Evidence for the Role of Home Visiting in Child Maltreatment Prevention
Kimberly Boller, PhD
Mathematica Policy Research, USA
In 2010, 3.3 million referrals of alleged acts of maltreatment involving 5.9 million children were made to child protective services agencies in the United States. Almost 1.8 million reports were investigated, and of those, 436,321 were substantiated and 24,976 were found to be indicated (unsubstantiated, but with suspected maltreatment or risk of maltreatment). An estimated 1,560 children died because of maltreatment, with the highest rates of victimization in the first year of life – 20.6 per 1,000 children.1 Research demonstrates that outcomes for children who survive child maltreatment (defined as neglect, abuse, or a combination of the two) are poor, with performance below national norms in a range of outcomes areas, including psychosocial and cognitive well-being and academic achievement.2,3,4 The costs to society overall of these children not reaching their full potential and the lower than expected productivity of adult survivors of abuse are estimated at as much as $50-90 billion per year in the U.S.5,6 These findings underscore the need for strategies to prevent child maltreatment in order to improve outcomes for children, families and communities.
Prenatal, infant and early childhood home visiting is one strategy that holds promise for preventing child maltreatment. Home visiting involves a trained home visitor working with parents in the family home to enhance the parent-child relationship, reduce risks of harm in the home, and provide a supportive environment. Most home visiting programs are voluntary, and states and communities encourage participation by families with risk for maltreatment (for example, families where parents have low levels of education, live in poverty, single-parent households, and parents who themselves were involved in the child welfare system). Over the past 40 years, more than 250 home visiting models have been developed by researchers and service providers, ranging widely in their approach to staffing, curriculum, length of service delivery, and demonstrated effectiveness in reducing rates of child maltreatment.7 This chapter provides an overview of the evidence about the effectiveness of home visiting in preventing child maltreatment, identifies research gaps and discusses implications for key stakeholders.
It is challenging for states and communities to decide how to select home visiting models that are appropriate for their target populations and effective in preventing child maltreatment. Public officials and decisionmakers need information to help them select from the different home visiting models. In many instances, the quality of the research is not sufficient to draw conclusions about the effects of a given model on child maltreatment.8
One measurement challenge is that states have different reporting and investigation requirements that hinder comparisons of rates of child maltreatment. In general, the rates of substantiated child abuse and neglect and emergency room visits for injuries and ingestions are relatively low, which means that much of the research includes measures of risk for child maltreatment, such as harsh parenting (use of corporal discipline techniques), maternal depression, substance abuse and domestic violence, and protective factors such as a positive home environment and a high-quality parent-child relationship. Assessing these risk factors using administrative and observational data collection techniques can be costly, and, although less costly, parent reports may not be as reliable. Another challenge is the potential for surveillance effects. Surveillance effects9 refer to the potential for increased reporting on families who participate in child welfare system services or research because more professionals are working with families and may file reports of suspected abuse and trigger an investigation, increasing the likelihood of a finding for these families compared to those who do not participate.
Research on child maltreatment has increased over the past 15 years and meta-analyses and reviews of the literature on the effectiveness of home visiting programs to prevent child maltreatment exist.10,11,12 However, until recently there was not a wide ranging systematic review of the evidence on home visiting.7,13,14,15,16 An effort launched in 2009 by the U.S. Department of Health and Human Services (HHS), the Home Visiting Evidence of Effectiveness (HomVEE), filled this gap by providing a systematic review of the early childhood home visiting research with particular attention to its applicability to the prevention of child maltreatment. The intent of the review was to assess the literature using pre-specified methodologies to identify and assess its quality. HHS used results of the review to identify which home visiting program models met requirements for evidence of effectiveness to guide state selection of models as part of a $1.5 billion federal initiative designed to increase the number of families and children served through evidence-based home visiting. The initiative is targeted at improving child and family outcomes, including decreasing rates of child maltreatment and improving parenting practices that may decrease risk for maltreatment. The nine national models that met the HHS evidence requirements as of October 2011 include Child FIRST, Early Head Start–Home Visiting (EHS–HV), Early Intervention Program for Adolescent Mothers (EIP), Family Check-Up, Healthy Families America (HFA), Healthy Steps, Home Instruction for Parents of Preschool Youngsters (HIPPY), Nurse-Family Partnership (NFP), and Parents as Teachers (PAT). As of July 2012, with completion of another round of the Home Visiting Evidence of Effectiveness reviews, three additional models met the U.S. Department of Health and Human Services evidence requirements, with detailed reports forthcoming.17 As summarized below for the nine models with full reviews available, not all demonstrated evidence of effectiveness in reducing child maltreatment and improving parenting practices.7,8
Key Research Questions
This review is designed to address two research questions:
- What is the evidence of effectiveness of home visiting to reduce rates of child maltreatment?
