prior to the completion of
      data gathering and any analysis of treatment-control differences. We specify the original
      hypotheses and then indicate the revised hypotheses for maternal and child outcomes. Compared
      to control-group counterparts:

      Original Maternal Outcomes Hypotheses

        1. (Primary) The program will continue to improve maternal life-course (fewer short
           inter-birth intervals, less use of welfare, more stable partner relations), especially
           for mothers with higher psychological resources.

        2. (Secondary) The program will reduce maternal substance use disorders (SUDs) and
           depression, effects that will be more pronounced for a) mothers with low psychological
           resources, and b) those living in the most disadvantaged neighborhoods at registration.

      Revised Maternal Outcome Hypotheses

        1. (Primary) The program will continue to improve maternal life-course (reflected in total
           costs of welfare - SNAP, TANF, Medicaid), especially for mothers with higher
           psychological resources.

        2. (Secondary) The program will reduce maternal substance use disorders (SUDs) and
           depression.

           Original Child Outcomes Hypotheses

        3. (Primary) The program will improve the health and development of firstborn children who
           will exhibit: a) superior cognitive, language, and academic functioning, and executive
           cognitive functioning (ECF); b) less depression and anxiety; c) fewer failed conduct
           grades and school disciplinary actions, d) less violent behavior and gang membership,
           and fewer arrests, juvenile detentions, and convictions - especially for crimes
           involving interpersonal violence.

        4. (Primary) The program will reduce youth risk for HIV infection, including a) use of
           substances and SUDs; b) risky sexual behaviors; c) sexually transmitted infections
           (STIs) and d) pregnancies.

        5. (Primary) Program effects on youth will be more pronounced for a) males, b) those born
           to low-resource mothers, and c) those living in the most disadvantaged neighborhoods at
           registration.

      Revised Child Outcome Hypotheses 3. (Primary) The program will improve the health and
      development of firstborn children who will exhibit: a) superior cognitive, language, and
      academic functioning; b) less depression and anxiety; d) less gang membership, and fewer
      arrests, convictions, and self-reported antisocial behavior - especially for crimes involving
      interpersonal violence.

      4. (Primary) The program will reduce youth risk for HIV infection, pregnancies, births, use
      of substances, and SUDs.

      5. (Secondary) The program will improve firstborn children's executive cognitive functioning
      (ECF); and rates of high school graduation.

      6. (Primary) Program effects on cognitive, language, and academic functioning, and executive
      cognitive functioning will be more pronounced among those born to low-resource mothers and on
      arrests and convictions among females.

      Maternal and Child Outcomes (Not Revised) 7. (Secondary) Program effects on mothers and
      youth, in preliminary analyses, will be more pronounced for those with genetic
      vulnerabilities:

        1. Effects on youth depression and anxiety will be greater for those with low-activity
           genotypes (S/S, LG/LG, S/LG) of the serotonin transporter gene (SLC6A4) promoter
           polymorphism, 5-HTTLPR, compared to those with high-activity genotypes (LA/LA); effects
           on these outcomes will be of intermediate magnitude for those with intermediate
           activity-level genotypes (S/LA, LA/LG).

        2. Effects on youth violent antisocial behavior, SUDs, and risky sexual behavior will be
           more pronounced among males with the MAOA-LPR low activity alleles compared to males
           with MAOA-LPR high activity alleles, and among both males and females with 2 copies of
           the high-activity Val allele of the COMT Val158Met polymorphism compared to those with 2
           copies of the low-activity met allele or heterozygotes.

        3. Effects on maternal SUDs will be concentrated among mothers with 2 copies of the Val158
           alleles.

        4. Effects on child outcomes will be more pronounced among youth born to mothers with
           either 1) the S/S, S/LG and "LG/LG" (low-activity) genotypes of 5-HTTLPR (conferring
           susceptibility for depression under adversity) or 2) 2 copies of the high activity COMT
           Val158 allele (conferring susceptibility to compromised ECF and SUDs under conditions of
           adversity).

           8. (Secondary) Program effects on adolescent functioning will be explained by its
           improvement in prenatal health, early care of the child, maternal life-course, and
           earlier child academic and behavioral functioning.

           Examination of Intervention Effects on Subsequent Children With an administrative
           supplement, we addressed the following questions focused on subsequent children born
           within 5 years of the first child. Note that these questions were framed with no
           specific hypotheses about the degree to which particular subgroups would benefit from
           the intervention, given that intervention impact on pregnancy planning had been most
           pronounced on women with higher psychological resources.

             1. To what degree does this program improve the health and development of subsequent
                children in terms of their a) language, academic, and executive cognitive
                functioning (ECF); b) depression and anxiety; c) failed conduct grades, d) violent
                behavior and gang membership, and e) arrests, juvenile detentions, and convictions,
                especially for violent crimes?

             2. To what degree does this program reduce subsequent children's risk for HIV
                infection, including a) use and abuse of substances; b) risky sexual behaviors; c)
                sexually transmitted infections (STIs) and d) pregnancies?

             3. To what degree are the program effects on subsequent children more pronounced for
                a) males, b) those born to high-resource mothers, and c) those living in the most
                disadvantaged neighborhoods at registration?

             4. To what degree are program effects on subsequent children's functioning explained
                by its earlier impact on a) the timing and rates of subsequent births; b) families'
                use of welfare-related services; c) stability in partner relationships; d)
                improvements in neighborhood contexts; and e) antisocial behavior among the
                first-borns?

           Aims of the Benefit-Cost Analysis

           With an administrative supplement, we conducted a benefit-cost analysis of NFP in
           Memphis. The benefit-cost study was designed to:

             1. Estimate return on investment in Memphis NFP from the perspectives of government,
                society and individual participants.

             2. Estimate the quality-adjusted life year (QALY) savings produced by the Memphis NFP.

             3. Combine effectiveness estimates from Memphis NFP with those from other NFP
                evaluations and produce a combined estimate.

             4. Develop a model that states can use to estimate the value of funding NFP programs.

             5. Compare the cost-effectiveness of the NFP to other commonly delivered childhood
                interventions.
    

Intervention name(s): Nurse Home Visiting
Intervention type(s): Behavioral
Intervention description(s): Visits from nurses from mid-pregnancy to child age 2 years.
Observational model: Cohort
Time perspective: Retrospective
Sampling method: Probability Sample
Study population: 
        Very low-income African-Americans living in a major urban area. In this trial, 1,138
        low-income pregnant women (98% unmarried, 67% <19 years old, 92% African-American) were
        randomly assigned to experimental or comparison services; 742 were followed after delivery.
        The sample resided in extraordinarily stressful neighborhoods and endured extreme poverty.
        At registration, 85% of the sample had incomes below the federal poverty guidelines.
      
Biospecimen description: 
      Spit samples will be taken.
    
Keywords: nurse; home visits; pregnancy; welfare; child development; Child Rearing; Reproductive Behavior; Risk Reduction Behavior