The Impact of a Preventive Intervention on Persistent, Cross-Situational Early Onset Externalizing Problems

  • Michael F. LorberEmail author
  • David L. Olds
  • Nancy Donelan-McCall


The Nurse-Family Partnership (NFP) home visiting intervention for low-income first-time mothers was evaluated for its preventive impact on persistent, cross-situational early-onset externalizing problems (EXT). Seven hundred thirty-five women in the Denver, CO, area were randomly assigned into one of two active conditions (nurse or paraprofessional home visiting from pregnancy through child age 2) or a control group in which children were screened and referred for behavioral and developmental problems. Externalizing behavior was assessed by parent report when the children were 2, 4, 6, and 9 years old; teachers provided reports at ages 6 and 9. Latent profile analyses suggested the presence of persistent, cross-situational early onset EXT in approximately 6 to 7% of girls and boys. The intervention deflected girls away from these EXT and toward a pattern marked by a persistent moderate elevation of externalizing behavior that was evident at home and not at school. This finding should be interpreted cautiously given the small number of girls with the elevated EXT. Surprisingly, the intervention also moved girls away from stable low level externalizing behavior toward the moderately elevated pattern. Both of the significant effects on girls’ externalizing behavior were modest. No statistically significant effects were found for boys’ externalizing behaviors, which exhibited a somewhat different patterning across time and reporter. Effect sizes were generally similar for the nurse and paraprofessional-visited groups. The results are discussed in the context of prior efforts to prevent early EXT and emerging evidence on the normative development of externalizing behavior.


Prevention Externalizing Infancy Toddlerhood RCT 



The current phase of this research was supported by grants 99012, 99030, and 2001-049 from the Colorado Trust, 90PD0232 and 90XP0017 from the Administration for Children and Families, 2004-52854-CO-JS from the Office of Juvenile Justice and Delinquency Prevention, 2005-MU-MU-001 from the US Department of Justice, and 1R01MH069891, 1R01MH62485, and 1K05-MH01382 from the National Institute of Mental Health.

Compliance with Ethical Standards

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Colorado Multiple Institutional Review Board and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

Conflict of Interest

Michael Lorber and Nancy Donelan-McCall declare that they have no conflicts of interest. The Prevention Research Center for Family and Child Health (PRC), directed by David Olds, receives fees and travel expenses from governments and entities outside of the United States to implement the Nurse-Family Partnership©. Licensing fees are charged to international entities for implementing the program. The fees are used to support program implementation in international contexts and research on testing and improving the NFP and its implementation. In the US, the program is replicated by the NFP National Service Office, which provides funding to the PRC to conduct research aimed at improving the NFP model and its implementation. None of these fees are used to augment Dr. Olds’s university salary. Professor Olds does receive honoraria for writing and speaking about the NFP.

Supplementary material

11121_2018_973_MOESM1_ESM.docx (45 kb)
ESM 1 (DOCX 44.6 kb)


