Exploring the Relationships Between Maternal Mental Health Symptoms and Young Children’s Functioning in a Low-Income,Minority Sample

Poor maternal mental health, including depression and high stress levels, can negatively impact many domains of child development, particularly among low-income, ethnic minority families experiencing multiple stressors. Low-income minority mothers, particularly Hispanic mothers, are also at increased risk of experiencing exposure to community violence and other types of trauma. However, studies exploring the additional impact of maternal trauma symptoms on children’s functioning are rare. This study aims to address this gap by examining the impact of maternal trauma symptoms on young children’s functioning in a low-income, predominantly Hispanic sample through the mechanisms of maternal depressive symptoms, and mother’s experiences of parenting stress and strain. The sample consisted of 158 biological mothers (58% Hispanic, 13% African American, 5.7% White American) who were participating in community-based mental health treatment for their children (M_AGE?=?3.7, SD?=?1.2). Mothers completed questionnaires providing information on their children’s behaviors and their own mental health and stress levels at intake. Path analysis indicated that there was a significant indirect effect of maternal trauma symptoms on children’s behavior problems through maternal depressive symptoms and maternal stress in the parent-child relationship (β?=?0.09, p?<?0.01). In addition, there was a direct effect of maternal trauma symptoms on children’s behavior problems (β?=?0.32, p?<?0.001). The results suggest that maternal trauma symptoms, in addition to maternal depressive symptoms, contribute to poor maternal and child functioning.     

Emotion Regulation in Families of Children with Behavior Problems and Nonclinical Comparisons

The current study compared parents’ emotion regulation (ER) in clinical (those with a child with externalizing behavioral problems) and low-risk comparison families. Additionally, mediation models were explored with parent ER predicting child behavior problems through child ER. Participants were 60 families with children (71.7% boys; 73% Caucasian) ages 2 through 8 years (M?=?4.62; SD?=?1.69) from a rural population in the United States: 34 clinical families referred for parent training and 26 nonclinical families. A blocking design was used to balance the two groups on key demographic characteristics. Parents’ and children’s ER was assessed using parent-report surveys and structured behavioral observations. Analyses indicated higher rates of parental emotion dysregulation (specifically, more difficulty when upset with achieving goal-directed behaviors, p?=?.01, d?=?0.67; controlling impulses, p?=?.01, d?=?0.64; limited use of ER strategies, p?=?.02, d?=?0.62; and more negative verbalizations to their child during the observed task, p?<?.01, d?=?0.73) and child emotion dysregulation (specifically, more difficulty as reported by parents, p?<?.01, d?=??2.42) in the clinical group. Mediational analyses indicated there were indirect paths from parental ER to children’s behavioral problems through child ER. Findings from this research suggest a need to measure and target ER in both parents and their children when working with families who are referred for treatment of child behavior problems.     

Relationship between Disabilities and Adoption Outcomes in African American Children

Although many children adopted from the public child welfare system have special needs, little is known about the experiences of African American adopted children with disabilities and their families. The purpose of this study is to explore different categories of disabilities, including chronic health issues; emotional, mental, or behavioral (EMB) disorders; and intellectual or developmental disabilities (IDDs) on adoption outcomes in a sample of African American children. Data were from the Post-Permanency Round II Survey collected in 2008. A random sample of 412 adoptive parents or legal guardians self-reported their children’s disability diagnoses and family caregiving experiences. Hierarchical regression modelling was used to investigate the relationship between child disability and child and parental outcomes. Results indicated that chronic health issues (β?=?.10, p?<?.05), EMB disorders (β?=?.16, p?<?.01), and IDDs (β?=?.12, p?<?.05) were positively associated with parental burden. In addition, asthma (β?=?.10, p?<?.05), from the larger physical health issue category, was also associated with parental burden. However, none of the disability categories was significantly related with caregiver commitment or adoption dissolution. Future research should disentangle the definitions of special needs or disabilities.     

