标题：Behavioral and Socioemotional Outcomes Through Age 5 Years of the Legacy for Children Public Health Approach to Improving Developmental Outcomes Among Children Born Into Poverty
摘要：Objectives. We evaluated Legacy for Children , a public health strategy to improve child health and development among low-income families. Methods. Mothers were recruited prenatally or at the birth of a child to participate in Legacy parenting groups for 3 to 5 years. A set of 2 randomized trials in Miami, Florida, and Los Angeles, California, between 2001 and 2009 assessed 574 mother-child pairs when the children were 6, 12, 24, 36, 48, and 60 months old. Intent-to-treat analyses from 12 to 60 months compared groups on child behavioral and socioemotional outcomes. Results. Children of mothers in the intervention group were at lower risk for behavioral concerns at 24 months and socioemotional problems at 48 months in Miami, and lower risk for hyperactive behavior at 60 months in Los Angeles. Longitudinal analyses indicated that children of intervention mothers in Miami were at lower risk for behavior problems from 24 to 60 months of age. Conclusions. Randomized controlled trials documented effectiveness of the Legacy model over time while allowing for implementation adaptations by 2 different sites. Broadly disseminable, parent-focused prevention models such as Legacy have potential for public health impact. These investments in prevention might reduce the need for later intervention strategies. More than 15 million children were living below the Federal poverty line in 2009. 1 These children are at increased risk for poor health and developmental outcomes concurrently, including lower vaccination rates, 2 higher rates of severe chronic disease 3 and conditions that require medical attention, 4 and more cognitive and behavioral difficulties. 5–12 Poverty-associated stress in childhood also contributes to dysregulated cardiovascular stress responses, 13 which have been implicated in depressed immune function and the etiology of chronic diseases. 14,15 A 2002 review 16 concluded that lower socioeconomic status is reliably associated with rates of childhood injury, high blood pressure, respiratory illnesses, and active smoking. Poverty thus represents a significant risk factor for children’s health. Socioeconomic disparities in childhood health persist and magnify as the child develops. 17,18 Adolescents and adults with low socioeconomic childhoods are at greater risk for obesity 19 and heart disease, 20,21 have poorer dental health, 22 engage in more risk behaviors, and have lower academic performance. 23 As adults, they earn less than half as much and receive $826 per year more in food stamps than peers from more advantaged backgrounds. 24 In addition, poverty’s adverse effects can be perpetuated through intergenerational transmission. 25–28 This association between early socioeconomic disadvantage and long-term health makes childhood poverty a public health issue. Parents of infants and young children control much of their children’s proximal environment, including providing and modeling safe, stable, nurturing relationships, facilitating cognitively stimulating activities, using effective discipline strategies, offering nutritious foods, reinforcing and sharing healthy habits, accessing health care, and selecting playmates and other caregivers. Poverty is reliably associated with decrements in parents’ ability to provide such health- and development-promoting environments. Documented pathways of this effect include higher levels of neighborhood chaos and violence, 8,29,30 lower community social capital, 8,31 higher exposure to pollutants and toxins, 32 greater material hardship (e.g., food insecurity, inadequacy of medical care), 33 and challenges to caregiver mental health. 34 However, some parents exhibit healthy parenting despite these strong countervailing forces, 35 and positive parenting behaviors serve as protective factors for children in low-income families and neighborhoods. 36–41 Interventions to increase the number of parents who provide nurturing environments in socioeconomically disadvantaged circumstances could improve children’s short- and long-term health and development by placing vulnerable children on more optimal life-course trajectories. To produce the best return on investment, such strategies to promote human development are better targeted earlier, rather than later, in childhood. 18 Between 1994 and 1998, the Centers for Disease Control and Prevention (CDC), noting the growing evidence on poverty-associated differences in children’s cognitive and developmental outcomes, convened meetings with experts and other federal agencies to identify potentially effective public health strategies for intervening with vulnerable children and families. Prevailing evidence-based models at the time included providing high-quality, center-based educational experiences directly to preschoolers, 42–44 home visits to vulnerable mothers and infants, 45 a combination of home visiting and educational intervention, 46,47 and behavioral parent training to families with preschoolers at risk for or already evidencing problem behaviors. 48–51 The CDC sought to maximize the potential impact with this population by developing a primary prevention program for low-income parents of infants and young children, using group-based implementation in community settings to foster widespread dissemination and sustainability. Legacy for Children ( Legacy ) was designed to support mothers’ ability to engage in positive parenting behaviors and positive mother-child interactions by improving parenting efficacy and mothers’ sense of supportive community. A complete description of the study design and intervention has been provided elsewhere. 52 Legacy is being evaluated via a set of 2 randomized controlled trials ( {"type":"clinical-trial","attrs":{"text":"NCT00164697","term_id":"NCT00164697"}} NCT00164697 ) investigating the impact on children’s behavioral, socioemotional, cognitive, and language outcomes. This report contains the first results of the Legacy outcome evaluation, focusing on children’s behavioral and socioemotional outcomes, which are well-documented early predictors of long-term health. 53–58