- What is the evidence of effectiveness of home visiting to increase positive parenting practices associated with reductions in the risk of child maltreatment?
Recent Research Results
What is the evidence of effectiveness of home visiting to reduce child maltreatment?
The HomVEE systematic review of evidence found that there are studies of HFA and NFP that included measures of substantiated reports of child abuse and neglect. Although an NFP study conducted when children were 4 years old showed no effect,18 another study found reductions in substantiated reports of child maltreatment 15 years after enrollment.19 Across a number of HFA studies there was no evidence of near-term effects on substantiated reports,20,21,22,23 and there were no longer-term follow-up studies. One study of Child FIRST found positive effects on involvement with child protective services at three years.24 There are studies of Early Head Start–Home Visiting (EHS–HV), HFA, Healthy Steps, and NFP that measure effects on emergency room or doctor visits for injuries or ingestions but only NFP showed positive effects.13,18,25,26
Studies of HFA showed mixed but mostly no effects on a parent-reported measure of a range of abusive parenting behaviours. Some studies showed positive impacts of HFA on parent self-reports of reductions in the frequency of neglect, harsh parenting in the past week, and other types of abuse.8,21,22,23,27
What is the evidence of effectiveness of home visiting to increase protective factors associated with reductions in the risk of child maltreatment?
Seven of the nine models meeting the HHS evidence criteria have studies that report positive impacts on improving protective factors such as parenting practices and quality of parent-child interaction, and the safety and stimulation provided in the home environment (the study of Child FIRST did not include these outcomes and the Early Intervention Program for Adolescent Mothers studies did not show effects). Research demonstrates that NFP and PAT also have negative effects, such as program families having fewer appropriate play materials in the home than the comparison group families, using harsher discipline techniques and being less accepting of the child’s behaviour. The review also found that EHS–HV had positive effects on parent knowledge of infant development.8,14
Although there are studies of home visiting that report effects of child maltreatment on child and family outcomes, relatively few of them use rigorous methods that support drawing causal inferences about effectiveness. In fact, many studies of home visiting models that have a more early childhood education focus do not include measures of child abuse and neglect, rather they focus on risk and protective factors. Challenges to including measures of child maltreatment involve the complexity of obtaining consent from families and access to state child welfare records, the need for both short- and long-term follow-up to assess program impact, and concerns about the reliability and validity of parent or staff reports. Given the evidence that different types of home visiting may reduce maltreatment and increase protective factors, studies of home visiting should include measures of both.
The existing body of rigorous research has been conducted with relatively small sample sizes that do not allow for assessment of the impact of home visiting on child maltreatment for important race/ethnic, linguistic and poverty subgroups. For example, an evidence review of home visiting program models targeted to American Indian and Alaska Native children and families found that of the three studies that demonstrated high levels of evidence of effectiveness, none reported outcomes separately for these children.28
Studies of home visiting’s effectiveness as an intervention designed to prevent child maltreatment demonstrate some promise, but compared to the number of studies conducted that measure child maltreatment, risk for maltreatment, or protective factors, there are far more findings of no effects than reductions in maltreatment and improvements in child and family well-being. Research also demonstrates variation in evidence of effectiveness across home visiting models, which means that the decision about which model to implement is important. State and local policymakers and funders can use evidence of effectiveness to help make decisions about which model(s) to implement depending on community needs.