  1. Achenbach, T. M. (2009). Achenbach system of empirically based assessment (ASEBA): Development, findings, theory, and applications. Burlington, VT: Author.Google Scholar
  2. Aguilar, B., Sroufe, L. A., Egeland, B., & Carlson, E. (2000). Distinguishing the early-onset/persistent and adolescence-onset antisocial behavior types: From birth to 16 years. Development and Psychopathology, 12, 109–132. Scholar
  3. Alink, L. R. A., Mesman, J., Van Zeijl, J., Stolk, M. N., Juffer, F., Koot, H. M., et al. (2006). The early childhood aggression curve: Development of physical aggression in 10 to 50 month-old children. Child Development, 77, 954–966. Scholar
  4. Bugental, D. B., Ellerson, P. C., Lin, E. K., Rainey, B., Kokotovic, A., & O’Hara, N. (2002). A cognitive approach to child abuse prevention. Journal of Family Psychology, 16, 243–258. Scholar
  5. Crowne, S. S., Gonsalves, K., Burrell, L., McFarlane, E., & Duggan, A. (2012). Relationship between birth spacing, child maltreatment, and child behavior and development outcomes among at-risk families. Maternal and Child Health Journal, 16, 1413–1420. Scholar
  6. Donelan-McCall, N., Eckenrode, J., & Olds, D. L. (2009). Home visiting for the prevention of child maltreatment: Lessons learned during the past 20 years. Pediatric Clinics of North America, 56, 389–403. Scholar
  7. Eckenrode, J., Campa, M., Luckey, D. W., Henderson, C. R., Jr., Cole, R., Kitzman, H., et al. (2010). Long-term effects of prenatal and infancy nurse home visitation on the life course of youths: 19-year follow-up of a randomized trial. Archives of Pediatrics and Adolescent Medicine, 164, 9–15. Scholar
  8. Hay, D. F., Perra, O., Hudson, K., Waters, C. S., Mundy, L., Phillips, R., et al. (2010). Identifying early signs of aggression: Psychometric properties of the Cardiff infant contentiousness scale. Aggressive Behavior, 36, 351–357. Scholar
  9. Kitzman, H. J., Olds, D. L., Cole, R. E., Hanks, C. A., Anson, E. A., Arcoleo, K. J., et al. (2010). Enduring effects of prenatal and infancy home visiting by nurses on children: Follow-up of a randomized trial among children at age 12 years. Archives of Pediatrics and Adolescent Medicine, 164, 412–418. Scholar
  10. Lorber, M. F., & Egeland, B. (2011). Parenting and temperament in infancy: Testing a mutual exacerbation hypothesis to predict conduct problems. Child Development, 82, 2006–2020. Scholar
  11. Lorber, M. F., Del Vecchio, T., & Slep, A. M. S. (2015). The emergence and evolution of infant externalizing behavior. Development and Psychopathology, 27, 663–680. Scholar
  12. Loukas, A., Zucker, R. A., Fitzgerald, H. E., & Krull, J. L. (2003). Developmental trajectories of disruptive behavior problems among sons of alcoholics: Effects of parent psychopathology, family conflict, and child undercontrol. Journal of Abnormal Psychology, 112, 119–131. Scholar
  13. Love, J. M., Kisker, E. E., Ross, C., Raikes, H., Constantine, J., Boller, K., et al. (2005). The effectiveness of Early Head Start for 3-year-old children and their parents: Lessons for policy and programs. Developmental Psychology, 41, 885–901. Scholar
  14. Matjasko, J. L., Vivolo-Kantor, A. M., Massetti, G. M., Holland, K. M., Holt, M. K., & Dela Cruz, J. (2012). A systematic meta-review of evaluations of youth violence prevention programs: Common and divergent findings from 25 years of meta-analyses and systematic reviews. Aggression and Violent Behavior, 17, 540–552. Scholar
  15. Mesman, J., Stoel, R., Bakermans-Kranenburg, M. J., van IJzendoorn, M. H., Juffer, F., Koot, H. M., & Alink, L. R. (2009). Predicting growth curves of early childhood externalizing problems: Differential susceptibility of children with difficult temperament. Journal of Abnormal Child Psychology, 37, 625–636. Scholar
  16. Moffitt, T. E., Caspi, A., Harrington, H., & Milne, B. J. (2002). Males on the life-course-persistent and adolescence-limited antisocial pathways: Follow-up at age 26 years. Development and Psychopathology, 14, 179–207 Scholar
  17. Muthén, L. K., & Muthén, B. O. (1998-2017). Mplus user’s guide (8th ed.). Los Angeles, CA: Muthén & Muthén.Google Scholar
  18. NICHD Early Child Care Research Network, & Arsenio, W. F. (2004). Trajectories of physical aggression from toddlerhood to middle childhood: Predictors, correlates, and outcomes. Monographs of the Society for Research in Child Development, 69, 1–129. Scholar
  19. NIMH National Advisory Mental Health Council Workgroup on Mental Disorders Prevention Research (2001). Prevention and Treatment, Volume 4, Article 17. Retrieved May 15, 2005 from
  20. Olds, D. L., Henderson, C. R., Chamberlin, R., & Tatelbaum, R. (1986a). Preventing child abuse and neglect: A randomized trial of nurse home visitation. Pediatrics, 78, 65–78 Scholar
  21. Olds, D. L., Henderson, C. R., Tatelbaum, R., & Chamberlin, R. (1986b). Improving the delivery of prenatal care and outcomes of pregnancy: A randomized trial of nurse home visitation. Pediatrics, 77, 16–28 Scholar
  22. Olds, D. L., Holmberg, J. R., Donelan-McCall, N., Luckey, D. W., Knudtson, M. D., & Robinson, J. (2014). Effects of home visits by paraprofessionals and by nurses on children: Follow-up of a randomized trial at ages 6 and 9 years. JAMA Pediatrics, 168, 114–121. Scholar
