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Over the past 10 years, identification of Autism Spectrum Disorder (ASD) risk has dramatically increased due to the wide-spread implementation of screening programs; yet, there is limited understanding about parent perceptions and experiences during the time period when risk is identified, but prior to receiving a formal diagnosis—a period that can last months to years given the long wait-lists for formal ASD evaluations. The current study aimed to examine parent perceptions of family impact (i.e., the impact their child’s behaviors have on the family) between the time of risk-identification and formal diagnosis among 277 children identified as at-risk for ASD through screening positive in primary care. We aimed to compare family impact among those whose child met diagnostic criteria for ASD and those who did not. Parents of children who received a non-ASD diagnosis reported a higher baseline level of family impact (F[1, 274] = 5.82, p = .017); however, perceived difficult child behavior was a stronger predictor of family impact (t[6] = 13.11, p

Objective Families, pediatric providers, and service systems would benefit from expanded knowledge regarding (1) who is most likely to receive a recommended diagnostic evaluation after a positive primary care-administered autism screen and (2) of those who screen positive, who is most likely to be diagnosed with autism? Method Participants included 309 predominantly low-income, racial/ethnic minority parents and their child, aged 15 to 27 months, who screened positive on the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F). Generalized estimating equations were used to fit models of predictors for each binary outcome: receiving a diagnostic evaluation and receiving an autism diagnosis on evaluation. Results Significant predictors of diagnostic evaluation receipt included the parent being older or non-Hispanic and the child having private insurance, lower child communication functioning, or receiving Early Intervention services. Significant predictors of an autism diagnosis on evaluation included male child, lower child communication functioning, screening directly in the parent's preferred language, White/non-Hispanic parent, and no parent history of mood disorder. Conclusion Children with younger parents, Hispanic ethnicity, relatively higher communication skills, public insurance, and no Early Intervention services were less likely to receive recommended diagnostic care. Reduced likelihood of autism diagnosis after a positive screen in non-White/non-Hispanic subgroups supports previous research indicating issues with M-CHAT-R/F positive predictive power for racial/ethnic minorities. The use of telephonic interpreters to administer screens, as opposed to directly screening in families' preferred languages, may lead to identification of fewer true autism cases. Thus, multilingual clinical staff capacity may improve positive predictive power of autism screening.

Parents of children with autism spectrum disorder (ASD) show increased levels of parenting stress, but only one study has examined this association before a diagnostic evaluation. We conducted a cross-sectional study of parenting stress in 317 low SES parents with children at-risk for ASD before a diagnostic evaluation. Multiple regression modeling evaluated the associations between parenting stress and parent and child factors. Parenting stress was negatively associated with social support and positively associated with active avoidance coping and parental worry. However, parenting stress was not associated with the child’s ASD symptom severity or adaptive functioning, except for self-direction. Findings suggest parenting stress among parents of children at risk of ASD should be assessed prior to diagnosis.

Children in low-income families are at risk for delayed diagnosis of autism spectrum disorder (ASD). The cascade-of-care model, which examines steps of care for quality and efficacy, can identify lesions in the process for evaluation and diagnosis for children at risk for ASD. Little is known about predictors that influence key steps in this process. We performed a retrospective chart review of 110 children under age five years from an academic medical center with social communication concerns. We assessed predictors of age of referral for ASD diagnostic evaluation, time to diagnosis, and likelihood of diagnostic completion. Children with continuity of primary care were referred at an earlier age than those receiving primary care at multiple centers. Compared with children with missed visits, children attending all well-child visits had a shorter median time to diagnosis. These findings illustrate a need for primary medical homes to facilitate early and timely ASD evaluations.

Background Concern with depression during the perinatal period has resulted in multiple states enacting legislation to require universal screening of mothers for postpartum depression. Despite this concern, rates of women receiving mental health counseling during pregnancy and postpartum remain low. This study examines factors, especially inequities in race/ethnicity, associated with receiving perinatal mental health counseling. Methods This study draws on data from the Listening to Mothers in California survey of 2539 women, based on a representative sample of birth certificate files of women who gave birth in 2016. The survey included a series of mental health questions, based on the 4-item Patient Health Questionnaire (PHQ-4), and questions on the receipt of counseling, whether a practitioner asked respondents about their mental health, and whether the respondent was taking medications for anxiety or depression. Results We found non-Latina Black women to experience both higher rates of prenatal depressive symptoms and significantly lower use of postpartum counseling services and medications than non-Latina White women. Among women with depressive symptoms, those asked by a practitioner about their mental health status reported a 46% rate of counseling compared with 20% who were not asked, and in a multivariable analysis, those asked were almost six times more likely (aOR 5.96; 95% CI 1.6-21.7) to report counseling. Discussion These findings lend evidence to those advocating for state laws requiring universal screening for depressive symptoms to reduce inequities and help address the underuse of counseling services among all women with depressive symptoms, particularly women of color.

Maternity care in the United States is characterized by racial and income disparities in maternal and infant outcomes. This article describes an innovative, hospital-based doula model serving a racially and ethnically diverse, low-income population. The program's history, program model, administration requirements, training, and evaluations are described.

OBJECTIVE To identify factors associated with referral and enrollment in early intervention (EI) for infants with neonatal abstinence syndrome (NAS). METHODS We conducted a retrospective cohort study of 256 infants born with NAS (2006-2013) at a tertiary care hospital in (Springfield), Massachusetts, linking maternal-infant birth hospitalization records with Department of Public Health EI records. We calculated the percent of infants retained at each step in the EI enrollment process over the first 3 years of life. We conducted separate multivariable logistic regression analyses to identify factors associated with EI referral and enrollment. RESULTS Among mothers, 82% received medication-assisted treatment at delivery, 36% endorsed illicit drug use during pregnancy, and 76% retained custody of their child at discharge. Among infants, 77% were referred to EI and 48% were enrolled in services. Of infants discharged to biological parents, 81% were referred to EI versus 66% of infants discharged to foster care (p ≤ 0.05); this difference persisted in multivariable analysis [adjusted odds ratio, 2.30; 95% confidence interval (CI), 1.09-4.86]. Infants in the highest tertile for length of stay had 2.70 times the odds of EI enrollment (95% CI, 1.37-5.31). CONCLUSION Fewer than half of the eligible infants with NAS were enrolled in EI services. Discharge to a biological parent and longer hospital stay had the strongest associations with EI referral and enrollment, respectively. Efforts to improve EI referral rates during the birth hospitalization, particularly among infants discharged into foster care, and close follow-up for infants with shorter hospital stays would enhance the developmental supports for this vulnerable population.