Overall, the research on home visiting to prevent child maltreatment could be improved with use of rigorous methods, appropriate measures, longer follow-up periods, and inclusion of and reporting on important subgroups. New studies should be large enough to include assessment and reporting of impacts by important subgroups to improve our understanding of what works for which populations. Evidence-based decision-making requires high-quality evidence and an investment in the research pipeline.
Implications for Parents, Services and Policy
Given the limited rigorous research evidence on home visiting’s effectiveness to prevent child maltreatment, one potential impact of using an approach like Home Visiting Evidence of Effectiveness, which attaches state funding to the quality of the evidence, may be to increase the amount and quality of the child maltreatment prevention research conducted globally. Better research also may increase the use of evidence by service policymakers and service providers. Because the Home Visiting Evidence of Effectiveness and the U.S. Department of Health and Human Services evidence requirements and the resulting information about effectiveness are public, researchers can use them to increase the rigor of their evaluations. Likewise, policymakers can demand that evidence guide funding decisions and policy.29
One potential indicator of the success of increased attention to evidence of the effectiveness of home visiting on prevention of child maltreatment is the relative proportion of state and local funding available for evidence-based models compared to those with no or low levels of evidence. In turn, families will receive interventions that meet the highest levels of evidence for preventing child maltreatment, and they and the public can be confident that the programs they participate in and support through their tax dollars have the greatest potential to improve child and family well-being.
- U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2011). Child maltreatment 2010. Washington, DC: U.S. Department of Health and Human Services.
- RTI International (2008). From early involvement with child welfare services to school entry: A 5- to 6-year follow-up of infants in the national survey of child and adolescent well-being. Research Triangle Park, NC: RTI International.
- RTI International (2008). Adolescents involved with child welfare: A transition to adulthood. Research Triangle Park, NC: RTI International.
- RTI International (2010). Children involved in child welfare: A transition to adolescence. Research Triangle Park, NC: RTI International.
- Corso, P.S. (n.d.). Dollars and lives: The economics of healthy children. Chicago, IL: The Doris Duke Charitable Foundation. Available at: http://www.preventchildabuse.org/publications/cap/documents/CorsoWHTPPR.pdf. Accessed July 30. 2012.
- Corso, P. S., & Fertig, A.R. (2010). The economic impact of child maltreatment in the United States: Are the estimates credible? Child Abuse & Neglect, 34, 296–304.
- Paulsell, D., Avellar, S., Sama Miller, E., & Del Grosso, P. (2011). Home Visiting Evidence of Effectiveness: Executive summary. Princeton, NJ: Mathematica Policy Research.
- Supplee, L., Paulsell, D., & Avellar, S. (2012). What works in home visiting programs? In Curtis, P.A., Alexander, G. eds. What Works in Child Welfare. Washington, DC: Child Welfare League of American Press, 39-61.
- Waldfogel, J. Prevention and the child protection system. (2009). The Future of Children, 19, 195-210.
- Gomby, D. S. (2005). Home visitation in 2005: Outcomes for children and parents. Invest in kids working paper no. 7. Washington, DC: Committee on Economic Development.
- Sweet, M. A., & Applebaum, M. I. (2004). Is home visiting an effective strategy? A meta-analytic review of home visiting programs for families with young children. Child Development, 75, 1435-1456.
- Howard, K.S. & Brooks-Gunn, J. (2009). The role of home-visiting programs in preventing child abuse and neglect. The Future of Children, 19, 119-146.
- Home Visiting Evidence of Effectiveness. (2011a). Reductions in child maltreatment. Available at: http://homvee.acf.hhs.gov/document.aspx?rid=2&sid=4. Accessed July 30, 2012.
- Home Visiting Evidence of Effectiveness. (2011b). Positive parenting practices. Available at http://homvee.acf.hhs.gov/document.aspx?rid=2&sid=6. Accessed July 30, 2012.
