Research Project 1
Child maltreatment represents a pathogenic relational environment that confers significant risk for maladaptation (Cicchetti & Toth, 2015). The deleterious sequelae accompanying child maltreatment result in adverse physical and mental health consequences during childhood, as well as initiate a negative developmental cascade that continues throughout the life course (Masten & Cicchetti, 2010). The proximal environment involving the nuclear family, as well as more distal factors associated with the community and culture more broadly, transact to undermine normal, biological and psychological developmental processes in these vulnerable children (Cicchetti & Lynch, 1993). Developing early preventive interventions to reduce harsh/insensitive parenting, promote positive mother-child relations, and prevent child abuse and neglect are thus of high public health significance. Given the lifelong cascades that accompany maltreatment, the provision of preventive interventions to at-risk mothers is highly significant (Toth, Petrenko, et al., 2016). Promise examines whether adding Child-Parent Psychotherapy (CPP) to community home visitation (CHW) intensifies intervention results and positive outcomes compared with CHW support alone. We will determine when these interventions are optimally delivered (beginning prenatally or postnatally), the optimal duration of services (6 vs. 12 months), mechanisms of action (mediator analyses), and determine which intervention strategy works best for mothers with varying risk factors (moderator analyses).
CPP has demonstrated efficacy in transforming disorganized attachments in maltreated infants to secure attachment organizations (Cicchetti, Rogosch, Toth, 2006) that endure one year post intervention (Stronach et al., 2013). However, mechanisms of action and parenting outcomes have yet to be determined. CPP holds promise as an early intervention that improves parenting and prevents child maltreatment, yet further work is needed to identify issues such as the processes through which change occurs and for whom specific forms of treatment delivery are most efficacious. Attention to these dimensions will significantly advance intervention feasibility and community uptake. Findings will yield greater insight into the mechanisms of change and the interrelations between biological and psychological processes.
Promise Specific Aims are:
Aim 1. To evaluate whether CPP delivered prenatally, at 3 months postpartum, or both, to high-risk low-income women promotes sensitive and responsive parenting, fosters a secure mother-infant attachment relationship at child age 1 year, and protects against child maltreatment, beyond CHW home visitation alone.
Hypotheses: Mothers who receive CPP will demonstrate more sensitive and responsive parenting at child age 9 months and their infants will evince more secure mother-infant attachment and developmental competencies and fewer instances of child maltreatment at child age 1 year, compared to mothers/infants randomized to CHW home visitation alone.
Aim 2. To evaluate the efficacy of different implementation strategies for CPP in combination with CHW.
Hypotheses: Each of the three individual CPP intervention strategies (i.e., 12 months CPP, brief prenatal CPP, brief postnatal CPP) will demonstrate superior outcomes compared to CHW alone. Overall, mothers/infants in the 12 months CPP condition will show more positive outcomes than those in the 6 months CPP that begins prenatally is expected to be superior to CPP that is initiated postnatally.
Aim 3. To identify the significant mechanisms of CPP preventive intervention effects. We will investigate three primary pathways of CPP efficacy: mothers’ improvement in 1) internal representations, 2) parenting cognitions, and 3) stress responsivity.
Hypotheses: The CPP group will show greater improvements in maternal attachment representations, parenting cognitions, and stress reactivity, which will protect against child maltreatment and predict superior parenting and child outcomes at one-year post-intervention follow-up compared with CHW alone.
Aim 4. To increase precision in identifying for whom each CPP intervention strategy (i.e., 12 months CPP, brief prenatal CPP, brief postnatal CPP) may be particularly efficacious, we will examine whether maternal characteristics at baseline (e.g., maternal depression, trauma history and intimate partner violence (IPV)) moderate the efficacy of implementation strategies.
Hypotheses: Mothers without a history of maternal maltreatment, depression, or IPV will benefit from the shortened versions of CPP, whereas mothers with higher levels of risk will require more intensive CPP preventive intervention (i.e., 12 months CPP).