The Nurturing Program: An Intervention for Parents of Children with Special Needs

Evidence-based psychosocial family interventions enhancing empathy and empowerment are particularly beneficial to families of children who have developmental disabilities. This study assessed the effectiveness of an intervention called the Nurturing Program for Parents and Their Children with Special Needs and Health Challenges (SNHC). Eighty-seven families were enrolled and randomly assigned to a control or treatment group. Forty-six families in the control group received individualized case management (CM) services and forty-one families in the treatment group were assigned to 12 sessions of the SNHC curriculum along with case management services. Before and after the intervention, participants in both conditions completed the Adult and Adolescent Parenting Index-2 assessing parents’ attitudes toward child rearing and the Family Empowerment Scale (FES) measuring family empowerment. Caregivers in the intervention condition improved in empathy towards children’s needs, F(1, 54)?=?4.52, p?=?.04; and all families, both control group and treatment group, improved their attitudes towards the use of corporal punishment by posttest, F(1, 54)?=?6.56, p?=?.013. Also, all caregivers increased in their empowerment over the course of the intervention, F(1, 50)?=?13.28, p?=?.001. Attrition, 22–26% among CM and 51–56% among SNHC+CM, limited generalizability as did participants not completing all SNHC sessions. Despite these limitations, findings suggest that early interventions catering to families of children with developmental disabilities have a positive impact on parenting. To varying degrees, both conditions provided caregivers with tools that positively affected the quality of the parent–child relationships and promoted empowerment.     

Early Feeding,Child Behaviour and Parenting as Correlates of Problem Eating

Mealtimes are a common source of stress for families. Examining factors related to problem eating may provide markers by which to identify families requiring assistance and salient targets for treatment. The current study investigated parenting practices and cognitions, generalisation of child behavioural issues, and early feeding history as they relate to problem eating in typically developing young children. We compared a community sample of 105 parents of 1.5–6-year-old children via survey and observation with 96 parents seeking treatment for their child’s problem eating. History of problems with breastfeeding, χ²(1)?=?3.88, p?=?.049, and the transition to solids, χ²(1)?=?7.27, p?=?.007, were more common among problem eaters than comparisons. Problem eaters had a greater number of problem behaviours outside of mealtimes, F(1181)?=?10.88, p?=?.001, though not more frequently than comparisons and not to clinical levels, F(1181)?=?1.81, p?=?.181. Parents of problem eaters reported more unhelpful mealtime parenting strategies, F(1155)?=?22.59, p?<?.001, yet general parenting style was similar by group, F(1187)?=?0.42, p?=?.527. Parents’ cognitions about mealtimes, F(1155)?=?119.81, p?<?.001, including mealtime-specific self-efficacy, F(1155)?=?171.30, p?<?.001, were poorer amongst problem eaters, and were the only factors to predict problem eating in the total sample. General parenting self-efficacy was poorer in parents of problem eaters (Behaviour: F(1187)?=?42.36, p?<?.001; Setting: F(1187)?=?10.64, p?=?.001). Evidence of feeding issues in infancy may support early detection of and intervention for later problem eating. The significance of broader child behaviour is less clear. Parent factors, particularly those specific to mealtimes, and cognitive in nature (including mealtime parenting self-efficacy) clearly differentiated the groups, and represent important targets for intervention.     

Maternal Depression in Families of Children with ADHD: A Meta-Analysis

Although research has demonstrated a relationship between maternal depression and child attention deficit/hyperactivity disorder (ADHD); the strength of the relationship is currently unclear. The results of some studies have found a strong association between maternal depression and child ADHD, while other studies have found little or no association. A meta-analysis was conducted to clarify the strength of the association between maternal depression and child ADHD. The current study included 51 published and unpublished studies that included a quantitative comparison between maternal depression and child ADHD. Mothers of children with ADHD had significantly higher levels of depressive symptoms than mothers of children without ADHD (d?=?0.58; 95% CI [0.43, 0.74]; p?<?.001; k?=?18). The relationship between maternal depressive symptoms and child ADHD symptoms was moderate (r?=?.22; 95% CI [.17, .28]; p?<?.001; k?=?21). 17.11% of mothers of children with ADHD currently met criteria for a depressive disorder (95% CI [11.95, 23.89], p?<?.001, k?=?19). The DSM version used to evaluate child ADHD status was the only moderator that was statistically significant (p?=?.021, k?=?15). Specifically, studies that used the DSM-III or DSM-III-R were associated with larger effect sizes than studies that used the DSM-IV or DSM-IV-TR. The results suggest that clinicians should screen for the possible co-occurrence of maternal depression when working with families of children with ADHD.     

