Sharon Landesman Ramey, Ph.D. Distinguished Research Scholar of Human Development Virginia Tech Carilion Research Institute Professor of Psychology and Psychiatry, Virginia Tech Plenary Session April 24, 2014 Emerging “Brain” Knowledge to Inform the Field of Home Visiting

Why, when, and how should home visiting protocols evolve? In an era of “evidence-based practices” to inform health and social supports for families, what are the potential risks and benefits of changing home visiting protocols? Reasons to justify changes must be compelling, including: Changes targeted to reach those for whom home visiting was less effective or ineffective New evidence since original model tested Changes will not dilute core content of the evidence-based package

Emerging Knowledge Topics to consider in home visiting How pre-conception health and planning can improve maternal & child outcomes. The ways adolescents and adults differ in decision- making (executive function and self-regulation). The importance of valuing (versus discounting) the future in making everyday choices. That maternal stress and obesity produce lasting intergenerational influences on well-being. Individual differences in receptivity to change and motivation to try new behaviors.

Pre-conception health and planning 2011: 49% of pregnancies in U.S. unintended (48% in 2001). Among 15–17 yr old mothers, 80% unintended -with increase in disparities. Chinese requirement that women prepare for pregnancy/parenting starting 1 year prior to conception. Long history of high-quality, well-intentioned prenatal programs having limited impact on pregnancy outcomes and child development.

Ways to add pre-conception health to home visiting protocols Expand idea of parent well-being to include pregnancy preparedness, minimize major life disruptions and complications. Increase information about maternal indicators of readiness for pregnancy (Lu, 2009). Make referrals when appropriate. Recognize that many home visiting programs designed for (or work best with) first-time parents. Thus, half or more will have future pregnancies.

Neuroscience of human decision-making Increasing evidence about prefrontal cortex and amygdala development from teen years through adulthood. Decision-making strategies correlate with mental health. Decision-making skills can be explicitly taught and applied to real-life situations. Risk-taking is part of decision-making.

Ways to add human decision-making evidence to home visiting protocols Tailor how information is shared, demonstrated, and applied to the age and neurocognitive profiles of parents. Include well-developed modules that teach parent decision-making related to parenting, one’s own life choices, recognizing problems early, and knowing when and how to seek help and advice. Explore the pros and cons of different types of risk-taking for parents and children.

Valuing (versus discounting) the future Time discounting is a major factor in addictive behaviors (drugs, smoking, alcohol, food, gambling). Time discounting strongly linked to socioeconomic status. New neurocognitive training interventions may help increase valuing the future. For example, short-term memory training increases future valuation and planning.

How to add valuing the future evidence to home visiting protocols Consider collecting data about how far into the future a parent is thinking Monitor addictive behaviors and non-optimal choices to minimize harm to family Incorporate time-based assistive tools to help link parenting goals and behavior to time Consider pilot-testing cognitive training modules as an adjunct to home visiting programs (e.g., short-term memory improvement)

Inter-generational stress and obesity physiology Increasing evidence about effects of maternal stressors and stress perceptions on pregnancy outcomes. Maternal stress linked to both her cardiometabolic risks and those of her child(ren). Maternal obesity predictive of multiple poor pregnancy and child outcomes (e.g., IQ at 5, child high-risk cardiometabolic profile in first 5 yrs). Evidence-based obesity reduction/exercise increase programs designed for mothers and children are available and have been proven to work.

Ways to add inter-generational stress and obesity info to home visiting protocols Create learning modules to share if mother expresses interest or shows concern for her child(ren)’s health and ability to handle stress Explore stress-reduction and exercise options as “add-ons” or referrals (high levels of interest in many community programs) Consider peer support groups and family- based or friendship-based activities designed to address these risks

Receptivity to change and adult learning styles Benefits of professional learning for childcare providers and early childhood educators influenced by ratings of “receptivity to change,” but not by their own (self) ratings. Health promotion as a field was transformed when separate motivational or receptivity to change interventions developed for use prior to treatment. Systematic consideration of home visitors’ or early interventionists” own views/beliefs as source of influence on their effectiveness warrants more study. Teen mothers in multisite home visiting program often felt their mothers were “set in their ways” and this created opposition for following through with home visitor advice they wanted to put into action.

Ways to use receptivity to change in home visiting protocols Consider adding this as specific topic (not merely implied) to portions of home visiting Engage significant others in some (or most) of the home visiting program, to promote social validation and support for new behaviors Consider testing motivational packages to use at beginning (and/’or throughout) the home visiting program to see if receptivity to change improves

The future of home visiting To have reproductive health and parenting preparedness more universally embedded in our society, educational system, and health care delivery. To have alternative forms, since much of home visiting does not occur in the home and many visits “don’t make” and high dropout rates persist. To have stronger guidelines for individual tailoring of home visiting in terms of dosage, content, review, motivational components. To link more closely and intentionally with other early experience factors known to influence child health and education outcomes.