Violence Prevention: Early Childhood Home Visitation To Prevent – Child Maltreatment

Summary of CPSTF Finding

The Community Preventive Services Task Force (CPSTF) recommends early childhood home visitation programs based on strong evidence of their effectiveness in reducing child maltreatment among high-risk families.

The CPSTF has related findings for early childhood home visitation to prevent the following:

Intervention

Home visitation to prevent violence includes programs in which parents and children are visited in their home by:
  • Nurses
  • Social workers
  • Paraprofessionals
  • Community peers

Some visits must occur during the child’s first two years of life, but they may be initiated during pregnancy and may continue after the child’s second birthday.

CPSTF Finding and Rationale Statement

Read the CPSTF finding.

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review of 21 studies (search period through December 2001). The review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to violence prevention.

Context

In this review, maltreatment includes all forms of child abuse and neglect.

Summary of Results

Twenty-one studies were included in the review.
  • Child maltreatment in high-risk families: median reduction of 38.9% in episodes (interquartile interval: 74.1% to 24.0%; 21 studies, 26 study arms)
    • Longer-duration programs produced larger effects; programs of less than 2 years duration did not appear to be effective.
    • Professional home visitors may be more effective than trained paraprofessionals, but longer-duration programs with trained paraprofessionals can also be effective.

Summary of Economic Evidence

  • One study qualified for the review of economic evidence. Estimates are reported in 1997 U.S. dollars.
  • The study evaluated the net benefits of a nurse home visitation program provided to first-time mothers in a semi-rural county.
  • The costs and benefits analyzed for this intervention were limited to government costs and benefits, not those of program participants, the healthcare system, or society at large.
    • Program costs considered were through the child’s second birthday and included nurse salaries and fringe benefits; nurse training; part-time secretary; part-time supervisor; taxicab; linked services such as the Women, Infants, and Children (WIC) nutritional supplementation program; supplies; and overhead.
    • The benefits considered were through the child’s fourth birthday and included reduced use of government services (i.e., AFDC, Child Protective Services, Food Stamps, and Medic aid) and newly generated tax revenues from mothers returning to work.
  • For a subsample of low-income families, governmental benefits more than offset program costs, for a net benefit to government of $350.61 per low-income family.
  • For the whole sample, governmental costs exceeded benefits, which resulted in a net benefit of $3,081 per family.

Applicability

These programs should be applicable to most families considered to be at high risk of child maltreatment (e.g., single or young mothers, low-income households, families with low birth weight infants).

Evidence Gaps

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

The following outlines evidence gaps from reviews of early childhood home visitation programs to prevent child maltreatment, intimate partner violence, violence by children participating in the program, and violence by parents (other than child maltreatment or intimate partner violence)

Although we have demonstrated the effectiveness of home visitation in the prevention of child maltreatment, evidence on the other outcomes assessed (violence by children, violence by parents, and intimate partner violence) was insufficient to determine effectiveness. Further research on the effectiveness of home visitation in the prevention of these outcomes would clarify other possible benefits of this intervention. Findings of large, but statistically nonsignificant, effect sizes for some of these outcomes suggest that studies may be of low statistical power; we believe that larger sample sizes should be considered. Suicidal behavior by visited children and diverse forms of victimization should also be assessed as outcomes in home visitation programs. Follow-up studies should determine long-term as well as short-term effects.

The evidence we reviewed indicates a benefit of home visitation for the reduction of child maltreatment in populations that have been shown to be at elevated risk of maltreatment. The population that might benefit is a large one. In 1999, 33% of the 3.6 million births in the United States were to single mothers, 12% were to teen mothers, and 22% were to mothers with less than a high school education (Eberhardt et al., 2001); 43% of births approximately 1.7 million were to mothers with at least one of these characteristics (B. Hamilton, National Center for Health Statistics, “personal communication,” Sept. 9, 2002). Given such a large need, it will be useful to conduct research, perhaps in the form of demonstration projects, to make the intervention more effective. Because the visitation programs reviewed are heterogeneous and differ in content, organization, personnel, intensity, and other characteristics, questions that should be addressed include:

  • What number, spacing, and duration of home visits is optimal for cost-effective programs that are acceptable to visited families?
  • What training for professional and paraprofessional home visitors maximizes cost-effectiveness?
  • What circumstances enhance the effectiveness of paraprofessional visitors (e.g., educational background and origin)?
  • How should the curriculum of home visits be organized, in terms of:
    • Structure?
    • Specific components and contents?
  • How strong is the need for program fidelity (i.e., degree of adherence to initially proposed curriculum and schedule) for the reduction of violent behaviors?
  • What is the utility of additional components, such as parent support groups, child daycare, enhanced pediatric care, free transportation to appointments, and linkage with social support services?
  • What are the essential components of home visitation programs, and what components are dispensable?
  • What populations are most likely to benefit from home visitation programs and what program characteristics are most important for specific populations?