A Psychometric Evaluation of the Behavioral Inhibition Questionnaire in a Non-Clinical Sample of Israeli Children and Adolescents

This study examined the psychometric properties of a Hebrew version of the Behavioral Inhibition Questionnaire (BIQ) in a non-clinical sample of Israeli children and adolescents. We produced a Hebrew translation of the BIQ and collected 227 responses to it from parents of children aged 4–15. Some respondents in the larger sample also completed the Screen for Child Anxiety Related Emotional Disorders (SCARED) questionnaire (n?=?91) and the Conners’ Abbreviated Parent-Teacher (CONNERS) questionnaire (n?=?39), in addition to the BIQ. Lastly, 21 children of BIQ respondents (aged 8–14) completed a self-report version of the questionnaire. Confirmatory factor analysis (CFA) was performed to assess how well the established six correlated factor model of the BIQ applied to the sample data. The Hebrew BIQ demonstrated good internal consistency (Chronbach’s α?=?.94, n?=?227) and 3 month test–retest reliability, (r?=?.95, p?<?.001, n?=?21). It also showed both convergent validity, as scores on the BIQ were correlated with the SCARED (r?=?.66, p?<?.01. n?=?91), and discriminant validity, as BIQ scores were not correlated with the CONNERS (r?=?.24, n?=?39). Finally, mother reports of BI were significantly correlated to child reports of BI via the BIQ (r?=?.60, p?<?.01, n?=?21). Thus, through this preliminary study we demonstrated that the Hebrew version of the BIQ is an effective tool for screening for BI among Israeli children, making it a useful instrument for future research.     

Parents’ Intelligence Mindsets Relate to Child Internalizing Problems: Moderation Through Child Gender

Parental belief systems can strongly influence children’s affect, behavior, and mental health. However, associations between specific kinds of parental beliefs and children’s mental health have not been thoroughly explored. One relevant belief system is parental intelligence mindset: beliefs about the malleability of intelligence. Children of parents who view intelligence as static (known as a fixed intelligence mindset), rather than malleable through effort (known as a growth intelligence mindset), experience more academic, self-regulatory, and motivational difficulty. However, associations between parental intelligence mindset and child mental health problems are unclear. Accordingly, we tested whether parents’ intelligence mindsets related to internalizing problems in their children (N?=?131, ages 5–8). Overall, parents with stronger fixed intelligence mindsets had children with greater internalizing problems, particularly social anxiety (characterized by fear of negative evaluation). Results further revealed that parents’ fixed intelligence mindsets were associated with overall internalizing problems and depressive symptoms in boys, but not girls. Results are the first to suggest and parse direct links between parents’ intelligence mindsets and youth internalizing problems.     

Family Exploration: The Contribution of Stability and Change Processes

Building upon the redefinition of exploration as a family process, this study analyses how the processes of family stability and change may favour exploration by members of multiple family relational contexts. Sixty non-clinical family triads (mother, father, child) participated in an experimental observational study and were video-recorded while playing in different interactive configurations. The children (37 females and 23 males) were 4–5 years old (M?=?55 months). The mothers’ ages ranged from 29 to 45 (M?=?38) and the fathers’ ages ranged from 29 to 46 (M?=?39). All the parents were employed and were living together. All participants were Caucasians of Italian nationality. Using the Triadic Interactions Analytical Procedure (TIAP), the family morphostatic processes and the family morphogenetic processes were analysed in relation to the family members’ exploration. Data analyses showed that family stability continual construction (morphostasis) and family change (morphogenesis) involve different interactive and relational dynamics (χ²(8)?=?13.84, p?>?.05; CFI?=?.97, TLI?=?.94, SRMR?=?.06), even if they are intertwined processes (p?<?.001). Both morphostatic and morphogenetic processes were correlated to the level of exploration showed by family members (respectively r?=?.32, p?<?.05, and r?=?.59, p?<?.001), even if the morphogenetic processes had a stronger relation with family exploration (z?=?1.85, p _one-tailed ?<?.05).     

