Dr. Adriana Weisleder and colleagues, in a study being released this week in Pediatrics (10.1542/peds.2015-3239) have conducted a remarkable randomized controlled trial that examines the impact of two positive parenting interventions, as compared to routine care, on socioemotional outcomes of toddlers from low-income predominantly Hispanic families.Each of the two evidence-based interventions, “Video Interaction Project” (VIP) and “Building Blocks” (BB) has been previously shown to promote responsive parenting and reduce maternal depression, but neither had been specifically trialed as an intervention to promote socioemotional development. In the VIP group, an interventionist meets with families after well care visits to videotape a 5-7 minute play/shared reading interaction (using a gifted toy or book), followed by watching the video together, and then by a “debriefing” to promote self-reflection and generalization of positive interactions to the home environment. In the BB group, parents received monthly by mail a book or toy and a newsletter that shared activities that could be used to meet specific developmental goals.
The authors report very good adherence, with 67% of families completing more than half of the interventions. Outcome measures at 14 and 24 months included maternal interview with subscales of the ITSEA (Infant-Toddler Social and Emotional Assessment-revised) related to attention, play and separation distress, and at 36 months included maternal interview with subscales of the BASC-2 (Behavior Assessment System for Children, 2nd edition) related to social skills, attention problems, hyperactivity and aggression. All children including the control families received the “Reach out and Read” (ROR) intervention during well care visits. This study was truly an ambitious undertaking, particularly since >90% of parents were low income, >50% were not high school graduates, and 34% were classified as at increased psychosocial risk due to, for example, homelessness, prior mental illness or other hardship.
The results are highly encouraging, and I urge you to read the paper to understand the subtleties. The VIP was more successful than routine care (control) in promoting measured socioemotional development, with significantly reduced hyperactivity and externalizing problems at 36 months, and with a “dose response” for each additional VIP visit after the first 5 visits. Although BB showed improvements in imitation and play between 14 and 24 months, the big winner was VIP. For families classified as at increased psychosocial risk, just 4 families would need to receive VIP to prevent a single child from being in the “at risk for hyperactivity” category, and just 5 families would need to receive VIP to prevent one child from being categorized as “at risk for externalizing problems”- a truly phenomenal finding.
My immediate thought after reading this study is that I need to find a way to bring this intervention (VIP) to my own clinic. The authors quote a figure of $150-200 per child per year. However, I note that we would have to budget, train and hire the interventionist, who is a degreed individual. We would need this person to have excellent availability, in order to support the continuity that characterized the VIP study , with the potential for meaningful amounts of interventionist downtime, depending on clinic show rates and scheduling. Could we have him/her in the waiting room serving as a facilitator or reader during down time?
Probably the answer is yes, though volunteers are a lower budget solution for the waiting room role. In order to hire the interventionist(s), we would need to make a case to administration for a long-term investment in our patients lives and outcomes, which could be bolstered, potentially, by additional follow up data: are recipients of VIP more likely to enroll their children in Head Start;are their children more likely to stay in school and graduate; and are they less likely to have educational and attentional problems that come to medical attention or interfere with graduation?
It is cliché to say that more research is needed, and certainly the results that Dr. Weisleder and colleagues report are convincing and satisfying to me as a clinician, but more data might increase the feasibility of broadly introducing VIP into urban and low-income clinics across the country. I hope the authors continue this vein of study, and commend them for the excellent and innovative work reported here.