Applicability

The effectiveness of home visitation for child maltreatment prevention has been demonstrated in a variety of geographic areas and “at-risk” populations. Although we found insufficient evidence to determine the effectiveness of home visitation on child violence, parental violence, and other outcomes among both visited children and parents, evidence from the Elmira study indicated beneficial effects for these outcomes among visited low SES households with single parents. It is still unclear whether other specific subgroups (e.g., racial/ethnic populations) within the general category of “population at-risk” are likely to benefit more than other subgroups.

Studies of the effectiveness of home visitation in preventing violence by visited children have examined diverse populations, but too few studies are available, and they provide inconsistent evidence. Evidence about parental violence outcomes is limited to a mostly white population from the northeastern United States, principally from the study by Olds et al (1997; 1998). If found to be effective, the applicability of early home visitation for these outcomes in different populations should also be determined. In addition, it will be useful to determine if home visitation is effective in the general population (as well as in “at-risk” populations), and if so, if benefits exceed costs.

Other Positive or Negative Effects

As noted, this review did not systematically summarize evidence of the effectiveness of home visitation programs on nonviolent outcomes. Such outcomes might include children’s cognitive, emotional, and physical development; school achievement; substance use; sexual activity; access to health care; immunization coverage; quality and safety of the home environment; employment of parents; educational achievement of parents; and family planning, including spacing and number of subsequent pregnancies. We are hopeful that the research questions that we have just developed for home visiting and violence might also inform additional studies or reviews of home visiting to achieve other outcomes as well. Concerning negative effects, questions that should be addressed include:

  • How serious is the problem of stigmatization by risk criteria when home visitation programs are directed at “at-risk” populations?
  • If stigmatization is an important problem (under some or all circumstances), what can be done in program design to minimize the negative effects of stigmatization?
  • What role can community coalitions play in preventing or alleviating stigmatization?

Economic Evidence

The available economic evidence was limited. Considerable research is warranted on the following questions:

  • What is the cost and cost effectiveness of the various alternative home visitation programs?
  • How can effectiveness in terms of health outcomes or quality-adjusted health outcomes be better measured, estimated, or modeled?
  • How can the cost benefit of this program be estimated from a societal perspective?
  • How do specific characteristics of this approach contribute to economic efficiency?

Barriers

Several important barriers may adversely affect implementation and outcomes of home visitation programs. Addressing the following research questions may help to avoid or overcome these barriers:

  • What program components or design features improve the retention of program participants?
  • Can baseline characteristics of families that are more likely to drop out of home visitation programs be identified? Might such identification improve efforts to retain participants in the programs?
  • What design characteristics of home visitation programs improve the work satisfaction and retention of home visitors?
  • What background characteristics of visitors and required pre-program training minimize visitor dropout and maximize program performance?
  • What features of service systems are essential for efficient implementation and sustainability of home visitation programs?
  • What is the minimum level of services infrastructure needed to support adequate supervision of lay home visitors?
  • What combination of community characteristics provides optimal community readiness for implementation and sustainability of home visitation programs?

Study Characteristics

  • All studies were conducted in the United States, except for one in Canada.
  • Home visitation programs were conducted with teenage parents; single mothers; families of low socioeconomic status (SES); families with very-low-birth weight infants; parents previously investigated for child maltreatment; and parents with alcohol, drug, or mental health problems.

Publications

Bilukha O, Hahn RA, Crosby A, et al. The effectiveness of early childhood home visitation in preventing violence: a systematic review. American Journal of Preventive Medicine 2005;28(2S1):11-39.

Task Force on Community Services. Recommendations to reduce violence through early childhood home visitation, therapeutic foster care, and firearms laws. American Journal of Preventive Medicine 2005;28(2S1):6-10.

Centers for Disease Control and Prevention. First reports evaluating the effectiveness of strategies for preventing violence: early childhood home visitation: findings from the Task Force on Community Preventive Services. MMWR 2003;52(RR-14):1-9. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5214a1.htm.

Lipsey MW. The challenges of interpreting research for use by practitioners: comments on the latest products from the Task Force on Community Preventive Services. American Journal of Preventive Medicine 2005;28(2 Suppl 1):6-10.

Calonge N. Community interventions to prevent violence: translation into public health practice. American Journal of Preventive Medicine 2005;28(2 Suppl 1):4-5.

Task Force on Community Services, Zaza S, Briss PA, Harris KW. Violence. In: The Guide to Community Preventive Services: What Works to Promote Health? Atlanta (GA): Oxford University Press; 2005:329-84.

Analytic Framework

Effectiveness Review

Analytic Framework – See Figure 1 on page 14

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Summary Evidence Table

Effectiveness Review

Summary Evidence Table
Contains evidence from reviews of early childhood home visitation programs to prevent child maltreatment, intimate partner violence, violence by children participating in the program, and violence by parents (other than child maltreatment or intimate partner violence)

Included Studies

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Armstrong KA. A treatment and education program for parents and children who are at-risk of abuse and neglect. Child Abuse Neglect 1981;5:167 75.

Barth RP. An experimental evaluation of in-home child abuse prevention services. Child Abuse Neglect 1991;15:363 75.