Mothers’ Mental Health Treatment Associated with Greater Adolescent Mental Health Service Use for Depression

Despite concerns surrounding depression in adolescence and the existence of effective treatments, adolescent depression often goes untreated. In 2014, only 41.2% of adolescents experiencing a major depressive episode (MDE) received mental health treatment. Parents play a key role in adolescents’ treatment utilization. We examined whether among mothers with any mental illness, mothers’ utilization of mental health treatment was associated with greater likelihood of their adolescent children who experienced an MDE receiving mental health treatment. Using nationally representative data from the National Survey on Drug Use and Health (2008–2014), we performed logistic regression analysis to model the odds of adolescents (aged 12 to 17 years) with a past year MDE receiving any mental health treatment in the past year as a function of their mothers’ mental health treatment utilization in the past year, adjusting for control variables. The rate of adolescent treatment utilization was 66% when mothers had utilized treatment, as compared to 45% when mothers did not utilize treatment (p?<?0.001). The odds of an adolescent with an MDE receiving mental health treatment were two times greater when the mother received mental health treatment as compared to adolescents whose mothers did not receive any mental health treatment (OR?=?2.09, 95% CI [1.04, 4.17]). There was no effect of adolescent gender (OR?=?1.15, 95% CI [0.40, 3.28]) or interaction between gender and mothers’ treatment (OR?=?0.95, 95% CI [0.26, 3.46]). Barriers to adolescent mental health treatment may be lower when mothers receive mental health treatment.     

Impact of Physical Abuse on Internalizing Behavior Across Generations

This study investigated the multigenerational impact of mothers’ own exposure to physical maltreatment on internalizing symptoms in her child after accounting for her parenting practices, depression, and the child’s own exposure to stressful life events. Children (n?=?101, ages 5–16), predominantly African American, were recruited into this cross sectional study using ethnographic mapping and targeted sampling for high-risk neighborhoods. Mothers reported retrospectively on their own exposure to physical maltreatment in childhood, their parenting practices, as well as current depressive symptoms. Maternal report of her child’s exposure to stressful life events and child behavior was also collected. Maternal childhood exposure to physical maltreatment was significantly associated with her child’s internalizing symptoms (p?=?.004); this effect remained after accounting for child sex, maternal depressive symptoms, harsh parenting practices, and the child’s own exposure to stressful life events. Formal tests of mediation through these pathways were non-significant. Findings suggest mothers’ experience of childhood maltreatment contributes uniquely to children’s internalizing symptoms, potentially through previously uncharacterized pathways. Examination of additional behavioral, psychosocial and biological pathways may help better describe the multi-generational effects of child maltreatment.     

Distance-Delivered Parent Training for Childhood Disruptive Behavior (Strongest Families™): a Randomized Controlled Trial and Economic Analysis

Disruptive behavior disorders are prevalent in youth, yet most children with disruptive behavior do not have access to timely, effective treatment. Distance-delivered service (e.g., via telephone, Internet) can overcome several barriers to care. This study tested the effectiveness of a 12-week parent training program, Strongest Families? Parenting the Active Child, delivered via written material, skill-based videos, and telephone coaching sessions, as compared to usual care in reducing child externalizing behavior. Participants were 172 primary caregivers of a 6- to 12-year-old (29% girls; M age?=?8.5 years) recruited from community children’s mental health clinics. Participants were randomized to either Strongest Families? or usual care and completed measures of child externalizing behavior, parenting practices, parent distress, and intervention services consumed at baseline and 5-, 10-, 16-, and 22-months post-baseline. Growth curve analysis showed significant reductions in externalizing behavior in both conditions over time. Improvements were significantly greater at 10 months in the Strongest Families? condition (d =?0.43). At 22 months, however, the differences were not significant and small in magnitude (d =??0.05). The intervention decreased inconsistent discipline significantly more than usual care. Parents in both conditions showed significant reductions in distress. We also conducted a cost-effectiveness analysis to assess the value for money of the Strongest Families? program versus usual care. Distance parent training is a promising way to increase access to, and reduce costs associated with, mental health care for families with a child with disruptive behavior.     

Antisocial Process Screening Device Subscales Predict Recidivism in an Australian Juvenile Offender Sample

The present study is the first to examine the psychometric properties of the self-report Antisocial Process Screening Device (APSD-SR), and the predictive utility of its subscales for reoffending, among Australian juvenile offenders (N?= 308, M age = 17.00, SD?=?1.49). Exploratory factor analysis supported a modified three-factor structure in which four items loaded differently to prior studies. Total APSD-SR and modified subscale scores were positively associated with criminal history and mental health problems (e.g., internalizing and externalizing problems, alcohol and substance abuse/dependence). Survival analyses indicated that youth scoring high on the APSD-SR total score were faster to reoffend nonviolently (Hazard Ratio [HR]?= 1.31, p?=?.0003) and violently (HR?=?1.42, p?=?.0003) than those scoring low. Whereas the modified grandiose-manipulative subscale predicted faster time to nonviolent recidivism (HR?=?1.18, p?=?.026) as a single predictor, when all subscales were simultaneously entered into the model only callous-unemotional (CU) traits and impulsivity predicted nonviolent recidivism (HR?=?1.19, p?=?.026 and 1.22, p?=?.015, respectively), and only impulsivity predicted violent recidivism (HR?=?1.26, p?=?.014). Findings inform current understanding of the relative contribution of adolescent psychopathy dimensions to designating a particularly high-risk group of Australian youth in custody.     

