Mental Health: A Report by the Surgeon General

The Elmira Prenatal/Early Infancy Project is an excellent example of a preventive intervention that targeted an at-risk population to prevent the onset of a series of health, social, and mental health problems in children and in their mothers (Olds et al., 1998 and previous years3 ). This study warrants special attention because of its positive and enduring findings, randomized, controlled design, cost-benefit analysis, and unusually long-term follow up of 15 years. The study began by focusing on pregnant women bearing their first child in a small, semirural county in upstate New York. The children of these women were considered high risk because of their mother’s young maternal age, single-parent status, or low socioeconomic level. There were four study groups to which random assignment was made. The first group received developmental screening at ages 1 and 2; the second group received screening and free transportation to health care; the third group received screening, transportation, and nurse home visits once every 2 weeks during pregnancy; and the fourth group received all of the above plus continued home visits by a nurse on a diminishing schedule until the infants were 24 months of age. The intervention focused on parent education, enhancement of the women’s informal support systems, and linkage with community services.

Women in both groups receiving home visits from nurses had many positive behavioral outcomes compared with groups that received screening only or screening plus transportation. Among the women at highest risk for caregiver dysfunction, those who were visited by a nurse had fewer instances of verified child abuse and neglect during the first 2 years of their children’s lives. They were observed in their homes to restrict and punish their children less frequently, and they provided more appropriate play materials. There were no differences between groups in the rates of new cases of child abuse and neglect or in the children’s intellectual functioning in the period when the children were 25 to 48 months of age. However, nurse-visited children had fewer behavioral and parental coping problems (as noted in the physician record). Nurse-visited mothers were observed to be more involved with their children than were mothers in the comparison groups.

A cost-benefit analysis estimated program costs (direct costs of nurse visitation, costs of services to which nurses linked families, and costs of transportation) and benefits (cost outcomes presumed to be affected by the program through improved maternal and child functioning, such as less use of Aid to Families With Dependent Children, Medicaid, food stamps, child protective services, and greater tax revenues generated by women’s working). Taking a time point of 2 years after the program ended, the net cost of the program for the sample as a whole was $1,582 per family, but for low-income families, the cost of the program was recovered with a dividend of $180 per family.

Fifteen years after the birth of the index child (13 years after termination of the intervention), women who were visited by nurses during pregnancy and infancy had significantly fewer subsequent pregnancies, less use of welfare, fewer verified reports of abuse and neglect, fewer behavioral impairments due to use of alcohol and other drugs, and fewer arrests. Their children, now adolescents, reported fewer instances of running away, fewer arrests, fewer convictions and violations of probation, fewer lifetime sex partners, fewer cigarettes smoked per day, and fewer days having consumed alcohol in the last 6 months. The parents of these adolescents reported that their children had fewer behavioral problems related to use of alcohol and other drugs.

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