In this podcast Professor David Olds talks to freelance journalist Jo Carlowe about his career, attachment and the work of Family Nurse Partnership.
David is Professor of Pediatrics and Director, Prevention Research Center for Family and Child Health, University of Colorado Department of Pediatrics, talks to freelance journalist Jo Carlowe about his career and the Family-Nurse Partnership.
David is the Keynote Speaker at the Emanuel Miller Memorial Lecture and National Conference – ‘Attachment & Early Intervention: Improving emotional wellbeing and relationships in the family, and at school.’
The title of his talk is ‘Using Randomized Clinical Trials of the Family-Nurse Partnership to Inform Policy, Practice, and Developmental Science.’
David says of his discussion: ‘I will use our experience in developing, testing, and replicating the Nurse-Family Partnership to address the following questions. How can we design early parental interventions to maximize their likelihood of working? How can we design research to build a strong evidence-base for early-intervention? How can we scale evidence-based early interventions to maximize their societal impact?’
Intro Speaker: This podcast is brought to you by The Association for Child and Adolescent Mental Health, ACAMH for short. You can find more podcasts and other resources on our website, www.ACAMH.org and follow us on social media by searching ACAM.
Interviewer: Hello and welcome to the In Conversation podcast series for The Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in psychology. Today, I’m talking to Professor of Paediatrics, David Olds, who is director at the prevention research center of family and child health at the University of Colorado Department of Paediatrics. David will be speaking at the Emanuel Miller Memorial Lecture and the National Conference in March (see lecture here from March 2019). The theme is attachment and early intervention and David will be discussing his experience in developing and testing the Nurse Family Partnership Scheme. David, welcome. Can you say a little about yourself by way of an introduction?
Professor David Olds: Sure, Jo. You know, my work has been devoted to figuring out the degree to which we can promote health and development over the life course by helping improve the conditions for pregnancy and early care of the child in the early years of the child’s life. So, in some ways, I think it’s sensible for me to reflect a little bit about my own early experience.
Interviewer: Please do.
Professor David Olds: I grew up in Ohio, in a very poor family. My father was an alcoholic and an inconsistent provider. He’d grown up in an abusive, violent family and my mother worked in a factory and was a steady, caring mother supported by a very loving, religious grandmother who lived with us. My mother eventually divorced my father and, as the oldest in the family, I found myself developing a sense of growing responsibility, both for my family and increasingly, for those around me. As an adolescent, I developed this wildly romantic idea that I might devote my life to supporting poor children in India or Africa and in high school, developed an interest in international relations. I applied to the Johns Hopkins School for Advanced International Studies and was accepted, with a full scholarship. That was a very big deal because we had nothing and so, they made it possible for me to attend a very high calibre school with a program of studies that really aligned with something that I felt very passionate about.
Interviewer: Right. Were you the first of your generation to do so?
Professor David Olds: Oh, yes. Yeah, absolutely and when I began the program in international relations in 1966, I found myself taking courses focused on international power politics, with a pretty significant focus on finding ways of building a counterforce to the Soviet and Chinese threats to the US. It was all very interesting but not something that really aligned with my sense of who I was. So, I gave up the scholarship and started taking courses in developmental psychology and ended up taking a course with a professor named Mary Ainsworth.
Interviewer: Oh, wow. Okay.
Professor David Olds: Mary was a major collaborator of John Bowlby’s, the principal architect of attachment theory and I worked in Mary’s Baltimore study of infant attachment security. All this was taking place at a point in US history when the counterculture was at its height and there was a an increased consciousness of racism and classism and social injustice. It was in that context that I began to formulate a growing sense of my personal direction, but it was really poorly formed.
I think that’s really critical in helping understand how I got from this poor family into a role that would eventually take me into the line of work that I am doing today. While I was finishing up my PhD I, worked at a non-profit organisation, south of Ithaca, New York, where I began evaluating a program for poor children in the Appalachian region of New York State. It was a developmental screening and referral service. It was in that context that I went to the agency director and said, I actually am not… First of all, we’re not going to be able to figure out conclusively, whether this program makes a difference. I said to him I honestly don’t think it will make much of a difference but I said, if you give me some time, I will work toward developing a proposal for developing an intervention that will stand a chance, I think, of making a difference and also setting it up in a format where we can estimate its effects with greater confidence.