Mother-Child Interactions and Preschoolers’ Emotion Regulation Outcomes: Nurturing Autonomous Emotion Regulation

Emotion regulation is a complex process that begins in infancy and continues through childhood with parents’ support. Early parent-child interactions shape the way children learn emotion management. We took a sociocultural and social learning approach to exploring the specific components of mother-child interactions that are related to mothers’ perceptions of her child’s regulatory ability and the child’s observed emotion regulation. Thirty mothers and their preschool children were recruited from two New England urban areas: one community sample and one head start sample. Dyads engaged in a free play session, children completed an observed compliance task, and mothers completed a set of questionnaires assessing their perceptions of their child’s regulation. Regression analyses revealed that maternal behaviors during free play predicted child’s observed hostility (F _(2,29)?=?3.137, p?<?.05) and mothers’ perceptions of her child’s regulatory ability predicted observed child compliance (F _{(2, 17)}?=?4.990, p?<?.05). Child behaviors during play significantly predicted child’s compliance (F _(3,20)?=?4.722, p?<?.05) and child’s hostility (F _{(1, 26)}?=?9.220, p?<?.001). Maternal modeling and intentional scaffolding as well as perceptions of her child’s regulatory capacity have a powerful impact on her child’s observed regulation. Results indicate that it is particularly important for mothers of preschoolers to support autonomy while guiding socially appropriate behavior. Interventions that target improving mothers’ negative perceptions of their children, educating on appropriate preschool expectations, and facilitating preschoolers’ mature play may help mothers interact with their children in the ways that foster children’s autonomous emotion regulation.     

The Impact of Ethnicity,Language, and Anxiety on Quality of Life in Children with Cancer

Undergoing cancer treatment significantly impacts quality of life (QOL). This study evaluated the role of anxiety, ethnicity, and language on QOL in children with a cancer diagnosis. Participants included 156 parent–child dyads in 3 groups: English-speaking Hispanic, Spanish-speaking Hispanic, and English-speaking non-Hispanic White. Parents completed measures of self-reported anxiety and their children’s perceived QOL. Children completed self-reported measures of anxiety and QOL. Families in which parents primarily spoke English reported higher parent-reported generic-module QOL (p?=?0.0062), higher parent-reported cancer-specific QOL (p?=?0.004), lower parent trait anxiety (p?=?0.0005)), and lower child trait anxiety (p?=?0.013), compared to families in which parents primarily spoke Spanish. Regression analyses were strongly supportive of a mediational role of parent trait anxiety in the association of ethnicity/language and parent-reported QOL. The results of this study suggest that children of Spanish-speaking parents may be at greater risk of decreased quality of life, as a function of increased parental anxiety.     

Examining Parents’ Preferences for Group Parent Training for ADHD When Individual Parent Training is Unavailable

Parent training programs are considered well-established interventions for attention deficit hyperactivity disorder in children as they reduce behavioral impairment, but limited parent engagement decreases service effectiveness. We used a discrete choice experiment to examine how parent preferences for group vs. individual format might influence their participation in Parent training. Parents (N?=?260) seeking mental health services for children with elevated symptoms of attention deficit hyperactivity disorder in Ontario, Canada were participants. They preferred Individual parent training in another study and completed a discrete choice experiment composed of 30 choice tasks measuring Parent training format preference. In this paper, parents’ preferences for alternatives to Individual Parent training, specifically Group Parent training and Minimal Information options, were estimated. Specifically, this study asked “if first choice is unavailable, what is the second choice?” This question is important as many clinics may not be able to offer both group and individual therapy given state funding cuts for youth mental health services. Simulations predicted that 85.8?% of parents who initially preferred Individual Parent training would switch to Group Parent training that included step-by-step solutions to children’s emotional and behavior problems, and the possibility of feeling informed and confident. The remaining 14.2?% of parents preferred Minimal Information; these parents preferred internet services offered conveniently and timely. Findings highlight consideration of less appealing factors that families might trade for more desirable service elements in a cost-restrictive environment.     

