Journals > Journal: Preventing Child Maltreatment > Article: The Role of Home-Visiting Programs in Preventing Child Abuse and Neglect
Journal Issue: Preventing Child Maltreatment Volume 19 Number 2 Fall 2009
Kimberly S. Howard Jeanne Brooks-Gunn
Program Dimensions Linked to Effectiveness
To make more sense of the often disparate findings, we move toward identifying the core features of effective programs. In a 2003 paper in the American Psychologist, Maury Nation and colleagues identified a set of characteristics that were associated with the most effective prevention programs in the areas of substance abuse, risky sexual behavior, delinquency and violence, and school failure.114 John Borkowski, Leann Smith, and Carol Akai subsequently summarized the key themes of the Nation paper and identified a set of ten principles of effective prevention programs. In terms of treatment content, effective programs were theoretically based, comprehensive in their programming, used varied teaching methods, and fostered positive relationships. In terms of procedure, the dosage of the treatment was appropriate given the nature of the problem, the treatment was appropriately timed for prevention, and staff were well trained and culturally sensitive to the needs of participants. Finally, effective programs utilized rigorous evaluation methods and examined meaningful outcomes.115 In the field of home visiting, many programs lack one or more of these critical elements, a shortcoming that can be useful for understanding why some programs failed to show positive effects.
Home Visitor Credentials
One of the more controversial questions within the home-visiting field involves whether the visitors should be nurses and social workers or, instead, trained paraprofessionals and volunteers. According to the Olds model of home visiting, the expertise of the nurse visitor is critical. Indeed, Hawaii Healthy Start and the Comprehensive Child Development Program used paraprofessional home visitors instead of nurses and failed to produce change in any domain that they studied. However, the Healthy Families New York program also used paraprofessional home visitors, only about one-third of whom had college degrees. Even so, the program had significant benefits in decreasing child abuse and neglect and harsh parenting behaviors.116
In Denver, Olds and colleagues addressed this question empirically by randomly assigning families to three groups: a nurse-visited group, a group visited by paraprofessionals, and a control group. They reported that the effects associated with paraprofessional visitors were approximately half those of nurse visitors—though in most domains, the differences were not statistically significant. Nurses did seem to perform better in reducing maternal smoking and encouraging children’s language development.117
Although the consensus in the research literature suggests a benefit for using professional staff as home visitors, debate continues about whether health professionals or social professionals are more effective in bringing about positive change for families. The answer to this question may depend in large part on the overall goals of the program. For example, in the Nurse-Family Partnership, one of the goals is to improve pregnancy outcomes and promote child health. In that case, the choice of public health nurses as home visitors is ideal. Indeed, one of the largest effects of the NFP is a delay in the timing of second births among teenagers, which in and of itself can have ripple effects on the child and on the mother’s life course. In contrast, the program tested by van Doesum and colleagues was focused on improving parenting sensitivity and fostering attachment security in the mother-infant relationship. Accordingly, the home visitors were master’s level psychologists with additional training in prevention or health education, and the results suggested that they were successful in promoting parenting sensitivity.
Targets of Intervention
It is difficult to say whether home visiting confers more benefits on disadvantaged families than on more advantaged families. The vast majority of programs offer services only for mothers deemed at risk either because of their youth, low educational attainment or socioeconomic status, or poor mental health. However, within these categories of risk, it is possible to examine which mothers benefit the most. In fact, the findings of programs targeting adolescent mothers tended to differ from those of programs that enrolled mothers from a wider variety of backgrounds. For example, the Elmira and Memphis demonstrations of the Nurse-Family Partnership enrolled primarily adolescent mothers, whereas the Denver program enrolled a more diverse group. The greatest effects were found among low-income, first-time adolescent mothers. Furthermore, within the Elmira and Memphis evaluations, those families at the highest risk (because of poverty or lack of psychological resources) tended to gain the greatest benefits from the program.
The Healthy Families New York evaluation made specific efforts to replicate the type of participants served in the NFP, which has consistently demonstrated much more positive outcomes than Healthy Start. In addition to overall comparisons between families in the treatment and control groups, Kimberly Dumont and colleagues also identified a “prevention subgroup” of adolescents who were first-time mothers and who were enrolled in the program prenatally. They also identified a “psychologically vulnerable group” who were rated as being both high in depressive symptoms and low in self-mastery. Consistent with findings in Elmira and Memphis, these groups benefited most from the intervention. Within the prevention subgroup, mothers in the intervention showed significantly less physical aggression and harsh parenting toward their children. The psychologically vulnerable mothers in the intervention displayed significantly less serious abuse and neglect than psychologically vulnerable control group mothers.118
It is significant that home-visiting programs are particularly effective in preventing child abuse and neglect among first-time adolescent mothers, because these women provide the truest test of a primary prevention program. In other words, a home-visiting program may be able to prevent first-time mothers, who have never engaged in poor parenting or child abuse and neglect, from ever doing so in the first place. In contrast, mothers who already have children or who were enrolled postnatally may already be acting on ingrained patterns of poor parenting that place their children at risk. In such cases, the goal of the program is not simply to prevent a behavior from occurring, but to intervene and change a pattern of behaviors to prevent recurrence. Previous research has suggested that it is much more difficult to prevent recurrence of child abuse than to prevent it from happening in the first place.119
Service Delivery
Analyses investigating whether the effectiveness of programs is more closely linked to the number of planned visits or to the number of visits that take place have shown that programs with more planned visits tend to be most effective. Not surprisingly, families who benefit the most are those who receive the highest dosage of the intervention. One very likely reason for limited effects found in home-visiting evaluations is the fairly high percentage of families in the treatment group who receive little (or in some cases, no) treatment. Selecting home visitors who are well trained and culturally sensitive to the families they serve will likely encourage mothers to accept more home-visiting services.
It is also important to ensure that the program staff are highly trained and familiar with the goals of the program and that the program is being administered with fidelity to its model. One reason cited for the effectiveness of the Abecedarian project was that program goals were clearly stated and well understood by those who were administering services as well as those who were designing and conducting program assessments. And one critical failing found in the assessment of the Hawaii Healthy Start program was that the home visitors rarely referred families to additional services in the community, even for serious problems such as suspected child abuse or domestic violence, even though linking families to community resources was a primary goal of the program.120 That finding suggests that the program was not carried out as originally planned, resulting in an inadequate test of the HSP model of home visiting.
Finally, using a theoretically based curriculum is crucial to ensure that programs produce optimal results. Home-visiting programs have often been criticized for their high degree of flexibility and corresponding lack of specific curriculum, making it difficult to replicate programs or results. For many programs, including Early Head Start and Healthy Families America, home-visiting services center on meeting the needs of individual families, and therefore the content of visits varies dramatically from family to family. This variation across (and even within) sites likely contributes to the inconsistent patterns of findings. Initially, the Nurse-Family Partnership (originally known as the Nurse Home Visiting program) had a curriculum with less formal structure, but as the program has been replicated in other cities and has begun extending to sites around the nation, program content has become more specific and replicable, likely contributing to its success.