Interviewer: When was it?
Professor David Olds: So, that began in 1976 and in 1977, we received the first funding from the Bureau of Maternal and Child Health, for the first trial of what’s now known as the Nurse Family Partnership.
Interviewer: So, to be clear, this was the creation of a program that provided a supportive relationship between trained nurses and first-time mothers?
Professor David Olds: Yes. I mean, one of the things that I focused on, one of the features of the intervention, was that we focused on women who had no previous live births and we did that because at the time, I thought that women going through these profound role changes would experience a sense of vulnerability about becoming a parent. Suddenly moving from being a student or a daughter to becoming a parent and that transition and role would create a certain kind of receptivity on their part, to offers of help and especially offers of help from someone who was really, an authority on prenatal health? What does this back pain mean? What does this discharge mean? What’s it going to be like to give birth to a fragile newborn? Nurses have a natural legitimacy, given their training , at least in the US, and my guess is in the UK as well, nurses are the most trusted professionals across the entire spectrum. It’s because of their genuine caring and their ability to address issues of physical health, which is something that virtually every individual has a sense of vulnerability about.
So, in either case, I guess the other piece of this is that I learned a lot from the nurses who joined us in developing the program. Among the things that they drove home to me, I knew this intellectually, but they really helped me appreciate just how critical it is that you have individuals who are non-judgmental and who look for individual’s strengths and can find a way of building upon strengths as a way of building a growing sense of efficacy and managing life’s challenges. Yeah.
Interviewer: Can I ask what would be, certainly with the first program but then also, when the scheme came to be known as the Nurse Family Partnership, what is a typical profile of the first-time mothers that the nurses are working with?
Professor David Olds: You know, Jo, when we begin this work in the very first trial, we didn’t know who would benefit the most and so we focused on first-time mothers and actively recruited women who were either poor, unmarried or teenaged but allowed anyone in the community who was bearing a first child who enrol in the program to avoid creating a program that was stigmatized as only for the poor or for people with problems. But one of the things we found was that the benefits, especially the benefits in terms of qualities of care-giving and child outcomes were most pronounced where those sociodemographic risks overlapped. So, we had our first indication that the benefits were most pronounced where vulnerabilities were greatest.
Interviewer: I’m going to ask you more about the trials but taking a step back. Can you tell me more about how the Nurse Family Partnership Works? What types of advice and interventions does it provide?
Professor David Olds: When we began this work, we were quite clear, Jo, about what we were trying to accomplish and if you want, the model for accomplishing those outcomes was grounded in theory. Grounded in attachment theory, grounded in human ecology theory, grounded in theories of behavioural change and it was also grounded in an understanding of developmental epidemiology. That is, what are those early behaviours or contacts that can compromise gestational development or early child health and development or mother’s own ability to manage their lives well? And they were woven together into a coherent model and those activities are grounded in the following kinds of things.
First of all, nurses spend time getting to know mothers and getting to know what their aspirations are, what they hope for themselves and it’s not uncommon, by the way, for mothers to desperately want to protect their babies. Nurses are able to leverage that motivation to help parents think about what they might do to accomplish that. So, there are three major goals that the nurses have. The first is to help women improve the outcomes of their pregnancy by helping them improve their prenatal health. That would include things like reducing tobacco use and illegal drug use and alcohol use, helping women to reflect on the qualities of their diets and to identify emerging obstetric complications so that they can have those problems, infections or other emerging hypertensive disorders treated more promptly and reliably in the healthcare system so that they don’t compromise the growing fetus.
The second is to help parents promote their children’s early health and development and especially, develop a sense of, if you want, attachment security by helping parents provide sensitive responsive care. To help parents understand what their babies are signalling to them and how to respond in ways that will create a sense of comfort on the part of the child. But also, to simultaneously, gradually promote children’s language development and growing cognitive development, an inquisitiveness and sense of the child’s own efficacy in being able to accomplish what she or he wants. All of that is woven into a set of detailed guidelines to help parents accomplish what they want in protecting their children, promoting their children’s health and development.