Significant disparities exist between Hispanic and non-Hispanic families in time-to-diagnosis among children identified as at risk of autism spectrum disorder; yet, little is known about parent experiences throughout the diagnostic process that may contribute to or help explain these disparities. The current study examined longitudinal trajectories of parenting stress, coping, and perceived family impact during the autism spectrum disorder diagnostic process among an ethnically and racially diverse low-income, urban sample, allowing for comparisons between Hispanic and non-Hispanic families. Hispanic families reported lower levels of parenting stress (χ2 = 5.35(1), p = 0.021), avoidant (χ2 = 9.66(1), p = 0.002) and approach (χ2 = 8.61(1), p = 0.003) coping, and negative family impact (χ2 = 5.39(1), p = 0.020) across time (main effects) compared with non-Hispanic families. Furthermore, there were differences in the change in use (Time Period × Ethnicity interaction effects) of both avoidant (χ2 = 10.80(3), p = 0.013) and approach (χ2 = 11.57(3), p = 0.009) coping, as well as negative family impact (χ2 = 9.81(3), p = 0.020), between Hispanic and non-Hispanic parents over time. These differences begin to shed light on the unique experiences of Hispanic parents. Because of the strengths that Hispanic families demonstrate, interventions that leverage those strengths and focus on education, empowerment, and resilience might be particularly beneficial for Hispanic families and may also better inform work to increase resilience in non-Hispanic families. Lay abstract Little is known about parent experiences throughout the diagnostic process for autism or how these parent experiences may help explain the disparities that exist between Hispanic and non-Hispanic families in time-to-diagnosis among children identified as at risk for autism. The current study examined trajectories of parenting stress, coping, and perceived family impact over time, throughout the autism diagnostic process among Hispanic and non-Hispanic families. Hispanic families reported lower levels of parenting stress, coping, and negative family impact across time. Further, there were differences in the change in use of coping and the amount of negative family impact reported between Hispanic and non-Hispanic parents over time. These differences shed light on the unique experiences and strengths of Hispanic families demonstrate. Interventions that leverage those strengths and focus on education, empowerment, and resilience might be particularly beneficial for Hispanic families and may also better inform work to increase resilience.

* Abbreviations: FERPA — : Family Educational Rights and Privacy Act HIPAA — : Health Insurance Portability and Accountability Act PHI — : protected health information STI — : sexually transmitted infection In the American Academy of Pediatrics statement “Role of the School Nurse in Providing School Health Services,” the authors acknowledge that misinformation about federal privacy laws can be problematic,1 creating misunderstandings among pediatricians and school nurses that impact student care. Confusion arises when clinicians, covered by the Health Insurance Portability and Accountability Act (HIPAA), work collaboratively with school nurses, covered by the Family Educational Rights and Privacy Act (FERPA), to conduct health programs. The majority of school nurses report working with their local health department2 but are unsure about what procedures to follow for documenting and communicating health information, and existing federal guidance does not speak adequately to the complications arising from cross-sector collaboration.3 In this article, we use an example of a school-based sexually transmitted infection (STI) screening program to highlight the 2 main federal privacy laws that impact school and health provider collaboration: FERPA and HIPAA. State privacy laws and institutional policies impose restrictions beyond federal law. These local laws and policies vary, as does their intersection with federal law. School and health department collaborators must negotiate this complex web when they plan joint projects. Passed in 1974, FERPA is designed to protect students’ educational records.4 Any educational institution receiving funding from the US Department of Education must allow parents or an eligible student (>18 years of age or has begun postsecondary education) to access the student’s … Address correspondence to Patricia A. Elliott, DrPH, Department of Community Health Sciences, School of Public Health, Boston University, 801 Massachusetts Ave, Room 440, Boston, MA 02118. E-mail: pelliott{at}bu.edu

This study aimed to define the core components of Family Navigation for autism spectrum disorder, a promising intervention to reduce disparities in care for this population. Teams from four trials of Family Navigation for autism spectrum disorder completed the Template for Intervention Description and Replication checklist to outline intervention components. Through intervention component analysis and qualitative synthesis, we identified 11 core components across three domains: Training and Supervision, Navigator Tools, and Navigator Activities. We discuss the importance of identifying these core components and implications for future research and practice.

The authors sought to determine whether a multicomponent, community-based program for preventing maternal depression also promotes engagement with mental health services for individuals with persistent symptoms.Mothers of children enrolled in Head Start were randomly assigned between February 2011 and May 2016 to Problem-Solving Education (PSE) (N=111) or usual services (N=119) and assessed every two months for 12 months.Among 230 participants, 66% were Hispanic; 223 participants were included in the analysis. For all PSE participants, engagement with specialty mental health services increased from approximately 10% to 21% between two and 12 months. The PSE group was more likely than the control group to be engaged in specialty services at 12 months (adjusted odds ratio [AOR]=2.36, 95% confidence interval [CI]=1.07-5.20), and the rate of engagement with specialty services over time (treatment × time interaction) favored PSE (p=.016). Among PSE participants with persistent depressive symptoms over the follow-up period, engagement with specialty services increased from 12% (two months) to approximately 46% (12 months), whereas among control group participants, engagement fluctuated between 24% and 33%, without a clear trajectory pattern. At 12 months, PSE participants with persistent symptoms were more likely to engage with specialty care compared with their counterparts in the control group (AOR=6.95, CI=1.50-32.19). The treatment × time interaction was significant for the persistently symptomatic subgroup (p=.029) but not for the episodically symptomatic or the asymptomatic subgroups.Embedding mental health programs in Head Start is a promising strategy to engage parents with depressive symptoms in care, especially those with persistent symptoms.

Objective Depression is highly prevalent among caregivers of children with attention-deficit/hyperactivity disorder (ADHD). We examined the association between caregiver depressive symptom trajectories and changes in child ADHD symptoms. Methods We analyzed data from a randomized trial of 2 ADHD care management systems for children aged 6 to 12 years and their caregivers (n = 156 dyads). Child ADHD symptoms were measured using the Swanson, Nolan, and Pelham rating scale (SNAP-IV). Caregiver depressive symptoms were measured using the Quick Inventory of Depressive Symptomatology (QIDS). Measures were assessed at baseline, 6 months, and 12 months. We used multivariable models to examine associations between changes in caregiver depressive symptoms and changes in child ADHD symptoms. Results From baseline to 12 months, children of caregivers with improved depressive symptoms had significantly greater reductions in SNAP-IV scores (change score: -1.43) compared with those whose depressive symptoms did not change (change score: -0.97) or worsened (change score: -0.23, p = 0.003). In adjusted models, improved caregiver depressive symptoms were associated with greater reductions in SNAP-IV scores over the 12-month period. Compared with those with worsening caregiver depressive symptoms, children whose caregivers showed no significant changes in depressive symptoms had a -0.78 point (95% confidence interval [CI]: -1.40 to -0.17) greater reduction in the SNAP-IV score, and those children whose caregiver depressive symptoms improved had a -1.31 point greater reduction in the SNAP-IV score (95% CI: -1.97 to -0.66). Conclusion Given the longitudinal association between caregiver depressive symptom and child ADHD symptom trajectories, interventions that address the behavioral health needs of the family unit may offer promise for urban children with ADHD.

