1. Professor of Pediatrics, Psychiatry, and Preventive Medicine University of Colorado Health Sciences Center David Olds, PhD March 18, 2004

2. Baltimore, 1970

3. NURSE FAMILY PARTNERSHIP Program with power –Make sense to parents –Solid clinical underpinnings –Nurse home visits from pregnancy through child age two Rigorously tested

4. FAMILIES SERVED Low income pregnant women –Usually teens –Usually unmarried First-time parents

5. THREE GOALS 1.Improve pregnancy outcomes 2.Improve child health and development 3.Improve parents’ economic self- sufficiency

6. Preterm Delivery and Low Birthweight Neurodevelopmental Impairment Child Abuse and Neglect Childhood Injuries Rapid Successive Unintended Pregnancies Reduced Participation in Work Force Conduct Disorder Crime and Delinquency Problems Targeted

7. Child Neurodevelopmental Impairment Emotional/Behavior Dysregulation Cognitive Impairment Program Prenatal Health-Related Behaviors Dysfunctional Caregiving Maternal Life Course Closely Spaced Unplanned Pregnancy Welfare Dependence Substance Abuse Negative Peers Antisocial Behavior Substance Abuse Child/Adolescent Functioning

8. TRIALS OF PROGRAM Low-income whites Semi-rural Low-income blacks Urban Large portion of Hispanics Nurse versus paraprofessional visitors Elmira, NY N = 400 Memphis, TN N = 1,138 Denver, CO N = 735

9. CONSISTENT RESULTS ACROSS TRIALS Improvements in women’s prenatal health Reductions in children’s injuries Fewer subsequent pregnancies Greater intervals between births Increases in fathers’ involvement Increases in employment Reductions in welfare and food stamps Improvements in school readiness

10. Elmira Maltreatment & Injuries (0 - 2 Years) 80% Reduction in Child Maltreatment (Poor, Unmarried Teens) 56% Reduction in Emergency Room Visits (12-24 Months)

11. 91011121314 100 60 50 40 30 20 10 0 Simultaneous Region of Treatment Differences (p <.10) % Abuse / Neglect Maternal Sense of Control Comparison Nurse

13. LOW-INCOME, UNMARRIED 15-YEAR FOLLOW-UP ELMIRA SUSTAINABLE RESULTS: Mothers Verified reports of child abuse and neglect 79% Behavioral problems due to drug or alcohol use 44% Arrests 69%

14. ELMIRA SUSTAINABLE RESULTS: Adolescents Arrests 54% Convictions 69% Sexual Partners 58% Cigarettes Smoked 28% Number of days consuming alcohol 51% 15-YEAR OLDS BORN TO UNMARRIED, LOW-INCOME MOTHERS

15. Cumulative Cost Savings: Elmira High-Risk Families Cumulative dollars per child Age of child (years) Cumulative Costs Cumulative savings

16. Memphis Design Urban Setting Sample (N = 1139 for prenatal and N = 743 for postnatal) 92 % African American 98% Unmarried 85% < Federal Poverty Index 64% < 19 years at intake Randomized Trial

17. Memphis Program Effects on Childhood Injuries (0 - 2 Years)  23% Reduction in Health- Care Encounters for Injuries & Ingestions  80% Reduction in Days Hospitalized for Injuries & Ingestions

18. Diagnosis for Hospitalization in which Injuries and Ingestions Were Detected Nurse-Visited (n=204) AgeLength (in months)of Stay  Burns (1 0 & 2 0 to face)12.0 2  Coin Ingestion12.1 1  Ingestion of Iron Medication20.4 4 Kitzman, H., Olds, D.L., Henderson, Jr., C.R., et al. JAMA 1997; 278: 644-652.

19. Diagnosis for Hospitalization in which Injuries and Ingestions Were Detected - Comparison (n=453) Age Length (in months) of Stay  Head Trauma 2.4 1  Fractured Fibula/Congenital Syphilis 2.4 12  Strangulated Hemia with Delay in Seeking  Care/ Burns (1 0 to lips) 3.5 15  Bilateral Subdural Hemotoma 4.9 19  Fractured Skull 5.2 5  Bilateral Subdural Hemotoma (Unresolved)/ Aseptic Meningitis - 2nd hospitalization 5.3 4  Fractured Skull 7.8 3  Coin Ingestion10.9 2  Child Abuse Neglect Suspected14.6 2  Fractured Tibia14.8 2  Burns (2 0 face/neck)15.1 5  Burns (2 0 & 3 0 bilateral leg)19.6 4  Gastroenteritis/Head Trauma20.0 3  Burns (splinting/grafting) - 2nd hospitalization20.1 6  Finger Injury/Osteomyelitis23.0 6

20. 1.5 1.0 0.5 0.0 Nurse Comparison Simultaneous Region of Treatment Differences (p <.05) 60708090100110120130 Mothers’ Psychological Resources No. Health Care Encounters with Injuries/Ingestions

21. Nurse Simultaneous Region of Treatment Differences (p < 0.05) Comparison 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0 60110120130809010070 Mothers’ Psychological Resources No. Days Hospitalized with Injuries/Ingestions

22.  31% Fewer Closely Spaced (<6 months) Subsequent Pregnancies  50% Fewer Subsequent Therapeutic Abortions  30% Fewer Subsequent Admissions to Neonatal Intensive Care  3.64 Fewer Months of Welfare Use  32% Increase in Father Presence in Household  50% Increase in Marriage Enduring Effects on Maternal Life-Course in Memphis Kitzman, Olds, Sidora, et al. Journal of the American Medical Association, April 19, 2000 1983-1989.

23.  Higher IQ’s  Better language development  Fewer mental health problems Growing Effects on Child Development Memphis 6-Year

24. Denver Design 735 Families Nurses N=236 Controls N=255 Paraprofessionals N=244

25. Denver Maternal Characteristics Married13% Mexican American46% African American17% European American (Non-Hispanic)35% Monolingual Spanish Speakers 4% Cigarette Smokers25%

26. Pattern of Denver Program Effects Maternal and Child Functioning ComparisonParaNurse

27. 100 0 -100 -200 -300 -400 Change in Cotinine From Intake to End of Pregnancy Control -36.6 Para -73.8 Nurse -235.6* *P <.05 Change In Cotinine

29. Preschool Language Scale 21 months (Born to Low-Resource Mothers) P C-N =.04

30. Child Executive Functioning Index 4-Years (Born to Low-Resource Mothers) P c-p =.06, ES =.29; P c-n =.000, ES =.47

31. Child Activity Level - 4-Years (Born to Low-Resource Mothers) P c-n =.02 ES =.39

32. Now operating in over 250 counties in 23 states, serving over 12,000 families per year. NATIONAL REPLICATION

33. Nurturing Community, Organizational, and State Development Training and Technical Assistance Program Guidelines Clinical Information System Assessing Program Performance Continuous Improvement FROM SCIENCE TO PRACTICE

34. Effective Replication of the NFP

35. 13 3 77 46 5 1 3 11 2 1 1 30 4 1 6 1 2 23 2 1 3 8 * Numbers indicate number of counties in which the program serves clients Communities Served as of January 2004 1

36. Typical Sources of Funding  Medicaid  TANF  Child Welfare  Maternal and Child Health  Juvenile Justice