The third major goal is to help mothers and fathers develop a vision for themselves and to start imagining what kind of life they want for themselves in terms of being able to protect their child, financially and socially. So, nurses spend time just helping parents start to imagine what life might be like if things were better. They started guiding women to think about staying in school and finding work and, most critically, planning the timing of subsequent pregnancies because rapid success of pregnancies can compromise parent’s abilities to care well for themselves and for the firstborn and can interfere with their ability to complete their educations and find work. All of these pieces of the program are woven together. In terms of being able to address the kinds of contextual factors that compromise parents abilities to protect themselves and their children, nurses really work through with parents, things like well, to what degree are grandmothers really there and supportive and aligning with mother’s aspirations to protect the child? Or not just grandmothers but it could be other family members or friends. Are they in alignment with this desire to protect the child or are they engaged in behaviours that undermine mother’s abilities to protect herself or her child? To guide women to think about what they might do to both rely on support when it’s constructive, or to find ways of managing those other social influences when they are not so supportive. But they also work to address some of the common, obvious challenges that poor families have, such as problems with housing, homelessness, income security, food security. It’s not uncommon for mothers to have mental health problems or substance abuse problems and nurses systematically link families up with other needed health and human services in the community and create, in varying degrees, depending on the way the local systems work, a sense of shared commitment on the part of the other service providers in addressing the needs of mothers, and fathers.
Interviewer: And David, how widespread is the scheme? Does it run across all States?
Professor David Olds: Yeah. In the US, it is now in 42 States, serving about 50,000 families a year and the program, the evidence from the NFP serves as the primary evidentiary foundation for a very large investment in evidence-based home visiting, set in motion under the Obama administration ten years ago. In the meantime, we’ve supported expansion of the program in seven other societies including England, Scotland, Northern Ireland, Norway, Bulgaria, Canada, Australia, where it’s serving Aboriginal families. Outside of the US, the program is serving about 18,000 families. Young Mother in Scotland, throughout the country. It’s available in Northern Ireland in I’m forgetting how many local authorities right now and in England, it was up to 131 local authorities and it’s now dropped down to closer to 100, with some of the financial distress that’s occurred in England in recent years.
One of the things that is reassuring to me, Jo, is that the program is, one of the things I wasn’t at all sure of is whether the program would resonate to families with dramatically different cultural experiences and living in very different contexts. We see in Australia, for example, that among Aboriginal families, that the program takes hold, that families were able to adapt the program to local cultural sensibilities. And this whole notion that there is something fundamental about parent’s protection of their children, community’s protection of their children is really wide widespread. Here in the US, in American Indian communities, one of the things that we’ve learned is that, and we learned this from local tribal leaders, is that children are considered gifts from the Creator. And there is this kind of very special place played for children in the lives of communities and the lives of parents, that we think we are leveraging. This is not just nurses coming in and fixing something. Its power really comes from this alignment and this elicitation of something that is deep within all of us, from an evolutionary perspective.
Interviewer: Okay. Are you saying you have to put it into some sort of cultural framework in terms of how you apply attachment theory for it to make sense to your clients, let’s say?
Professor David Olds: Sure, of course, and I think that the basic principles hold but I think that we need to find a way of languaging this and framing it that aligns with cultural sensibilities.
Interviewer: Can you tell me a little bit about the trials that have taken place and also, the outcomes? I know there’s been a wealth of data that you have showing positive outcomes. So, perhaps you could highlight some of the ones that stand out for you.
Professor David Olds: I think there’s a couple of things that I want to emphasize, Jo, and that is that we held off for 20 years before offering up the program for public investment because I wanted to make sure that the effects of the program were replicable. It’s when you see replicated effects in randomized clinical trials, that you start to have greater confidence that these are real findings. And, so I waited in the US until we had completed the early phase of the original Elmira trial and the beginning findings from the Memphis trial were emerging before offering up the program for public investment.
Interviewer: Can you say something about the findings of those trials?
Professor David Olds: Yes. Among the things that we found is that there are consistent effects on women’s prenatal tobacco use, for example, biochemically validated reductions in tobacco use. Significant reductions in hypertensive disorders of pregnancy, significant reductions in children’s healthcare encounters for injuries. Really, most importantly, serious injuries that are revealed in our Memphis trial, where nurse-visited women or children were less likely to be seen for or hospitalized for long periods due to their experience of abusive head trauma, broken long bones, burns, the kinds of things that are indications of the children having experienced abuse and neglect. I think that one of the features of the program that’s been highlighted by independent reviewers, has been that the program has the strongest evidence of any in the world, that it prevents abuse and neglect. It’s based on a combination of both direct assessments of child protective service records and these reviews of serious medical healthcare encounters for injuries.
