Pediatric primary care, which has the potential to provide low-cost parenting interventions that can be applied population-wide beginning early in infancy, represents a significant opportunity for enhancing developmental trajectories among children from families with low SES, who are already at risk. Both of the interventions studied in this trial, VIP and BB, had effects on aspects of parent-child interaction critical to early development.
Regarding our first hypothesis, VIP and BB, which begin in early infancy, were associated with enhanced parent-child interactions at 6 months. Our findings represent a generalization of those from a prior RCT of VIP,11,12
reflecting varying interventions across a sociodemographically broader range of families. These findings are important because they suggest that pediatricians should consider intervening with families beginning in early infancy. We note that this analysis took place at 6 months, the age at onset of ROR, which precluded direct assessment of the effects of VIP and BB beyond that of standard ROR. Analyses of the cohort at later ages will enable us to determine whether increasing intensity of intervention will result in enhancement of long-term trajectories related to parent-child interaction and child development.
Regarding our second hypothesis, VIP, with greater intensity, had effects on parenting that were greater and more consistent than those of BB. For VIP, effects were found across all domains of verbal interaction, including provision of toys, shared reading, teaching, and parental verbal responsivity; for BB, effects were found primarily related to provision of toys and reading. Examples of specific effects likely to be clinically important included initiation and frequency of reading, interactions, naming of objects, telling stories, and talking together about surroundings. Compared with controls, the VIP families spent nearly twice as many minutes per day reading aloud. Compared with the BB families, the VIP families had statistically stronger effects for teaching (parental involvement in developmental advancement) and provision of infant toys for the sample as a whole and stronger effects for parental verbal responsivity for mothers with literacy levels of ninth grade or higher. The effects of VIP were further supported by within-group analyses showing associations between visit attendance and both teaching and verbal responsivity. It is not clear why similar within-group findings were not present for reading aloud, given our robust between-group differences in this domain. Ongoing study of the cohort will assess whether effects are also found on early development and school readiness, as have been previously shown in a prior RCT of VIP.11,12
As with ROR, the targeted nature of VIP and BB may represent an important factor in their being associated with enhanced parenting outcomes without need for home visits. Results of this study stand somewhat in contrast with those32,33
regarding Healthy Steps for young children, a pediatric primary care intervention program that addresses parenting broadly but has found fewer effects on shared reading and play. Our study of VIP and BB, together with prior studies of ROR and Healthy Steps, suggests that a targeted approach may be preferred for primary care interventions to promote parent-child interaction and early child development.
Given the likely lower cost of targeted pediatric primary care interventions compared with home-based programs,34
cost-effectiveness analyses will be needed to better understand implications for public health policy. Such analyses will provide data regarding whether pediatric interventions should be used for the population as a whole or for specific at-risk populations.
There were 3 main limitations to this study. First, there was larger-than-expected loss to follow-up at 6 months because of limitations in resources, which led us to prioritize later assessment points. The threat to validity resulting from loss to follow-up may have been limited because assessed participants were equivalent across groups for all measures. Second, results at 6 months were based on parent report, which can be subject to biases. However, StimQ has been shown to be reliable and valid, and convergent results regarding shared reading were found using 2 different types of interviews (a structured interview [StimQ] and an open-ended reading diary). Later assessments will also include observational measures based on videos made of parents and children. Third, participating mothers were primarily first-generation Hispanic/Latino immigrants. Results may not be generalizable to families with other sociodemographic characteristics.
This study showed limited effects for families scoring in the lowest third of word reading in this low-SES, at-risk sample, consistent with previous findings in studies of VIP.10,11
Although interventions such as VIP and BB may have important effects on most families with low SES, who are already at risk, other approaches (higher intensity or conceptually different) may be necessary in families with the lowest levels of education and literacy.
In conclusion, 2 interventions provided in pediatric primary care for families with low SES, namely, VIP and BB, resulted in enhanced parent-child interactions critical for early development and school readiness. These interventions began early in infancy and used innovative strategies to support enhanced interactions, including videotaping with self-reflection in VIP and parent recording of written observations and plans for both interventions. Refinement and dissemination of pediatric primary care interventions can play an important role in addressing the public health issue of school readiness and educational achievement in at-risk families.