In 2013, the National Institute of Mental Health funded five trials of unique, multicomponent, systems-based innovations designed to improve access to early screening, diagnosis, and treatment of autism spectrum disorder—collectively known as the Autism Spectrum Disorder Pediatric, Early Detection, Engagement, and Services Network. As part of an ongoing effort to pool data and learn from shared experience, we collected information across all studies about innovation components and implementation strategies. First, each study group completed standardized checklists based on the Template for Intervention Description and Replication and the Expert Recommendation for Implementing Change. Then, we interviewed principal and co-investigators of each study (n = 9) to further explore innovation components and assess barriers and facilitators to implementation. Innovation strategies were diverse (five different autism spectrum disorder screeners were used, 40% included early intervention trainings, 60% involved new technology). Common implementation strategies included developing stakeholder relationships and provider trainings. Barriers included inefficient systems of care, difficulty engaging families in the innovations, provider attitudes, and organizational culture (e.g. difficulty changing clinic processes). These findings suggest that—despite diverse settings and a variety of innovation content—common facilitators and challenges exist in implementing innovations to enhance access to early autism spectrum disorder screening, diagnosis, and treatment.

We sought to assess potential mechanisms of action of a patient navigation intervention in Head Start, designed to help depressed mothers engage with mental health care. We employed mixed methods, linking qualitative interviews (n = 21) to a randomized intervention pilot (n = 47). Early in follow-up, navigated mothers had lower mean depressive symptom scores than non-navigated mothers (9.61 vs. 12.95, p = 0.03). These differences attenuated but preceded a greater likelihood of engaging with care among navigated mothers. Navigated mothers reported greater self-esteem (score 21.45 vs. 18.60, p = 0.05) and greater confidence in their ability to self-manage depression (7.65 vs. 5.67, p = 0.01). In qualitative interviews, navigated mothers linked decreased symptom burden to feeling activated; they communicated optimism toward the future and a willingness to work toward symptom improvement by trying something new. Early symptom relief, behavioral activation, self-esteem, self-management, and optimism represent plausible navigation mechanisms of action. These constructs require formal testing.

Background Delivery of behavioral interventions is complex, as the majority of interventions consist of multiple components used either simultaneously, sequentially, or both. The importance of clearly delineating delivery strategies within these complex interventions—and furthermore understanding the impact of each strategy on effectiveness—has recently emerged as an important facet of intervention research. Yet, few methodologies exist to prospectively test the effectiveness of delivery strategies and how they impact implementation. In the current paper, we describe a study protocol for a large randomized controlled trial in which we will use the Multiphase Optimization Strategy (MOST), a novel framework developed to optimize interventions, i.e., to test the effectiveness of intervention delivery strategies using a factorial design. We apply this framework to delivery of Family Navigation (FN), an evidence-based care management strategy designed to reduce disparities and improve access to behavioral health services, and test four components related to its implementation. Methods/design The MOST framework contains three distinct phases: Preparation, Optimization, and Evaluation. The Preparation phase for this study occurred previously. The current study consists of the Optimization and Evaluation phases. Children aged 3-to-12 years old who are detected as “at-risk” for behavioral health disorders (n = 304) at a large, urban federally qualified community health center will be referred to a Family Partner—a bicultural, bilingual member of the community with training in behavioral health and systems navigation—who will perform FN. Families will then be randomized to one of 16 possible combinations of FN delivery strategies (2 × 2 × 2× 2 factorial design). The primary outcome measure will be achieving a family-centered goal related to behavioral health services within 90 days of randomization. Implementation data on the fidelity, acceptability, feasibility, and cost of each strategy will also be collected. Results from the primary and secondary outcomes will be reviewed by our team of stakeholders to optimize FN delivery for implementation and dissemination based on effectiveness, efficiency, and cost. Discussion In this protocol paper, we describe how the MOST framework can be used to improve intervention delivery. These methods will be useful for future studies testing intervention delivery strategies and their impact on implementation. Trial registration ClinicalTrials.gov, NCT03569449. Registered on 26 June 2018.

OBJECTIVES: Family Navigation (FN), a care management strategy, helps families overcome systems and person-level barriers to care. We previously demonstrated FN’s feasibility, acceptability, and potential efficacy for increasing access and reducing time to autism-related diagnostic services among low-income, minority children. In this paper, we describe modifications to FN in response to concerns raised in our first pilot randomized controlled trial (RCT), and then assess these modifications in a second pilot RCT. METHODS: An advisory group recommended modifications to recruitment procedures and study conditions. 40 parent-child dyad participants with autism-related concerns were randomized to receive modified usual care (UC) or modified FN. We compared whether the first and second pilot RCTs differed in: participant enrollment, satisfaction with clinical care, and timely completion of the diagnostic assessment. RESULTS: Recruitment improved under the modified protocol with significantly fewer potentially eligible families refusing (19.5% vs. 4.8%, p < .05) or being excluded from study enrollment (43.6% vs. 0%, p < 0.01). Comparing the first and second pilot RCTs, regardless of study arm, families in the second pilot were more likely to complete diagnostic assessment (UC: HR 3.41, 95% CI [1.20, 9.68]; FN: HR 2.64, 95% CI [1.31, 5.30]) and report greater satisfaction with clinical care. In the second pilot, compared to UC, FN continued increase the likelihood of completing the diagnostic assessment (HR: 2.57; 95% CI [1.22, 5.40]). CONCLUSIONS: Easy-to-implement system-level enhancements improved study recruitment, satisfaction with care, and completion of a diagnostic assessment. With enhancement, FN continued to confer benefits to families.