  23. Olds, D. L., Kitzman, H., Cole, R., Robinson, J., Sidora, K., Luckey, D. W., et al. (2004b). Effects of nurse home-visiting on maternal life course and child development: Age 6 follow-up results of a randomized trial. Pediatrics, 114, 1550–1559. Scholar
  24. Olds, D. L., Kitzman, H., Hanks, C., Cole, R., Anson, E., Sidora-Arcoleo, K., et al. (2007b). Effects of nurse home visiting on maternal and child functioning: Age-9 follow-up of a randomized trial. Pediatrics, 120, e832–e845. Scholar
  25. Olds, D. L., Robinson, J., O’Brien, R., Luckey, D. W., Pettitt, L. M., Henderson, C. R., et al. (2002). Home visiting by paraprofessionals and by nurses: A randomized, controlled trial. Pediatrics, 110, 486–496. Scholar
  26. Olds, D. L., Robinson, J., Pettitt, L., Luckey, D. W., Holmberg, J., Ng, R. K., et al. (2004a). Effects of home visits by paraprofessionals and by nurses: Age 4 follow-up results of a randomized trial. Pediatrics, 114, 1560–1568. Scholar
  27. Olds, D. L., Sadler, L., & Kitzman, H. (2007a). Programs for parents of infants and toddlers: Recent evidence from randomized trials. Journal of Child Psychology and Psychiatry, 48, 355–391. Scholar
  28. Olds, D., Henderson, C. R., Jr., Cole, R., Eckenrode, J., Kitzman, H., Luckey, D., et al. (1998a). Long-term effects of nurse home visitation on children's criminal and antisocial behavior. Journal of the American Medical Association, 280, 1238–1244. Scholar
  29. Olds, D., Henderson, C., Birmingham, M., et al. (1983). Final report to the Maternal and Child Health and Crippled Children’s Services Research Grants Program, Bureau of Community Health Services, Health Services Administration, Public Health Service, Department of Health and Human Services, grant MCJ-36040307. November, 1983.Google Scholar
  30. Olds, D. L., Henderson, C. R., Kitzman, H., Eckenrode, J., Tatelbaum, R., Robinson, et al. (1998). Prenatal and infancy home visitation by nurses: a program of research. In C. Rovee-Collier, L. P. Lipsitt, & H. Hayne (Eds.), Advances in infancy research (Vol. 12) (pp. 79–130). Stamford: Ablex Publishing Corp.Google Scholar
  31. O'Leary, S. G., Slep, A. M. S., & Reid, J. (1999). A longitudinal study of mothers' overreactive discipline and toddlers' externalizing behavior. Journal of Abnormal Child Psychology, 27, 331–341. Scholar
  32. Pearlin, L. I., & Schooler, C. (1978). The structure of coping. Journal of Health and Social Behavior, 19, 2–21. Scholar
  33. Robins, L. N. (2006). Conduct disorder. Journal of Child Psychology and Psychiatry, 32, 193–212. Scholar
  34. Rothbaum, F., & Weisz, J. R. (1994). Parental caregiving and child externalizing behavior in nonclinical samples: A meta-analysis. Psychological Bulletin, 116, 55–74. Scholar
  35. Shaw, D. S., Gilliom, M., Ingoldsby, E. M., & Nagin, D. S. (2003). Trajectories leading to school-age conduct problems. Developmental Psychology, 39, 189–200. Scholar
  36. Shipley, W. (1940). A self-administered scale for measuring intellectual impairment and deterioration. Journal of Psychology, 9, 371–377. Scholar
  37. Sidora-Arcoleo, K., Anson, E., Lorber, M., Cole, R., Olds, D., & Kitzman, H. (2010). Differential effects of a nurse home-visiting intervention on physically aggressive behavior in children. Journal of Pediatric Nursing, 25, 35–45. Scholar
  38. Silberg, J., Moore, A. A., & Rutter, M. (2015). Age of onset and the subclassification of conduct/dissocial disorder. Journal of Child Psychology and Psychiatry, 56, 826–833. Scholar
  39. St. Pierre, R. G., & Layzer, J. I. (1999). Using home visits for multiple purposes: The comprehensive child development program. Future of Children, 9, 134–151 Scholar
  40. Streiner, D. L. (2003). Being inconsistent about consistency: Whencoefficient alpha does and doesn’t matter. Journal of Personality Assessment, 80, 217–222.
  41. Van Zeijl, J., Mesman, J., van IJzendoorn, M. H., Bakermans-Kranenburg, M. J., Juffer, F., Stolk, M. N., et al. (2006). Attachment-based intervention for enhancing sensitive discipline in mothers of 1- to 3-year-old children at risk for externalizing behavior problems: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 74, 994–1005. Scholar
  42. Wakschlag, L. S., Pickett, K. E., Kasza, K. E., & Loeber, R. (2006). Is prenatal smoking associated with a developmental pattern of conduct problems in young boys? Journal of the American Academy of Child and Adolescent Psychiatry, 45, 461–467. Scholar
  43. Ware, J. E., Veit, C. T., Donald, C. A. (1985). Refinements in the Measurement of Mental Health for Adults in the Health Insurance Study. Santa Monica, CA: RAND Corp.Google Scholar
  44. Whitley, E., Gale, C. R., Deary, I. J., Kivimaki, M., & Batty, G. D. (2011). Association of maternal and paternal IQ with offspring conduct, emotional, and attention problem scores: Transgenerational evidence from the 1958 British birth cohort study. Archives of General Psychiatry, 68, 1032–1038. Scholar

Copyright information

© Society for Prevention Research 2019

Authors and Affiliations

  • Michael F. Lorber
    • 1
    • 2
    Email author
  • David L. Olds
    • 2
  • Nancy Donelan-McCall
    • 2
  1. 1.New York UniversityNew York CityUSA
  2. 2.University of Colorado at Denver Health Sciences CenterDenverUSA

Personalised recommendations