Depression is prevalent in new mothers and has been shown to have profound negative impacts on parenting, maternal life course, and child development. High rates of maternal depression have been found in home visitation, a widely disseminated prevention approach for high risk mothers and their children. This paper reviews the emerging literature on the prevalence, impact, and treatment of depression in the context of home visitation. Findings are synthesized and methodological and design limitations are considered in interpretation of results. Promising approaches to addressing maternal depression and supporting home visitors in working with this clinical population are described. Recommendations for research and practice are offered that build upon the strong foundation of current efforts in this area.

Despite negative outcomes for depressed mothers and their children, no treatment specifically designed to address maternal depression in the context of home visitation has emerged. In-Home Cognitive Behavioral Therapy (IH-CBT) is an adapted treatment that is delivered in the home, focuses on the needs of new mothers, and leverages ongoing home visiting to optimize engagement and outcomes. This study examined the efficacy of IH-CBT using a randomized clinical trial. Subjects were 93 new mothers in a home visiting program. Mothers with major depressive disorder identified at 3 months postpartum were randomized into IH-CBT and ongoing home visitation (n=47) or standard home visitation (SHV; n=46) in which they received home visitation alone and could obtain treatment in the community. Depression was measured at pre- and posttreatment, and 3-month follow-up using interviews, clinician ratings, and self-report. Mothers receiving IH-CBT showed improvements in all indicators of depression relative to the SHV condition and these gains were maintained at follow-up. For example, 70.7% of mothers receiving IH-CBT were no longer depressed at posttreatment in terms of meeting criteria for major depressive disorder compared to 30.2% in the SHV group. These findings suggest that IH-CBT is an efficacious treatment for depressed mothers in home visitation programs.

METHODS: Searches of Medline, Cumulative Index to Nursing and Allied Health Literature, Cochrane Database of Systematic Reviews, Cochrane Controlled Trial Register, PsycINFO, and Embase were conducted. Criteria for inclusion were (1) cohort or controlled trial designs; (2) homebased, preventive services for infants at medical or social risk; and (3) outcomes reported for infants born preterm or low birth weight (,2500 g). Data from eligible reports were abstracted by 2 reviewers. Random effects meta-analysis was used to synthesize data for developmental and parent interaction measures. RESULTS:Seventeen studies (15 controlled trials, 2 cohort studies) were reviewed. Five outcome domains were identified: infant development, parent-infant interaction, morbidity, abuse/neglect, and growth/ nutrition. Six studies (n = 336) demonstrated a pooled standardized mean difference of 0.79 (95% confidence interval 0.57 to 1.02) in Home Observation for Measurement of the Environment Inventory scores at 1 year in the home-visited groups versus control. Evidence for other outcomes was limited. Methodological limitations were common.

Objectives Depression is prevalent in mothers receiving home visiting. Little is known about the impact of treatment on associated features of maternal depression in this population. The purpose of this study was to examine the impact of a novel, adapted treatment for depressed mothers in home visiting on psychological distress and social functioning. Methods In-Home Cognitive Behavioral Therapy (IH-CBT) was developed to treat depressed mothers in home visiting. A randomized clinical trial design was used in which subjects were 93 new mothers in a home visiting program. Mothers with major depressive disorder identified at 3 months postpartum were randomized into IH-CBT and ongoing home visiting (n = 47) or standard home visiting (SHV; n = 46) in which they received home visitation alone and could obtain treatment in the community. Measures of psychological distress, social support, and social network were measured at pre-treatment, post-treatment, and three-month follow-up. Clinical features of depression and home visiting parameters were examined as potential moderators. Results Subjects receiving IH-CBT reported decreased psychological distress at post-treatment (ES = 0.77) and follow-up (ES = 0.73). Examination of types of psychological distress indicated broad improvements at both time points. Those receiving IH-CBT reported increased social support over time relative to those in the SHV condition. Effect sizes were modest at post-treatment (ES = 0.38) but increased at follow-up (ES = 0.65). Improvements were seen in affiliative and belonginess aspects of social support, in contrast to tangible support which was statistically non-significant. Findings were not moderated by clinical features of depression or home visiting parameters. No group differences were found in size of and involvement with social networks. Conclusions IH-CBT is effective in reducing psychological distress and improving perceived social support in depressed mothers receiving home visiting. To the extent that mothers are better adjusted and feel socially supported, they are more available to their children and more amenable to home visiting services. IH-CBT is a feasible, readily adopted treatment that is compatible with multiple home visiting models. As a result it is a promising approach to help depressed mothers in home visiting. Additional interventions may be needed to support depressed mothers in building sizable and stable social networks.