BACKGROUND AND OBJECTIVES: Opioid-exposed infants frequently qualify for early intervention (EI). However, many eligible families choose not to enroll in this voluntary service. This study aims to understand the perceptions and experiences that may impact engagement with, and the potential benefits of, EI services among mothers in recovery from opioid use disorders (OUDs). METHODS: We conducted semistructured qualitative interviews (n = 22) and 1 focus group (n = 6) with mothers in recovery from OUDs in western Massachusetts. Transcripts were coded and analyzed by using a descriptive approach. RESULTS: The mean participant age was 32 years, and 13 had a high school degree or less. Five major themes emerged revealing mothers’ development through stages of engagement in EI services: (1) fear, guilt, and shame related to drug use (emotions acting as barriers to enrollment); (2) the question of whether it is “needed” (deciding whether there is value in EI for opioid-exposed infants); (3) starting with “judgment” (baseline level of perceived stigma that parents in recovery associate with EI); (4) breaking down the “wall” (how parents overcome the fear and perceived judgment to build partnerships with providers); and (5) “above and beyond” (need for a personal connection with mothers and concrete supports through EI in addition to the child-focused services provided). CONCLUSIONS: Barriers to engagement in EI among mothers in recovery from OUDs include a range of emotions, perceived stigma, and ambivalence. An effort to purposefully listen to and care for mothers through a strengths-based, bigenerational approach may help establish greater connections and foster stronger EI engagement among families affected by OUDs.

Importance Early identification of autism spectrum disorder (ASD) is associated with improved cognitive and behavioral outcomes. Targeted strategies are needed to support equitable access to diagnostic services to ensure that children from low-income and racial/ethnic minority families receive the benefits of early ASD identification and treatment. Objective To test the efficacy of family navigation (FN), an individually tailored, culturally informed care management strategy, to increase the likelihood of achieving diagnostic ascertainment among young children at risk for ASD. Design, Setting, and Participants This randomized clinical trial of 249 families of children aged 15 to 27 months who had positive screening results for possible ASD was conducted in 11 urban primary care sites in 3 cities. Data collection occurred from February 24, 2015, through November 5, 2018. Statistical analysis was performed on an intent-to-treat basis from November 5, 2018, to July 27, 2020. Interventions Families were randomized to FN or conventional care management (CCM). Families receiving FN were assigned a navigator who conducted community-based outreach to families to address structural barriers to care and support engagement in recommended services. Families receiving CCM were assigned to a care manager, who did limited telephone outreach. Families received FN or CCM after positive initial screening results and for 100 days after diagnostic ascertainment. Main Outcomes and Measures The primary outcome, diagnostic ascertainment, was measured as the number of days from randomization to completion of the child's clinical developmental evaluation, when a diagnosis of ASD or other developmental disorder was determined. Results Among 250 families randomized, 249 were included in the primary analysis (174 boys [69.9%]; mean [SD] age, 22.0 [3.5] months; 205 [82.3%] publicly insured; 233 [93.6%] non-White). Children who received FN had a greater likelihood of reaching diagnostic ascertainment over the course of 1 year (FN, 108 of 126 [85.7%]; CCM, 94 of 123 [76.4%]; unadjusted hazard ratio [HR], 1.39 [95% CI, 1.05-1.84]). Site (Boston, New Haven, and Philadelphia) and ethnicity (Hispanic vs non-Hispanic) moderated the effect of FN (treatment × site interaction; P = .03; Boston: HR, 2.07 [95% CI, 1.31-3.26]; New Haven: HR, 1.91 [95% CI, 0.94-3.89]; and Philadelphia: HR, 0.91 [95% CI, 0.60-1.37]) (treatment × ethnicity interaction; P

CONTEXT Women seeking timely and affordable abortion care may face myriad challenges, including high out-of-pocket costs, transportation demands, scheduling difficulties and stigma. State-level regulations may exacerbate these burdens and impede women's access to a full range of care. Women's reports of their experiences can inform efforts to improve pathways to abortion care. METHODS In 2014, semistructured qualitative interviews were conducted with 45 women obtaining abortions in South Carolina, which has a restrictive abortion environment. Interviews elicited information about women's pathways to abortion, including how they learned about and obtained care, whether they received professional referrals, and the supports and obstacles they experienced. Transcripts were examined using thematic analysis to identify key themes along the pathways, and a process map was constructed to depict women's experiences. RESULTS Twenty participants reported having had contact with a health professional or crisis pregnancy center staff for pregnancy confirmation, and seven of them received an abortion referral. Women located abortion clinics through online searches, previous experience, and friends or family. Financial strain was the most frequently cited obstacle, followed by transportation challenges. Women reported experiencing emotional strain, stress and stigma, and described the value of receiving social support. Because of financial pressures, the regulation with the greatest impact was the one prohibiting most insurance plans from covering abortion care. CONCLUSIONS Further research on experiences of women seeking abortion services, and how these individuals are affected by evolving state policy environments, will help shape initiatives to support timely, affordable and safe abortion care in a climate of increasing restrictions.

Key Points Question What are the principal mechanisms by which problem-solving education prevents depression among low-income mothers? Findings In this mediation analysis of 230 Head Start mothers participating in a randomized clinical trial, those receiving problem-solving education experienced a reduction in depressive symptom episodes. Across an array of plausible theory-based intervention mediators, improvement in perceived stress was associated with both intervention participation and depressive symptom outcomes; however, the mechanism for much of the intervention’s impact on depression remained unexplained. Meaning Problem-solving interventions may reduce depressive symptom burden, in part, by helping recipients manage stress; successfully scaling such interventions may require expanding intervention components related to stress management and reducing components that are unrelated., This study uses data from a clinical trial suggesting that problem-solving education (a form of cognitive behavioral therapy [CBT]) can prevent depression in low-income mothers to explore the mechanisms by which the intervention might be effective., Importance Although problem solving has been an important component of successful depression prevention and treatment interventions, evidence to support problem solving’s mechanism of action is sparse. Objective To understand the mechanism of an efficacious depression prevention intervention, problem-solving education (PSE). Design, Setting, and Participants A multivariate path analysis was embedded within a randomized efficacy trial (February 15, 2011, to May 9, 2016). Participants were mothers with depressed mood, anhedonia, or depression history (but not in current major depressive episode) at 1 of 6 Head Start agencies. Participants were followed up for 12 months with serial assessments of potential intervention mediators and depressive symptoms. Interventions Problem-solving education (n = 111) and usual Head Start services (n = 119). Main Outcomes and Measures Primary outcomes were depressive symptom elevations, which were measured bimonthly. Eight plausible intervention mediators were assessed: problem-solving ability; mastery; self-esteem; perceived stress; behavioral activation; and avoidant, problem-focused, and social coping. Results Among 230 participants, 152 (66.1%) were Hispanic; mean (SD) age was 31.4 (7.3) years. Based on associations with either PSE participation or depressive symptom outcomes, problem-solving ability, perceived stress, behavioral activation, and problem-focused coping were included in a parsimonious, multivariate path model. In this model, only perceived stress was associated with both PSE participation and depressive symptoms. Participants in the PSE group had adjusted standardized perceived stress change scores that were 11% lower than controls (95% CI, −0.19 to −0.03), and improvement in perceived stress generated an adjusted rate ratio (aRR) of 0.42 (95% CI, 0.33-0.53) for depressive symptom elevations. Participants in the intervention group also had standardized behavioral activation change scores 15% greater than controls (95% CI, 0.01-0.30) and problem-focused coping change scores 17% greater than controls (95% CI, 0.03-0.31); however, changes in these constructs were not associated with a differential rate of depressive symptom elevations. The direct effect of PSE on depressive symptom elevations (aRR, 0.72; 95% CI, 0.52-0.97) was greater than the mediated effect explained by improvement in perceived stress (aRR, 0.91; 95% CI, 0.85-0.98). Conclusions and Relevance Problem-solving education is efficacious in preventing depressive symptoms and appears to work by decreasing perceived stress; however, the mechanism for much of PSE’s impact on depression remains unexplained. These results can be used to simplify the intervention model in preparation for effectiveness testing. Trial Registration ClinicalTrials.gov Identifier: NCT01298804

