The Effectiveness of Early Childhood Home Visitation in the Prevention of Child Abuse

Robert Hahn, PhD, MPH (CDC)Oleg Biloukha, MD, PhD (CDC)Alex Crosby, MD (CDC)Mindy Fullilove, MD (Columbia University, Task

Force on Community Preventive Services) Akiva Liberman, PhD (NIJ)Eve Moscicki, ScD, MPH (NIMH)Susan Snyder, Ph.D. (CDC) Farris Tuma, ScD (NIMH)

The Guide to Community Preventive Services

Systematic reviews and evidence-based recommendations regarding community level interventions

Already published: Vaccine-Preventable DiseasesTobacco Use Prevention and ControlMotor Vehicle Occupant Injury PreventionSocial EnvironmentDiabetesPhysical ActivityOral Health

http://www.thecommunityguide.org

Examples of Interventions Under Review: Violence Prevention Chapter

Early childhood home visitation programs

Legislation restricting availability, sales, access, safety, deployment of firearms

Therapeutic foster care

Trying/sentencing/incarcerating juveniles as adults

Programs for the development of prosocial skills

Community policing

Etc.

Community Guide Methods: Suitability of Design

• Greatest – Prospective with concurrent comparison

• Moderate– Multiple pre/post measurements but no

concurrent comparison OR– Retrospective

• Least (may be excluded)– Single group before-and-after– Cross sectional

Community Guide Methods: Quality of Execution (penalties)

• Descriptions (1) • Sampling (1)• Measurement (2)

ExposureOutcome

• Data Analysis (1)

• Interpretation (3)Follow-upConfounding Other Biases

• Other (1)

Total of 9 points possible.

Studies with 5 flaws are excluded.

Community Guide Methods: Criteria for Evidence of Effectiveness

Evidence of Effectiveness

Quality of Execution

Design Suitability

Number of Studies

Consistent Effect Size

1. Strong

Good Greatest > 2 Yes Sufficient

Good Greatest or Moderate

> 5 Yes Sufficient

Good or Fair

Greatest > 5 Yes Sufficient

Meet criteria for sufficient evidence Large

2. Sufficient

Good Greatest 1 -- Sufficient

Good or Fair

Greatest or Moderate

> 3 Yes Sufficient

Good or Fair

Greatest, Moderate, or Least

> 5 Yes Sufficient

3. Insufficient Insufficient design or execution

Too few No Small

Child maltreatment reports in the US

Source: National Center for Juvenile Justice, 1999

Approximately 4.3% of children (<18 years) in 1996

Definition: Early Childhood Home Visitation

• Home visitation of parent(s) and child(ren) by trained personnel who:

• convey information, and/or • offer support, and/or • provide training

• Programs systematically reviewed only if they assess violence-related outcomes

Definition (cont’d): Home Visitation

• Visits may address: • training on infant care• training on parenting• training on problem solving• preventing child abuse and neglect• family planning assistance• educational and work opportunities for

parents• community service linkage

Definition (cont’d): Home Visitation

• Visitation must occur during first 2 years of child’s life; may begin prenatally and/or continue after age 2

• Participation voluntary or mandated

• Visitors: nurses, social workers, trained para-professionals, community peers, others

• Often targeted: low income, minority, single, young mothers, low birthweight infant, etc.

The Need is Great

In 1999, of 3.6 million births:• 12% of mothers were teens• 33% were single• 22% had <12 years of school

• 43% (1.5 million) had >1 of these characteristics

Analytic Framework: Early Childhood Home Visitation

Home visitation program

Violence by adolescent parent(s)

Partner abuse by adolescent

parent

Child maltreatment

Violent act by juvenile

ParentKnowledgeSkillsSelf-confidenceAccess to resourcesParenting

ChildDevelopmentSkillsHealth/ well-being

Proposed Recommendations

• Violent act by juvenile - inconsistent findings: insufficient evidence

• Violence by parents – suggestive findings: insufficient evidence

• Partner abuse of parent – possibly ineffective: insufficient evidence

• Child maltreatment- effective: recommended, strong evidence

Child Maltreatment

Child maltreatment (or victimization) includes abuse

and neglect

Measures of Child Maltreatment

Direct Measures • CPS reports• Parent’s reports• Other report or

observation of abuse, neglect, orvictimization

Proxy Measures • ER visits/

hospitalization for injury or ingestion

• Injury • Out-of-home

placement

Direct measures chosen over proxy measures

Study Ratings

Quality ofExecution

Suitability of study design

Greatest Moderate Least

Good(0 - 1)

4(4)

Fair(2 – 4)

21(16) 1(1)

Limited( 5)

1(1)

Number of intervention arms (number of studies)

Effect size measure

Effect size = Relative change in intervention group compared with relative change in intervention group