Brayden R, Altemeier W, Dietrich M, et al. A prospective study of secondary prevention of child maltreatment. J Pediatr 1993;122:511 6.

Brooten D, Kumar S, Brown LP, et al. A randomized clinical trial of early hospital discharge and home follow-up of very-low-birth-weight infants. N Engl J Med 1986;315:934 9.

Caruso Whitney GA. Early intervention for high-risk families: reflecting on a 20-year-old model. In: Albee GW, Gullotta TP, eds. Primary prevention works. Thousand Oaks CA: Sage, 1997:68 86.

Dawson P, Van Doornick WJ, Robinson JL. Effects of home-based, informal social support on child health. J Dev Behav Pediatr 1989;10:63 7.

Duggan A, Windham A, McFarlane E, et al. Hawaii’s healthy start program of home visiting for at-risk families: evaluation of family identification, family engagement, and service delivery. Pediatrics 2000;105:250 9.

Flynn L. The adolescent parenting program: improving outcomes through mentorship. Public Health Nurs 1999;16:182 9.

Gray JD, Cutler CA, Dean JG, Kempe CH. Prediction and prevention of child abuse and neglect. J Social Issues 1979;35:127 39.

Hardy JB, Street R. Family support and parenting education in the home: an effective extension of clinic-based preventive health care services for poor children. J Pediatr 1989;115:927 31.

Honig AS, Morin C. When should programs for teen parents and babies begin? Longitudinal evaluation of a teen parents and babies program. J Primary Prev 2001;21:447 54.

Huxley P, Warner R. Primary prevention of parenting dysfunction in high risk cases. Am J Orthopsychiatry 1993;63:582 8.

Katzev A, Pratt C, Henderson T, McGuigan W. Oregon’s Healthy Start effort: 1997 98 status report. Corvallis: Oregon State University Family Policy Program, 1999.

Kitzman H, Olds DL, Henderson Jr CR, et al. Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing: a randomized controlled trial. JAMA 1997;278:644 52.

Larson CP. Efficacy of prenatal and postnatal home visits on child health and development.Pediatrics 1980;66:191 7.

Marcenko MO, Spence M, Samost L. Outcomes of a home visitation trial for pregnant and postpartum women at-risk for child placement. Child Youth Services Rev 1996;18:243 59.

Mulsow MH, Murry VM. Parenting on edge: economically stressed, single, African American adolescent mothers. J Fam Issues 1996;17:704 21.

Olds DL, Eckenrode J, Henderson CR Jr, et al. Long-term effects of home visitation on maternal life course and child abuse and neglect: fifteen-year follow-up of a randomized trial. JAMA 1997;278:637 43.

Siegel E, Bauman KE, Schaefer ES, Saunders MM, Ingram DD. Hospital and home support during infancy: impact on maternal attachment, child abuse and neglect, and health care utilization. Pediatrics 1980;66:183 90.

Velasquez J, Christensen M, Schommer B. Intensive services help prevent child abuse. Am J Maternal Child Nurs 1984;9:113 7.

Wagner MM, Clayton SL. The Parents as Teachers program: results from two demonstrations. Future Child 1999;9:91 115.

Economic Review

Olds DL, Henderson Jr, CR Phelps C, Kitzman H, Hanks C. Effect of prenatal and infancy nurse home visitation on government spending. Med Care 1993;31:155 74.

Search Strategies

The following outlines the search strategy used for evidence reviews of early childhood home visitation programs to prevent child maltreatment, intimate partner violence, violence by children participating in the program, and violence by parents (other than child maltreatment or intimate partner violence).

Electronic searches for literature were conducted in Medline, EMBASE, ERIC, NTIS (National Technical Information Service), PsycINFO, Sociological Abstracts, NCJRS (National Criminal Justice Reference Service), and CINAHL. We also reviewed the references listed in all retrieved articles, and consulted with experts on the systematic review development team and elsewhere. We used journal papers, government reports, books, and book chapters.

The initial literature search on the topic was conducted in August 2000 and a second (update) search was conducted in July 2001. Articles were considered for inclusion in the systematic review if they had the following characteristics:

  • Evaluated the specified intervention
  • Published before July 2001
  • Assessed at least one of the violent outcomes specified
  • Conducted in an established market economy
  • Primary study rather than, for example, a guideline or review
  • Compared a group of people who had been exposed to the intervention with a group of people who had not been exposed or who had been less exposed (comparisons could be concurrent or in the same group over time)

Considerations for Implementation

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.
  • Barriers to implementing home visitation interventions frequently discussed in the literature include difficulties in the retention of study participants and program staff.
  • Home interventions have generally been targeted to families of low SES, who are in challenging life circumstances with few resources. Such families might be overwhelmed with other problems and lack sustained interest in or ability to commit to regular home visitation. They also might be hard to reach and retain in the program because of frequent life changes.
  • Home visiting personnel (especially when paraprofessional lay visitors are used) may be hard to recruit, train, and retain due to low pay and difficult work conditions. Paraprofessional visitors also may require more training and supervision than professionals (e.g., nurses).

Crosswalks