There is growing interest in Family Navigation as an approach to improving access to care for children with autism spectrum disorder, yet little data exist on the implementation of Family Navigation. The aim of this study was to identify potential failures in implementing Family Navigation for children with autism spectrum disorder, using a failure modes and effects analysis. This mixed-methods study was set within a randomized controlled trial testing the effectiveness of Family Navigation in reducing the time from screening to diagnosis and treatment for autism spectrum disorder across three states. Using standard failure modes and effects analysis methodology, experts in Family Navigation for autism spectrum disorder (n = 9) rated potential failures in implementation on a 10-point scale in three categories: likelihood of the failure occurring, likelihood of not detecting the failure, and severity of failure. Ratings were then used to create a risk priority number for each failure. The failure modes and effects analysis detected five areas for potential “high priority” failures in implementation: (1) setting up community-based services, (2) initial family meeting, (3) training, (4) fidelity monitoring, and (5) attending testing appointments. Reasons for failure included families not receptive, scheduling, and insufficient training time. The process with the highest risk profile was “setting up community-based services.” Failure in “attending testing appointment” was rated as the most severe potential failure. A number of potential failures in Family Navigation implementation—along with strategies for mitigation—were identified. These data can guide those working to implement Family Navigation for children with autism spectrum disorder.

* Abbreviations: ASD — : autism spectrum disorder ASQ — : Ages and Stages Questionnaire EAS — : Emotionality, Activity, and Sociability Temperament Survey MCHAT — : Modified Checklist for Autism in Toddlers MCHAT-R — : Modified Checklist for Autism in Toddlers-Revised USPSTF — : United States Preventive Services Task Force Although autism spectrum disorder (ASD) can be reliably detected by age 2, the average age of diagnosis ranges from age 4 to 6, depending on the population.1 Because earlier access to treatment is thought to improve outcomes,2 delays in diagnosis may lead to avoidable morbidity. In an effort to lower the average age of diagnosis, considerable efforts are being made to promote early ASD screening.3–5 Two predominant strategies exist: broad-based developmental surveillance and targeted ASD screening.6,7 Although there are data to support each strategy, targeted ASD screening has recently gained popularity. The American Academy of Pediatrics, for example, recommends all children receive an ASD-specific screener at their 18- and 24-month well-child visit, and it proactively supports these guidelines with resources and trainings.3 A number of studies support ASD-specific screeners (the Modified Checklist for Autism in Toddlers [MCHAT] and the Modified Checklist for Autism in Toddlers-Revised [MCHAT-R]) for detecting early ASD … Address correspondence to Sarabeth Broder-Fingert, MD, MPH, Division of General Pediatrics, Boston University School of Medicine, 850 Harrison Ave, Room 310A, Boston, MA 02118. E-mail: sarabeth.broder-fingert{at}bmc.org

Significant racial, ethnic, and socioeconomic disparities exist in access to evidence-based treatment services for children with autism spectrum disorder (ASD). Patient Navigation (PN) is a theory-based care management strategy designed to reduce disparities in access to care. The purpose of this study is to test the effectiveness of PN a strategy to reduce disparities in access to evidence-based services for vulnerable children with ASD, as well as to explore factors that impact implementation. This study uses a hybrid type I randomized effectiveness/implementation design to test effectiveness and collect data on implementation concurrently. It is a two-arm comparative effectiveness trial with a target of 125 participants per arm. Participants are families of children age 15–27 months who receive a positive screen for ASD at a primary care visit at urban clinics in Massachusetts (n = 6 clinics), Connecticut (n = 1), and Pennsylvania (n = 2). The trial measures diagnostic interval (number of days from positive screen to diagnostic determination) and time to receipt of evidence-based ASD services/recommended services (number of days from date of diagnosis to receipt of services) in those with PN compared to and activated control -Conventional Care Management – which is similar to care management received in a high quality medical home. At the same time, a mixed-method implementation evaluation is being carried out. This study will examine the effectiveness of PN to reduce the time to and receipt of evidence-based services for vulnerable children with ASD, as well as factors that influence implementation. Findings will tell us both if PN is an effective approach for improving access to evidence-based care for children with ASD, and inform future strategies for dissemination. NCT02359084 Registered February 1, 2015.

Children with autism spectrum disorder (ASD) are at high risk for being overweight and obese. Little is known about how obesity in children with ASD is being addressed in primary care. This article reports findings from a survey completed by 327 general pediatricians, which included a fictional clinical vignette and Likert-scales assessing attitudes, practices, self-efficacy, and barriers to obesity management. Although the majority of respondents agreed pediatricians should be the main providers to manage obesity in children with ASD, few reported receiving adequate training to do so. Pediatricians were more likely to refer to developmental-behavioral pediatricians and dietitians for a child with ASD compared to a child without ASD. Higher self-efficacy was associated with increased weight-related counseling frequency by pediatricians.