Maltreatment Results: Overall

Total intervention arms 26

Negative 19

Positive 7

Median -38.9

IQ range: lower -74.1

upper +24.0

Range: lower -100.0

upper +228.4

Effectiveness of Home Visitation

0

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9

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-120 -80 -40 0 40 80 120 160 200 240

BarthBraydenBrootenCarusoDawsonDugganFlynnGrayHardyHonig1Honig2HuxleyKatzevKitzmanLarson1Larson2MarcenkoMuslowOldsSiegel1Siegel2Siegel3VelasquezWagner1Wagner2Wagner3

Results: By Outcome

Abuse/ neglect

Injury Place-ment

Total intervention arms 20 5 1Negative 14 5 0Positive 6 0 1

Median -39.6 -31.9 +13.0IQ range: lower -74.6 -72.2 N/A upper +37.2 -10.8 N/ARange: lower -100.0 -100.0 N/A upper +228.4 -2.9 N/A

Results: By Outcome

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1 0

1 1

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1 7

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2 0

2 1

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2 7

-120 -80 -40 0 40 80 120 160 200 240Percent Change from Baseline

BarthBraydenBrootenCarusoDawsonDugganFlynnHardyHonig1Honig2HuxleyKatzevMuslowOldsSiegel1Siegel2Siegel3VelasquezWagner1Wagner2GrayKitzmanLarson1Larson2 Wagner3Marcenko

Abuse/neglect

Trauma/injury

Placement

Study Bias: Presence of Home Visitor Leads to Increased Reporting of Child Abuse

0123456789

10

ab

us

e c

as

es

, %

of

the

s

am

ple

Dawson '89 Brayden '93

Incl. visitorsExcl. visitorsControls

+ visitor/-visitor: 1.8 (Brayden) – 2.5 (Dawson)

Results: By Outcome (Adjusted for Reporting Bias, Factor 1.5)

Abuse/neglect

Injury Place-ment

Total intervention arms 20 5 1

Negative 17 5 1

Positive 3 0 0

Median -59.7 -54.6 -24.7

IQ range: lower -83.1 -81.5 N/A

upper -8.5 -40.6 N/A

Range: lower -100.0 -100.0 N/A

upper +118.9 -35.3 N/A

Results: By Outcome (Adjusted for Reporting Bias, Factor 1.5)

0

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5

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7

8

9

1 0

1 1

1 2

1 3

1 4

1 5

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1 7

1 8

1 9

2 0

2 1

2 2

2 3

2 4

2 5

2 6

2 7

-120 -80 -40 0 40 80 120 160 200 240Percent Change from Baseline

BarthBraydenBrootenCarusoDawsonDugganFlynnHardyHonig1Honig2HuxleyKatzevMuslowOldsSiegel1Siegel2Siegel3VelasquezWagner1Wagner2GrayKitzmanLarson1Larson2 Wagner3Marcenko

Abuse/neglect

Trauma/injuryPlacement

Results: By Visitor Type

Nurse Para-prof

Mental health worker

Total intervention arms 5 18 3Negative 5 11 3Positive 0 7 0

Median -48.7 -17.7 -44.5IQ range: lower -89.0 -65.7 N/A upper -24.6 +41.2 N/ARange: lower -100.0 -100.0 N/A upper -2.9 +228.4 N/A

Results: By Visitor Type

0

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5

6

7

8

9

1 0

1 1

1 2

1 3

1 4

1 5

1 6

1 7

1 8

1 9

2 0

2 1

2 2

2 3

2 4

2 5

2 6

2 7

-120 -80 -40 0 40 80 120 160 200 240Percent Change from Baseline

BrootenGrayKitzman OldsVelasquez BarthBraydenDawsonDugganFlynnHardyHonig1Honig2HuxleyKatzevMarcenkoMuslowSiegel1Siegel2Siegel3Wagner1Wagner2Wagner3 CarusoLarson1Larson2

Nurse

Para-professional

Mentalhealth worker

Home Visitation Effects by Duration of Program

-120

-60

0

60

120

180

240

0 1 2 3 4

Duration of the program, yrs

Rela

tive p

ct

ch

an

ge

ParaprofessionalsProfessionals

Spearman correlation:Whole sample: -0.52 (p=0.01)Paraprofessionals: -0.63 (p<0.01)Professionals: -0.32 (NS)

Other stratified analyses

No significant effect modification when stratified by:

• Program content (multi- vs. single-component)

• Time of initiation (pre- vs. post-natal)

• Group allocation procedure (randomized vs. non-randomized)

• Execution quality score

Conclusion: Effects of Early Childhood Visitation on Child

Maltreatment

• Strong evidence to recommend• Greater effect with professional home

visitors• With paraprofessional visitors, a

beneficial effect is found with longer program duration

Conclusion: Effects of Early Childhood Visitation on Child

Maltreatment

• Strong evidence to recommend• Greater effect with professional home

visitors• With paraprofessional visitors, a

beneficial effect is found with longer program duration

Other Benefits and Harms for Children: Mixed Effects

(Olds, Elmira), 15 yr follow-up:

All sample Low SES, single

Days used drugs -12.3% -38.1%

Days used alcohol +19.1% -56.2%

No. cigarettes per day -1.5% -40.0%

Percent ever had sex +20.0% +2.2%

No. of sex partners -25.6% -62.9%*

No. short-term suspensions -3.6% +18.8%

No. long-term suspensions -75.0% -73.3%

* significant at 0.05 level

Other Benefits and Harms for Mothers: Beneficial Effects

(Olds, Elmira), 15 yr follow-up:

All sample Low SES, single

No. of subsequent pregnancies -19.0%-31.8%*

Months receiving AFDC -19.9% -33.1%*

Months receiving food stamps -15.1% -44.1%*

Months employed +7.5% +19.9%

Substance use impairments -20.9% -43.8%*

* significant at 0.05 level

Other Reported Benefits

Children:• Improved mental and physical health• Better access to, and use of, medical care• Improved immunization coverage• Improved school achievement

Parents:• Improved family planning (e.g., spacing of

pregnancies)• Improved home environment• Higher level of education

Other Reported and Potential Harms

• Olds (Elmira, 1994) reports greater “restriction and punishment” among home-visited than among control parents. Evidence suggests an association among home visited mothers of “restriction and punishment” and lower rates of injury.

• Stigmatization by target group criteria (e.g., low SES, single, minority, at risk for maltreatment)

Reported Barriers

• Retention of participants, even in research study settings. Many participants lead difficult lives with few resources. • Move frequently• Unemployment and job transitions• Lack of interest

• Retention of home-visiting personnel

Applicability

• Many early childhood home visitation programs reviewed were targeted at populations considered to be at high risk of poorer child well-being and related outcomes.

• Although Olds reports greater or more significant effects among single, low-SES-mother families, no general demographic characteristics distinguish more or less successful programs.

Conclusion

• Early childhood home visitation:

• Effective in prevention of child maltreatment

• Greater effects are found with programs delivered by professionals (e.g., nurses or mental health workers)

• With paraprofessional visitors, beneficial effects are found with programs of longer duration.

• Additional maternal and some child benefits; minor harms reported

Conclusion: Effects of Early Childhood Visitation on Child

Maltreatment

• Strong evidence to recommend• Greater effect with professional home

visitors• With paraprofessional visitors, a

beneficial effect is found with longer program duration

End

Results: Initiation time (Prenatal, Postnatal, or Either)

Pre Post Either

Total intervention arms 6 16 4Negative 4 11 4Positive 2 5 0

Median -23.7 -20.9 -74.3IQ range: lower -58.0 -59.5 N/A upper +66.8 +37.2 N/ARange: lower -93.2 -100.0 N/A upper +228.4 +127.6 N/A

Effects of Home Visitation on Child Maltreatment by Program Initiation Time

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-120 -80 -40 0 40 80 120 160 200 240Percent Change from Baseline

CarusoDawsonBarthKitzmanLarson1MarcenkoOldsBraydenBrootenDugganGrayHardyHonig1Honig2KatzevLarson2MuslowSiegel1Siegel2Siegel3VelasquezWagner3FlynnHuxleyWagner1Wagner2

Prenatal

Either

Postnatal

Results: Single vs. Multicomponent

Single Multi

Total intervention arms 14 12Negative 10 9Positive 4 3

Median -20.9 -46.0IQ range: lower -65.7 -89.4 upper +21.4 +22.4Range: lower -87.4 -100.0 upper +127.6 +228.4

Effects of Home Visitation on Child Maltreatment, Single vs. Multicomponent

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-120 -80 -40 0 40 80 120 160 200 240Percent Change from Baseline

BarthDugganFlynnHardyHonig1Honig2HuxleyLarson1Larson2MarcenkoMuslowSiegel1Siegel2Siegel3BraydenBrootenCarusoDawson Gray Katzev Kitzman Olds Velasquez Wagner1 Wagner2Wagner3

Singlecomponent

Multi-component

Home Visitation Effects by Study Execution Score

-120

-60

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180

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0 1 2 3 4 5

Execution score (i.e., # penalties)

Rel

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Results: Randomized vs. Non-randomized

Random Not Random

Total intervention arms 18 8Negative 13 6Positive 5 2

Median -27.5 -68.3IQ range: lower -46.9 -77.3 upper +19.6 +20.0Range: lower -100.0 -93.2 upper +228.4 +94.1

Effects of Home Visitation on Child Maltreatment, by Randomization

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-120 -80 -40 0 40 80 120 160 200 240Percent Change from Baseline

BarthBraydenBrootenDawsonDugganGrayHardyKitzmanLarson1Larson2MarcenkoOldsSiegel1Siegel2Siegel3Wagner1Wagner2Wagner3CarusoFlynnHonig1Honig2HuxleyKatzevMuslow Velasquez

Random

Non-random