Development and Validation of the Knowledge of Parenting Strategies Scale: Measuring Effective Parenting Strategies

The current study aimed to develop and evaluate a measure of parenting knowledge, the Knowledge of Parenting Strategies Scale (KOPSS); specifically, to establish the scales internal reliability, ensure a clinically appropriate length, provide a community sample for future comparison, demonstrate adequate test–retest reliability and convergent validity, and to compare the scale to dysfunctional discipline styles. A total of n?=?865 parents were involved in the development and evaluation of the scale. In Study 1, data was collected from n?=?229 parents and Rasch analyses revealed seven items did not fit the measurement model. Study 2 involved a further sample of community families (n?=?346) and revealed the scale could be further shortened to 16 items. Study 3 revealed the scale has good test–retest reliability over a one-week period (r?=?.88, p?<?.001). Study 4 demonstrated convergent validity through a comparison to the Knowledge of Effective Parenting Scale (r?=?.583, p?=?.009). Study 5 utilised a sample of community families (n?=?190), revealing the scale was negatively correlated with hostile and lax discipline (r?=??.29, p?<?.001; r?=??.15, p?<?.05). Lastly, Study 6 showed scores on the KOPSS significantly improved following clinic-based and Internet-based Behavioural Parent Training. The KOPSS was found to be a valid and reliable measure of parenting knowledge of effective parenting strategies, which can be used to evaluate knowledge acquisition in parenting programs, and test the role of knowledge in behaviour change.     

The Development,Pilot, and Process Evaluation of a Parent Mental Health Literacy Intervention Through Community Sports Clubs

The mental health literacy of parents may be critical in facilitating positive child and adolescent mental health outcomes. The purpose of this study was to develop, pilot, and evaluate a targeted parent mental health literacy intervention through community sports clubs. Sixty six parents (M_age?=?44.86?±?5.2 years) participated in either a brief mental health literacy intervention workshop delivered through community sporting clubs (n?=?42) or a community-matched control group (n?=?24). Participants’ mental health literacy was assessed at baseline, post-intervention and at 1 month follow-up. A mixed methods process evaluation was conducted with intervention participants to determine the acceptability and feasibility of the intervention. Participants in the experimental group showed greater increases in depression literacy, anxiety literacy, knowledge of help seeking options and confidence to assist an adolescent experiencing a mental health disorder, compared to those in the control group. Post-intervention changes in the experimental group were maintained at 1 month follow-up. A mixed methods process evaluation revealed that parents found the intervention content engaging, relevant to their needs, and practically useful in terms of actively supporting adolescent mental health. Findings provide evidence that a brief, targeted intervention through community sports clubs might be a particularly useful method of improving parental mental health literacy and facilitating positive youth mental health outcomes.     

Reproductive Health CHOICES for Young Adults with Sickle Cell Disease or Trait: Randomized Controlled Trial Outcomes over Two Years

Interventions to assist reproductive health decision-making in populations affected by sickle cell disease (SCD) or trait (SCT) lack proven efficacy over time. Our aim was to compare effects of CHOICES, a Web-based multimedia education program on implementing informed reproductive plans, and usual care education (e-Book) on reproductive knowledge, intention, and behavior over 24 months. We randomized 234 participants with SCD (n?=?138) or SCT (n?=?96) (age 18–35 years, 35 % male, 94 % African American) to CHOICES and e-Book groups. Participants completed a sickle cell-specific reproductive measure before and four times after the intervention (6, 12, 18 and 24 months). Compared to the e-Book group the CHOICES group had significantly more improvement in knowledge over time (p?=?.004) but not intention (p?=?.18) or behavior (p?=?.69). At baseline, 114 (48.7 %) participants reported having partners who would not put the couple at risk for their children inheriting SCD. Of the 116 (49.6 %) at-risk participants, a higher poroportion of those who were in the CHOICES group chose partners that reduced their risk by the last visit than the e-Book group (p?=?.04). Study findings provide important insights for designing a national trial of the CHOICES intervention focusing on subjects whose partner status puts them at risk for having a child with SCD.