The impact of depression interventions is often attenuated in women who have experienced trauma. We explored whether psychological avoidance could explain this phenomenon. We synthesized two pilot randomized trials of problem-solving education (PSE) among a total of 93 urban mothers. Outcomes included depressive symptoms and perceived stress. Mothers with avoidant coping styles experienced an average 1.25 episodes of moderately severe depressive symptoms over 3 months of follow-up, compared to 0.40 episodes among those with non-avoidant coping (adjusted incident rate ratio [aIRR] 2.18; 95 % CI 1.06, 4.48). PSE tended to perform better among mothers with non-avoidant coping. Among mothers with non-avoidant coping, PSE mothers experienced an average 0.24 episodes, compared to 0.58 episodes among non-avoidant controls (aIRR 0.27; 95 % CI 0.05, 1.34). Among mothers with avoidant coping, PSE mothers experienced an average 1.26 episodes, compared to 1.20 episodes among avoidant controls (aIRR 0.76; 95 % CI 0.44, 1.33). This trend toward differential impact persisted when avoidance was measured as a problem-solving style and among traumatized mothers with and without avoidant PTSD symptoms. Further research is warranted to explore the hypothesis that psychological avoidance could explain why certain depression treatment and prevention strategies break down in the presence of trauma.

OBJECTIVES: Although many attention-deficit/hyperactivity disorder (ADHD) care models have been studied, few have demonstrated individual-level symptom improvement. We sought to test whether complementing basic collaborative care with interventions that address common reasons for symptom persistence improves outcomes for children with inattention and hyperactivity/impulsivity. METHODS: We conducted a randomized comparative effectiveness trial of 2 care management systems for 6- to 12-year-old children being evaluated for ADHD (n = 156). All participants received care management with decision support. Care managers in the enhanced care arm also were trained in motivational and parent management techniques to help parents engage in their child’s treatment, address their own mental health needs, and manage challenging child behaviors. We used multivariable models to assess inattention, hyperactivity/impulsivity, oppositionality, and social skills over 1 year. RESULTS: Both treatment arms generated guideline concordant diagnostic processes in 94% of cases; 40% of children had presentations consistent with ADHD. For the entire sample, there were no differences in symptom trajectories between study arms; mean differences in change scores at 12 months were –0.14 (95% confidence interval –0.34 to 0.07) for inattention; –0.13 (–0.31 to 0.05) for hyperactivity/impulsivity; –0.09 (–0.28 to 0.11) for oppositionality; and 3.30 (–1.23 to 7.82) for social skills. Among children with ADHD-consistent presentations, enhanced arm participants experienced superior change scores for hyperactivity/impulsivity of –0.36 (–0.69 to –0.03), oppositionality –0.40 (–0.75 to –0.05), and social skills 9.57 (1.85 to 17.28). CONCLUSIONS: Among children with ADHD-consistent presentations, addressing barriers to engagement with care and challenging child behaviors has potential to improve the effectiveness of collaborative care.

We assessed dimensions of feasibility of a patient navigation system in the Head Start preschool setting to help low-income mothers with depression engage with mental health care. Forty-seven mothers participated; none refused. Navigators demonstrated excellent model fidelity; we experienced no adverse events. We discuss implications for future evaluation design.

Proponents of life course comment that while the theory is persuasive, translating theory to practice is daunting. This paper speaks to the challenges and possibilities of intervention based on life course theory. It describes Healthy Start in Housing (HSiH), a partnership between the Boston Public Health Commission (BPHC) and the Boston Housing Authority (BHA) to reduce stress due to housing insecurity among low-income, pregnant women. HSiH seeks improved birth outcomes and long term health of mothers and infants. BHA goals are improved quality of life for participants, greater public housing stability and enhanced impact of housing on community well-being. HSiH is a 1 year pilot offering 75 housing units to pregnant women at risk of adverse birth outcomes and homelessness. BHA provides housing and expedites processing of HSiH applications; BPHC staff oversee enrollment, guide women through the application process, and provide enhanced, long-term case management. Of 130 women referred to HSiH to date, 53 were ineligible, 59 have submitted applications, 13 are preparing applications and 5 dropped out. Nineteen women have been housed. Among eligible women, 58 % had medical conditions, 56 % mental health conditions, and 14 % prior adverse outcomes; 30 % had multiple risks. Standardized assessments reflected high levels of depressive symptoms; 41 % had symptoms consistent with post-traumatic stress disorder. Life course theory provides both the framework and the rationale for HSiH. HSiH experience confirms the salience of daily social experience to women's health and the importance of addressing stressors and stress in women's lives.

This study assesses the potential of social work–facilitated patient navigation to help mothers with depression engage with mental health care. We conducted a randomized pilot trial (N = 47) in Head Start—a U.S. preschool program for low-income children. Seven lay navigators received training and supervision from professional social workers. After 6 months, more navigated participants engaged with a psychologist, therapist, or social worker (45% vs. 13%, 95% confidence interval [CI] [2, 57]); engaged with any provider, (55% vs. 26%, 95% CI [1, 56]); and reported having a “depression care provider” (80% vs. 41%, 95% CI [9, 65]). Community-based navigation appears feasible; however, more definitive testing is necessary.

Emerging evidence suggests that autism spectrum disorder (ASD) can be diagnosed by age 18 months and that early intensive behavioral intervention positively affects ASD core deficits. This pilot randomized controlled trial examined the feasibility of using an adapted form of patient navigation, Family Navigation (FN), to improve timely diagnosis of ASD in low-income families from racial-ethnic minority groups.Forty children referred for an ASD diagnostic assessment were randomly allocated to receive FN or usual care. The primary outcome, time to diagnostic resolution, was assessed with survival analysis.Nineteen of 20 FN children completed the diagnostic assessment, compared with 11 of 19 children receiving usual care (hazard ratio=3.21, 95% confidence interval=1.47-6.98, p.01). In regard to engagement of participants, 17 of 20 families (85%) met with the navigator for the targeted three in-person visits (median=4, range 1-9).FN may be a promising intervention to address barriers that impede timely ASD diagnosis.

The purpose of this Letter to the Editor is to discuss the recent paper, “Lessons learned: Engaging culturally diverse families in neurodevelopmental disorders intervention research” by Ratto et al. Specifically, we are interested in further exploring the question of “who participates in autism spectrum disorder intervention research,” and how this question may impact interpretation of Ratto and colleagues’ paper.