But I need to say that the reliance on child protective service records as a basis for determining whether the program has an effect on maltreatment, is a terrible source of data. And the reason for that is that nurse-visited women today, are ethically and legally required to report suspected maltreatment to authorities to make sure the children are protected and, in some cases, removed from harm’s way. So, in our original trial of the Elmira program, we set up a relationship with local child protective services to make sure that the kinds of conditions we were observing were not crossing the threshold that would require a report for suspected maltreatment. And so, we have evidence that nurse-visited children were identified as being maltreated at lower thresholds of severity then their counterparts in the control group. So it makes sense, of course. If you’ve got someone who’s deeply involved with a family and concerned about it, then they’re going to be required by law to make a report and the same thing really applies to even, there are massive challenges with measurement in these kinds of trials for other reasons. Even if you look at healthcare encounters. Nurse-visited women, parents, naturally become more concerned about how the children are doing. So, if the child falls and bumps his head, they’re more likely to take that child in for an evaluation in the emergency department to make sure that there’s not something more serious going on. That’s exactly what the nurses encourage parents to do. So, there is this shift in the way the healthcare system is operating and it becomes even more challenging to fully interpret findings that come from usual healthcare when access to healthcare through usual mechanisms becomes more limited.
So, in making these determinations of program impact, ultimately the most reliable indicator would be reductions in mortality. In short of that, it would be reductions in serious healthcare encounters for injuries. If you looked at the effects of the program on injuries in the Elmira or the Memphis trial, if you look at the nature of those encounters, you could say that it’s only by the grace of God that many of these children didn’t die in the control group. And so, it’s important to keep some of these kinds of measurement challenges in mind in trying to interpret the effects of early interventions of this type.
We also see, Jo, consistent effects across all trials on children’s directly measured cognitive and language development and academic achievement. Those findings are limited to though, children born to mothers who are living with adversities and who are least capable of managing those adversities. By that, we mean they have higher rates of depression and anxiety and limited intellectual functioning and limited sense that they can manage those challenges in their lives. So, the benefits again, are more pronounced where there is an accumulation of adversity in mother’s limited capacities to cope with those adversities. So, it’s important, in planning studies like this, to keep that in mind. We also see consistent effects on both teacher and parent report of children’s behavioural adjustment at school entry. We see significant reductions in children’s substance abuse in early adolescence and significant reductions in depression and anxiety among young adolescents. So, these effects are replicated across trials and this gives us greater confidence that the effects are real.
Interviewer: Looking again at the trials. Can you say a little bit about how they are influencing practice?
Professor David Olds: One of the things that’s really gratifying to me, Jo, is that I hear frequently from nurses that they will say to me I feel like I’ve spent my whole career getting to a point where I can be part of this program. I feel really blessed, in some ways, to be part of this work and I think that part of it, there is a risk, I suppose, for the program to be watered down and compromised if we don’t find a way of ensuring that the program is delivered in accordance with the essential elements of the model. One of the things that we heard in England is that many of the nurses said that this is a dramatically different way of delivering these kinds of services and that this focus on strengths-based ways of interacting with families is really, really unique and inspiring. I actually believe that some of these kinds of general approaches that is being strengths-based, building on those aspirations on the part of mothers and fathers to do right by their children and so forth, is something that we, as a society, can build upon.
So, I’m increasingly confident as I look at the way the program is delivered around the world, that there is something truly unique about the design and delivery of the program. But at the same time, that we need, and that those principles can be applied more generally, but the program needs to be protected in the sense that it’s too easy for people to simply say oh, yeah, we know how to do that. We run the risk, then, of losing it all.
Interviewer: How do you ensure it’s transferred in a way where you don’t have that watered down effect that you describe?
Professor David Olds: Well, we’ve created a model for and a requirement for new sites, for nurses to go through the education. To adhere to certain model elements, to be clear about the targeting of the program, to develop a corresponding information system that nurses use to monitor, visit by visit implementation of the program. That can be used to determine the degree to which the program is on track or off track and that kind of continuous feedback of data can be used to continuously improve the program and heighten its performance.