Research Project 2
Adult Health Study Specific Aims:
Research on the sequelae of child maltreatment historically has focused predominately on mental health outcomes across the lifespan. However, research on child abuse and neglect effects on physical health suggest that maltreatment is associated with other adverse health outcomes related to allostatic overload, leading to increased morbidity and mortality. For example, maltreatment predicts increased hospital-based treatment of asthma, cardiorespiratory, and infectious disease in childhood (Lainer et al., 2009). Early child abuse has been linked to more health-related symptoms (e.g., sleep, eating, general health status), higher body mass index (BMI), obesity, and compromised immune system functioning in childhood and adolescence (Cicchetti, Miller, & Rogosch, in press; Danese et al., 2012; Miller, Chen, & Parker, 2011; Rogosch, Dackis & Cicchetti, 2011; Shirtcliff, Coe & Pollak, 2009). Furthermore, health liabilities extend into adulthood, as child maltreatment predicts adult cardiovascular disease, elevated inflammation levels, type II diabetes, HIV risk, self-reported physical symptoms across a range of organ systems, and decreased longevity (Carroll et al., 2013; Danese et al., 2007; Felitti et al., 1998; Widom et al., 2012; Wilson & Widom, 2011). Moreover, child maltreatment has been linked to shortened leucocyte telomere length and maltreatment may influence cellular aging (Asok et al., 2014; Drury et al.,2012; Shalev et al., 2012; Tyrka et al, 2010).
Understanding adult health outcomes within a developmental, lifespan framework holds substantial promise for determining the progression of liabilities ensuing from child maltreatment. The proposed research capitalizes on an existing large cohort of individuals with comprehensive child maltreatment determinations and multi-domain, multi-informant, multi-level assessments of functioning in childhood, including neuroendocrine regulation. Linking parameters of child maltreatment to variation in childhood adaptation and subsequent multi- level adult outcomes (allostatic load, epigenetic modifications, physical and mental health) has high public health significance. The Healthy People 2020 goals include multiple social determinants of health, which cover a host of the variables included in this proposal. In addition to the obvious targets of reducing homicides and physical assaults, integration of biological and psychological processes into developmental models of adult health holds great promise for elucidating long-term sequelae of child maltreatment.
To improve the health and well-being of maltreated children over the life course, our specific aims are to:
Aim 1. Evaluate the effects of child maltreatment on adult cumulative stress, personal resources, allostatic load, epigenetics, physical health, and mental health in a sample of maltreated and nonmaltreated children followed longitudinally. The influence of variation in child maltreatment experiences (onset age, chronicity, subtypes) also will be examined.
Hypotheses: Individuals followed into adulthood who experienced child abuse and neglect will have higher cumulative stress, fewer personal resources, higher allostatic load, greater epigenetic modifications (methylation/methylation age; telomere shortening), and poorer physical health and mental health status than individuals without child maltreatment history.
Aim 2. Examine the inter-relationships among cumulative stress, personal resources, allostatic load, epigenetics, physical health, and mental health in adults with and without childhood maltreatment histories.
Hypotheses: Allostatic load and epigenetic modifications will be more strongly related to physical and mental health outcomes in adults who were maltreated compared to those without maltreatment. Further, we hypothesize that latent profiles characterized by patterns of high cumulative stress, low personal resources, high allostatic load, greater epigenetic modifications, and poor physical and mental health will be more prevalent within the maltreated group.
Aim 3. Evaluate genetic moderation of the effects of child maltreatment on adult allostatic load, epigenetic modifications, physical health, and mental health.
Hypotheses: Genotypic variation will moderate the effects of child maltreatment on adult allostatic load, epigenetic modifications, physical health, and mental health, with specific gene variants related to more compromised outcomes within the maltreated group.
Aim 4. Examine childhood psychosocial adaptation markers and neuroendocrine regulation as prospective mediators of child maltreatment effects on adult physical health and mental health outcomes.
Hypotheses: Childhood psychosocial adaptation and neuroendocrine regulation will serve as mediators between child maltreatment history and adult cumulative stress, personal resources, allostatic load, epigenetic modifications, and physical and mental health.