To quantify racial differences in receipt of early intervention (EI) services among children ages birth to 3 years.Multivariable analyses of a nationally representative sample of children eligible for EI services using data from the Early Child Longitudinal Study, Birth Cohort was conducted. Birth weight1000 g, genetic and medical conditions associated with developmental delay, or low scores on a standardized measure of developmental performance defined EI eligibility. Receipt of EI services was ascertained from parent self-report. The effect of race on receipt of EI services was examined in main effect models and models stratified by EI qualifying condition, which was defined as either established medical condition or developmental delay in the absence of an underlying medical diagnosis.At 9 months of age, among the 1000 children eligible for EI services, 9% of children received services; there were no black-white racial differences in receipt of services. At 24 months of age, among the 1000 children eligible for EI services, 12% received services; black children were 5 times less likely to receive services than white children (adjusted odds ratio [aOR] 0.19; 95% confidence interval [CI] 0.09, 0.39). In models stratified by qualifying condition, black children who qualified for services at 24 months based on developmental delay alone were less likely to receive services (aOR 0.09; 95% CI 0.02, 0.39); there were no differences by race among children who qualified based on established medical conditions (aOR 0.56; 95% CI 0.18, 1.72).Racial disparities in EI service receipt, which were not present during infancy, emerged as children became toddlers. These disparities were found most consistently among children who qualified for services based on developmental delay alone.

Violent trauma is common in urban communities. We explored the hypothesis that past trauma could moderate the effect of a cognitive behavioral intervention designed to prevent depression among urban, low-income mothers.Synthesis of two pilot randomized trials of problem solving education (PSE) among 93 mothers of children hospitalized in the neonatal intensive care unit or enrolled in community-based Early Intervention programs. Outcomes included depressive symptoms, perceived stress, and social functioning. Results were adjusted for baseline depressive symptoms, then stratified according to subjects' trauma history.Fifteen of the 44 PSE subjects (34%) experienced a moderately severe depressive symptom episode during the 3-month follow-up period, as opposed to 21 of 45 control subjects (47%), for a nearly significant adjusted odds ratio (aOR) of 0.36 (95% CI: 0.13, 1.02). Among mothers without trauma histories, far fewer PSE mothers (5 of 24; 21%) experienced an episode of moderately severe depressive symptoms than control mothers (12 of 26; 46%) for a significant aOR of 0.15 (95% CI: 0.03, 0.79). Conversely, among mothers with trauma histories, a similar proportion of PSE mothers (10 of 19; 53%) experienced an episode of moderately severe depressive symptoms as control mothers (9 of 19; 47%). Similar trends held for perceived stress and social functioning.PSE may be more effective at preventing depression among mothers without trauma histories. Our results are consistent with the depression treatment literature, but are novel because they support the principle of intervention moderation in risk prevention, as opposed to treatment, paradigm.

Institutional review boards (IRBs) protect human research subjects by reviewing research to ensure compliance with federal regulations and institutional policies. One of the most important functions of IRBs is to ensure that investigators anticipate, plan for, and minimize risks to subjects. Under certain circumstances, however, participation in research may pose risks to nonsubject family members or other members of a subject's social network. In the context of a research protocol designed to test an intervention to prevent depression among a population of culturally diverse, urban mothers, we present two case studies of unanticipated problems, which demonstrate how nonsubject family members can either impact, or be impacted by, an individual's participation in research. The case studies illustrate the incongruence between federal regulations addressing IRB approval of research—which focus specifically on risks to subjects—and regulations on reporting incidents that occur during the conduct of the research, which extend to risks involving “others” as well. The cases also illustrate how risks to “others” can be accentuated in certain cultures where codependent family structures may increase the role that family members play in an individual's decision to participate in research. The question is raised as to whether this incongruence can inadvertently result in investigators and IRBs under-appreciating the risks that participation in research can pose to nonsubjects.

Objective Maternal depression is common among mothers of very low birthweight (VLBW) infants. In a cohort of mother–VLBW infant dyads followed to preschool age, the authors assessed the impact of maternal depression on mothers9 perceptions of their children9s social aptitude and reported participation in age-appropriate preschool activities. Methods Longitudinal multivariable analysis of a nationally representative sample of VLBW infants in the USA. Models were adjusted for children9s developmental abilities according to the Bayley Scales of Infant Development, Mental Development Index. Results 800 VLBW singletons (mean gestational age 28.9 weeks) were analysed. During the preschool years, depressed mothers perceived their children9s social abilities more negatively than non-depressed mothers. Specifically, they saw their children as less likely to be able to share with others (aOR 0.37, 95% CI 0.14 to 0.96), make friends (aOR 0.58, 95% CI 0.35 to 0.96) or play independently (aOR 0.30, 95% CI 0.16 to 0.58). These negative perceptions were not shared by the children9s preschool teachers. Children of depressed mothers were also less likely to participate in age-appropriate preschool activities (aOR 0.30, 95% CI 0.16 to 0.58). Each of these associations either lost significance or were substantially attenuated in a separate population of former healthy term infants. Conclusion Among former VLBW infants, maternal depression is associated with negative perceptions of children9s social abilities and decreased participation in preschool activities. Maternal mental health should be considered in ongoing efforts to maximise the social-emotional development of preterm infants.

OBJECTIVE. In this we study explored the relationship between food insecurity and compensatory maternal feeding practices that may be perceived as buffers against periodic food shortages among urban black families.METHODS. We interviewed a convenience sample of black mothers of children aged 2 to 13 years. Food-security status (predictor) was determined at the household level. Five maternal feeding practices (outcomes) were assessed. Two were based on Birch's Child Feeding Questionnaire (restricting access to certain foods and pressuring a child to eat), and 3 were derived from investigators' clinical experience (use of high-energy supplements, added sugar in beverages, and perceived appetite stimulants). Anthropometric data were collected from mothers and children.RESULTS. A total of 278 mother–child dyads were analyzed, and 28% of these mothers reported being food insecure. Use of Child Feeding Questionnaire feeding practices was defined as the top quartile of responses. Use of nutritional supplements, defined as “at least 1 to 2 times monthly,” ranged from 13% to 25%. In logistic regression models adjusted for child age, weight status, and ethnicity and maternal weight status, mothers from food-insecure households were significantly more likely to use high-energy supplements and appetite stimulants. The odds of using the remaining compensatory feeding practices (adding sugars to beverages, pressuring a child to eat, and restricting access to certain foods) were elevated among food-insecure households but did not reach statistical significance.CONCLUSIONS. Household food insecurity was independently associated with 2 of the 5 maternal compensatory feeding practices studied, and such practices may alter the feeding environment. Longitudinal research is necessary to determine how the relationship between food security and compensatory maternal feeding practices may affect child weight trajectories.