- The California Evidence-Based Clearinghouse for Child Welfare. (n.d.). Home visiting for prevention of child abuse and neglect. Available at: http://www.cebc4cw.org/topic/home-visiting-for-prevention-of-child-abuse-and-neglect/. Accessed July 30, 2012.
- The California Evidence-Based Clearinghouse for Child Welfare. (n.d.). Home visiting for child well-being. Available at: http://www.cebc4cw.org/topic/home-visiting/. Accessed July 30, 2012.
- Home Visiting Evidence of Effectiveness. (2011c). Latest releases. Available at http://homvee.acf.hhs.gov/document.aspx?rid=7&sid=29&mid=1. Accessed September 14. 2012.
- Olds, D. L., Henderson Jr., C. R., Chamberlin, R., & Tatelbaum, R. (1986). Preventing child abuse and neglect: A randomized trial of nurse home visitation. Pediatrics, 78, 65–78.
- Olds, D. L., Eckenrode, J., Henderson, C. R., Kitzman, H., Powers, J., Cole, R., et al. (1997). Long-term effects of home visitation on maternal life course and child abuse and neglect. Fifteen-year follow-up of a randomized trial. JAMA: The Journal of the American Medical Association, 278(8), 637–643.
- Chambliss, J. W. (1998). An experimental trial of a home visiting program to prevent child maltreatment (Doctoral dissertation, Georgia State University, 1998). Dissertation Abstracts International, 61(03B), 152–1628.
- Duggan, A., McFarlane, E., Fuddy, L., Burrell, L., Higman, S. M., Windham, A., et al. (2004). Randomized trial of a statewide home visiting program: Impact in preventing child abuse and neglect. Child Abuse & Neglect, 28(6), 597–622.
- Duggan, A., Caldera, D., Rodriguez, K., Burrell, L., Rohde, C., & Crowne, S. S. (2007). Impact of a statewide home visiting program to prevent child abuse. Child Abuse & Neglect, 31(8), 801–827.
- DuMont, K., Mitchell-Herzfeld, S., Greene, R., Lee, E., Lowenfels, A., Rodriguez, M., et al. (2008). Healthy Families New York (HFNY) randomized trial: Effects on early child abuse and neglect. Child Abuse & Neglect, 32(3), 295–315.
- Lowell, D.I., Carter, A.S., Godoy, L., Paulicin, B., &Briggs-Gowan, M.J. (2011). Child FIRST: A comprehensive home-based intervention translating research into early childhood practice. Child Development, 82 (1), 193-208.
- Olds, D. L., Henderson, C. R., & Kitzman, H. (1994). Does prenatal and infancy nurse home visitation have enduring effects on qualities of parental caregiving and child health at 25 to 50 months of life? Pediatrics, 93(1), 89–98.
- Kitzman, H., Olds, D. L., Henderson, C. R., Hanks, C., Cole, R., Tatelbaum, R., et al. (1997). Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing. A randomized controlled trial. JAMA: The Journal of the American Medical Association, 278(8), 644–652.
- Landsverk, J., Carrilio, T., Connelly, C. D., Ganger, W., Slymen, D., Newton, R., et al. (2002). Healthy Families San Diego clinical trial: Technical report. San Diego: The Stuart Foundation, California Wellness Foundation, State of California Department of Social Services: Office of Child Abuse Prevention.
- Del Grosso, P., Kleinman, R., Esposito, A.M., Sama Martin, E., & Paulsell, D. (2011). Assessing the evidence of effectiveness of home visiting program models implemented in tribal communities. Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services. Washington, DC.
- Avellar, S. & Paulsell, D. (2011). Lessons learned from the home visiting evidence of effectiveness review. Princeton, NJ: Mathematica Policy Research.
How to cite this article:
Boller K. Evidence for the Role of Home Visiting in Child Maltreatment Prevention. In: Tremblay RE, Boivin M, Peters RDeV, eds. Spiker D, Gaylor E, topic eds. Encyclopedia on Early Childhood Development [online]. http://www.child-encyclopedia.com/home-visiting/according-experts/evidence-role-home-visiting-child-maltreatment-prevention. Published September 2012. Accessed February 23, 2018.