I guess, the other thing is that it’s in that context that we recognise that the program is not always achieving what we would like and that we need to, we have fundamental efforts that need to be set in motion to improve its implementation, but also, the fundamental design of the program. The program itself will always be a work in progress, you know. It’s evolving and we try to develop new augmentations of the model in clinically coherent, rigorous ways that align with the underlying evidentiary foundations of the core program, itself. We do this with a lot of collaboration of nurses who are in the field.
In the US, there is a National Innovations Advisory Committee made up of over 100 nurses who are working on sub topics that are designed to help us get the program right, for them to reflect on what we’re proposing. To make sure that the education and clinical support is right, to identify new challenges with the program and to make sure that whatever is set in motion is done with their deep involvement and insight.
Interviewer: So what next, is in the pipeline for the Nurse Family Partnership? Anything new or exciting that you’d like to mention?
Professor David Olds: Sure. In the US, we’re increasingly feeling that we need to step outside of the focus on women having their first pregnancies and to determine the degree to which we might produce benefits for those women who have had previous live births. Especially with a focus on those where they’ve had previous live births and have overlapping psychosocial challenges. The program moves more from a preventive framework into more of a treatment focus. There’s no question that the challenges that are brought with families having previous live births and concentrated adversities are going to be challenging. But we’re doing formative work in 29 sites in the US to help us figure out the degree to which we might be able to make a difference with this population, with the goal of laying the foundation for a multi-site randomised clinical trial of the program with this particular segment of the population.
We’re also, in the US, increasingly interested in determining the degree to which we can make a difference with women who are addicted to substances. Again, the challenges are enormous and we’re quite sober about doing this work well, but with both of these populations, where we have some hope that at least for some women in these situations, that the drive to protect their babies and themselves, can be supported in ways that will reduce the damages that these conditions are creating for themselves and their children. So, we don’t know but we’re working on them.
Interviewer: You’ll be presenting at the National Conference in March. (NB recorded in Feb 2019 – watch lecture here) Can you give a brief summary of some of the areas you plan to cover.
Professor David Olds: Sure. First of all, I intend to spend some time helping the audience understand the early origins of the program, including some part of my own personal story and leading up to the development of the NFP. But also, helping people understand the underlying developmental epidemiology and theory of the program. Understanding some of the core clinical components of the program to see how the pieces fit together. Of course, I’ll spend some time discussing the evidence in-depth and giving the audience an appreciation for the degree to which the findings cohere across trials, with a particular focus on how the findings, at least with respect to children’s health and development, are most pronounced for those families where vulnerabilities are greatest. I will spend time talking about our efforts to improve the program’s implementation and improve the underlying model, itself and hopefully, create a sense of shared commitment to pooling our resources. To make early interventions both stronger, clinically and from an evidentiary standpoint and to share with the group, some of the key lessons that we’ve learned in trying to accomplish that.
Interviewer: Finally, David. What is your take-home message for listeners of this podcast?
Professor David Olds: I think that the take-home message really should be that there’s reason for hope. There’s reason to believe that we can really make a difference in the lives of vulnerable children and families but that we need to hold ourselves accountable, both from a scientific perspective, from the standpoint of making sure that these types of interventions are delivered well and that we remain committed to getting it better over time.
Interviewer: Great. Is there anything you want to add that I haven’t asked you?
Professor David Olds: Jo, I think you have been really thorough. I think we’re good. Anything else you want to ask me?
Interviewer: I think we’ve covered everything. It feels like you must feel very proud of your work. I mean, from your aspirations as a young boy, you’ve gone a fair way to achieve what you set out to do..
Professor David Olds: I guess there’s a feeling… Yes, there is a certain kind of pride, I suppose, in that, Jo but there’s also an ongoing feeling like I’m constantly holding my breath, you know. I think that there are many ways that this kind of work can go wrong and we need to be vigilant and by that, I mean not getting carried away with ourselves. Being realistic and, at the same time, having hope.
Interviewer: Right. Thank you ever so much. Professor David Olds will be speaking at the Emanuel Miller Memorial Lecture on the National Conference, (NB watch lecture here) which focuses on attachment and early intervention, improving emotional wellbeing and relationships in the family and at school. The conference takes place on 8 March 2019 in London. You can find details on the ACAMH website, www.ACAMH.com and on Twitter at ACAMH. ACAMH is spelt A-C-A-M-H.
Close: This podcast was brought to you by The Association for Child and Adolescent Mental Health, ACAMH for short.