The internatal period, the time between births of successive children, has become a focal point for risk assessment and health promotion in women's healthcare. This period represents a time when women are at high risk for a depressive disorder. The pediatric venue offers a unique opportunity for the identification and management of depression in the internatal period, as mothers who do not attend their own medical appointments are likely to accompany their child to pediatric visits. This paper discusses the role pediatric providers can undertake to improve women's health in the internatal period through the detection and management of maternal depression at well-child visits. Successful models of the management of depression in other primary care settings are explored for their potential for implementation in the pediatric venue. A specific model developed and implemented as part of a 3-year project is presented to highlight the feasibility of an evidenced-based approach to the management of maternal depression in the pediatric setting. We present evidence demonstrating that pediatric providers can successfully identify postpartum women with depression, monitor symptoms and treatment adherence, and communicate results to a woman's healthcare provider. Yet more investigation is needed to create preventive interventions for maternal depression that integrate evidenced-based practice standards for the treatment of depression in primary care venues into pediatric settings. Future programs and policies targeting maternal depression in the pediatric environment should address patient mental health literacy and stigma, the training and education of pediatric providers, and issues of privacy and reimbursement.

Objectives: The purpose of the study was to examine the effect of language proficiency on enrollment in a state-sponsored child health insurance program. Methods: 1055 parents of Medicaid-eligible children, who were enrolled in a state-sponsored child health insurance program, were surveyed about how they learned about the state program, how they enrolled their children in the program, and perceived barriers to Medicaid enrollment. We performed weighted χ2 tests to identify statistically significant differences in outcomes based on language. We conducted multivariate analyses to evaluate the independent effect of language controlling for demographic characteristics. Results: Almost a third of families did not speak English in the home. These families, referred to as limited English proficiency families, were significantly more likely than English-proficient families to learn of the program from medical providers, to receive assistance with enrollment, and to receive this assistance from staff at medical sites as compared to the toll-free telephone information line. They were also more likely to identify barriers to Medicaid enrollment related to “know-how”—that is, knowing about the Medicaid program, if their child was eligible, and how to enroll. Differences based on language proficiency persisted after controlling for marital status, family composition, place of residence, length of enrollment, and employment status for almost all study outcomes. Conclusions: This study demonstrates the significant impact of English language proficiency on enrollment of Medicaid-eligible children in publicly funded health insurance programs. Strong state-level leadership is needed to develop an approach to outreach and enrollment that specifically addresses the needs of those with less English proficiency.

Importance Low-income and minority mothers experience a disproportionate incidence of depression and lack access to treatment services. Development of prevention strategies in accessible community-based venues is a potentially important public health strategy. Objective To determine the efficacy of a depression prevention strategy embedded in Head Start. Design, Setting, and Participants This randomized clinical trial was performed from February 15, 2011, through May 9, 2016, at 6 Head Start agencies serving families at or below the federal poverty level. Participants included mothers with depressed mood, anhedonia, or depression history but who were not in a current major depressive episode. Participants were followed up for 12 months with masked outcome assessments. Final follow-up was completed on May 9, 2016. Interventions Participants were randomized to a problem-solving education (PSE) intervention (n = 111) or usual Head Start services (n = 119). Main Outcomes and Measures Primary outcomes were problem-solving skills and depressive symptoms. To capture the chronicity and intensity of symptoms, the Quick Inventory of Depressive Symptoms was administered bimonthly, and rates of clinically significant symptom elevations were compared across groups. Secondarily, the presence of a major depressive episode was assessed using the Structured Clinical Interview for DSM-IV Axis I Disorders. Results Among the 230 participants, 152 (66.1%) were Hispanic, with a mean (SD) age of 31.4 (7.3) years. An intention-to-treat analysis among 223 participants contributing follow-up data found no differences in problem-solving skills across groups. The mean (SD) number of depressive symptom elevations among the PSE participants was 0.84 (1.39) compared with 1.12 (1.47) among the usual service participants (adjusted incident rate ratio [aIRR], 0.60; 95% CI, 0.41-0.90). In analyses stratified according to baseline depressive symptoms, PSE exerted a preventive effect among those with lower-level baseline symptoms, with a mean (SD) of 0.39 (0.84) elevations among PSE participants compared with 0.88 (1.37) among usual service participants (aIRR, 0.39; 95% CI, 0.21-0.75). However, no difference was observed among those with higher-level baseline symptoms (mean [SD] elevations, 2.06 [1.92] for PSE and 2.00 [1.91] for usual service; aIRR, 1.10; 95% CI, 0.67-1.80). Analysis of symptom scores followed the same pattern, with an adjusted mean reduction of 1.33 (95% CI, 0.36-2.29) among participants with lower-level baseline symptoms. Conclusions and Relevance The PSE intervention is efficacious in preventing depressive symptom episodes and performs optimally among those with initial low-level symptoms. Additional effectiveness studies in Head Start are necessary to develop meaningful public health programs. Trial Registration clinicaltrials.gov Identifier:NCT01298804

Many young children with developmental delay who are eligible for early intervention (EI) services fail to receive them. We assessed the relationship between depressive symptoms in mothers, a potentially modifiable risk, and receipt of EI services by their eligible children. We conducted multivariable analyses of a nationally representative sample of children eligible for EI services at 24 months using data from the Early Childhood Longitudinal Study-Birth Cohort. Maternal depressive symptoms were assessed at 9 and 24 months. Birthweight

We sought to assess the feasibility and document key study processes of a problem-solving intervention to prevent depression among low-income mothers of preterm infants. A randomized controlled pilot trial (n = 50) of problem-solving education (PSE) was conducted. We assessed intervention provider training and fidelity; recruitment and retention of subjects; intervention acceptability; and investigators' ability to conduct monthly outcome assessments, from which we could obtain empirical estimates of depression symptoms, stress, and functioning over 6 months. Four of four bachelor-level providers were able to deliver PSE appropriately with standardized subjects within 4 weeks of training. Of 12 randomly audited PSE sessions with actual subjects, all met treatment fidelity criteria. Nineteen of 25 PSE subjects (76%) received full four-session courses; no subjects reported negative experiences with PSE. Eighty-eight percent of scheduled follow-up assessments were completed. Forty-four percent of control group mothers experienced an episode of moderately severe depression symptoms over the follow-up period, compared to 24% of PSE mothers. Control mothers experienced an average 1.19 symptomatic episodes over the 6 months of follow-up, compared to 0.52 among PSE mothers. PSE appears feasible and may be a promising strategy to prevent depression among mothers of preterm infants.