Purpose Research on older children and high resource families demonstrates that maternal improvement in depression often leads to parallel changes in parenting and child adjustment. It is unclear if this association extends to younger children and low income mothers. This study examined if In-Home Cognitive Behavioral Therapy (IH-CBT), a treatment for depressed mothers participating in home visiting programs, contributes to improvements in parenting and child adjustment. Methods Ninety-three depressed mothers in home visiting between 2–10 months postpartum were randomly assigned to IH-CBT (n=47) plus home visiting or standard home visiting (SHV; n = 46). Mothers were identified via screening and subsequent of MDD diagnosis. Measures of depression, parenting stress, nurturing parenting, and child adjustment were administered at pre-treatment, post-treatment, and three month follow-up. Results Results indicated that there were no differences between IH-CBT and controls on parenting and child adjustment. Low levels of depression were associated with decreased parenting stress and increased nurturing parenting. There was no association between maternal depression and child adjustment. Conclusions Improvement in depression was related to changes in parenting in low income mothers participating in home visiting programs. IH-CBT was not independently associated with these improvements, although to the extent that treatment facilitated improvement there were corresponding benefits to parenting. Child adjustment was not associated with maternal depression, a finding possibly attributed to the benefits of concurrent home visiting or measurement limitations. Future research should focus on longer term follow-up, implications of relapse, and child adjustment in later years.

Parenting stress is associated with poor maternal and child outcomes. Multiple contributors to parenting stress have been proposed, but disaggregation of distinct pathways has been relatively unexplored. In addition, the contribution of maternal experience of childhood trauma has been inadequately considered. Childhood trauma and parenting stress are common in mothers in home visiting programs. Understanding the relation between childhood trauma and parenting stress holds promise for improvement of home visiting approaches. This study examined the relation between childhood trauma and parenting stress, with a focus on the mediating roles of depression and social support. Participants consisted of 208 first-time mothers enrolled in a home visiting program who were assessed at about 5 months' postpartum. Measures of maternal childhood trauma, depression, social support, and parenting stress were administered. A multiple mediator model revealed that childhood trauma was related to parenting stress, and the relation between childhood trauma and parenting stress was separately mediated by both depression and social support. Depression and social support uniquely and distinctly accounted for the association between childhood trauma and parenting stress. Home visiting programs may improve their impact on parenting stress by augmenting or modifying strategies to more effectively address maternal depression and social support.Parenting stress is defined as the gap between the demands of parenting and available personal resources and the negative mental appraisals that emerge in response to this discrepancy (Abidin, 1995). Although intermittent stress is common and normative in the parenting role, severe levels and chronic manifestations are highly disruptive and lead to poor outcomes in parents and children. Much of the research on parenting stress has focused on mothers, given their typical role as primary caregivers and their importance to child care and development. Optimal child development (particularly in infancy and early childhood) requires consistent and fo-

Research has documented the deleterious effects of maternal depression and childhood trauma on parenting and child development. There are high rates of both depression and childhood trauma in new mothers participating in home visitation programs, a prevention approach designed to optimize mother and child outcomes. Little is known about the impacts of maternal depression and childhood trauma on parenting in the context of home visitation. This study contrasted depressed and non-depressed mothers enrolled in the first year of a home visitation program on parenting stress, quality of home environment, social network, and psychiatric symptoms. Mothers were young, low income, and predominantly unmarried. Results indicated that depressed mothers displayed impairments in parenting, smaller and less robust social networks, and increased psychiatric symptoms relative to their non-depressed counterparts. Path analyses for the full sample revealed a path linking childhood trauma, depression, and parenting stress. Path analyses by group revealed several differential relationships between dimensions of social network and parenting. Number of embedded networks, namely the number of different domains in which the mother is actively interacting with others, was associated with lowered parenting stress among non-depressed mothers and increased parenting stress in their depressed counterparts with childhood trauma histories. In depressed mothers, social network size was associated with lower levels of parenting stress but decreased quality of the home environment, whereas number of embedded networks was positively related to quality of the home environment. Implications of findings for home visitation programs are discussed.

Home visiting (HV) is a strategy for delivering services designed to promote positive parenting and prevent exposure to toxic stress during a critical period of child development. Home visiting programs are voluntary and family engagement and retention in service can influence outcomes. Most participants receive less home visits and for a shorter time than prescribed by evidence-based models. The purpose of this study was to evaluate community-based enrichment of HV (CBE-HV), an approach that was developed and implemented to increase engagement and retention in HV. CBE-HV strategies included (1) community engagement, (2) ancillary supports for families in HV, and (3) enhancements to a HV program. A retrospective, quasi-experimental study was conducted to estimate the effect of CBE-HV on the retention of families in a HV program. Comparisons of study participants were made post-implementation of CBE-HV (n=2,191) and over time (n=3,786)—pre versus post CBE-HV implementation in the study communities. The CBE-HV effect was statistically significant and protective (hazards ratio [HR] 0.77, 95% confidence interval [CI]: 0.67, 0.88), indicating that attrition from HV was 23% less in the CBE-HV group relative to the post-implementation comparison group. In the temporal comparison of study communities, CBE-HV was also associated with a significantly lower risk of HV attrition (HR: 0.71, 95% CI: 0.56, 0.89). The study demonstrated that CBE-HV is a promising approach to achieve stronger retention and engagement in HV. Further research is needed to identify the components of CBE-HV approaches that are most effective.