Evidence for the Role of Home Visiting in Child Maltreatment Prevention

Introduction

In 2019, 4.4 million referrals of alleged acts of maltreatment involving 7.9 million children were made to child protective services agencies in the United States. Almost 2.4 million reports moved forward to receive an investigation or alternative response. Of those, reports for 656,000 children were substantiated. An estimated 1,840 children died because of maltreatment, with the highest rates of victimization in the first year of life – 22.9 per 100,000 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 $428 billion in lifetime costs incurred annually in the U.S.⁵ These findings underscore the need for strategies to prevent child maltreatment in order to improve outcomes for children, families and communities.

Subject

Prenatal, infant and early childhood home visiting is one strategy adopted by many countries to prevent 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 government and communities encourage participation by families living in situations associated with risk for maltreatment (for example, those experiencing intergenerational trauma caused by racism and ongoing economic disenfranchisement). Over the past 50 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.^6,7 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.

Problems

It is challenging for states and communities to decide how to select home visiting models that are appropriate for families and effective in preventing child maltreatment. Public officials and decision makers 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.^7,8

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. 

Research Context

Research on child maltreatment has increased over the past 25 years and influential meta-analyses and reviews of the literature on the effectiveness of home visiting programs to prevent child maltreatment and inform national and local policy.^9,10,11 However, until 2009 there was not a wide-ranging systematic review of the evidence on home visiting. The U.S. Department of Health and Human Services (HHS) 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 annual reviews (the Home Visiting Evidence of Effectiveness or HomVEE), was to assess the literature using pre-specified and periodically updated methodologies to identify and assess its quality.¹² 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, the Maternal, Infant and Early Childhood Home Visiting Program (MIECHV) is targeted at improving child and family outcomes, including decreasing rates of child maltreatment and improving parenting practices that may decrease risk for maltreatment. 

By July 2012, nine national models met HHS evidence review requirements. As of November 2021, nineteen of fifty models reviewed met the HHS requirements and were eligible for state use as an “evidence-based model.”⁷ As summarized below for the 19 models that met HHS criteria and have full reviews available, not all demonstrated evidence of effectiveness in reducing child maltreatment and improving parenting practices.⁷ In addition, a 12-state, legislatively mandated longitudinal impact and implementation evaluation of the MIECHV program (the Maternal and Infant Home Visiting Program Evaluation; MIHOPE), found few statistically significant impacts on child maltreatment and parenting practices among four of the most widely implemented models in the United States (Early Head Start-Home-based Option, Healthy Families America, Nurse-Family Partnership, and Parents as Teachers).¹³ 

Key Research Questions

This review is designed to address two research questions using findings from both the 2021 HomVEE systematic review and MIHOPE:

1. What is the evidence of effectiveness of home visiting to reduce rates of child maltreatment?
2. 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 2021 HomVEE systematic review of evidence found that of the eleven models with high or moderate quality studies that met the HHS review criteria, only five had favorable impacts on reducing child maltreatment (Early Start New Zealand, Healthy Access Nurturing Development Services Program [HANDS], Healthy Families America [HFA], Nurse-Family Partnership [NFP], and SafeCare Augmented).¹⁴ Overall, only a few studies included measures of substantiated reports of child abuse and neglect or emergency room or doctor visits for injuries or ingestions. These included studies of Early Start New Zealand, HANDS, HFA, and NFP that found favorable impacts in some, but not all, of these outcomes primarily collected from child protection service or medical records. Studies of NFP tended to include these measures and found some significant favorable impacts on substantiated reports hospitalizations, emergency department visits for accidents or poisoning, and number of injuries or ingestions, but the impacts were not consistent within and across different longitudinal follow-up periods. For example, one article on an NFP 15-year follow-up study reported favorable impacts on the incidence of substantiated reports of abuse and neglect¹⁵ but another reported no impacts on the percentage of substantiated abuse and the percentage of substantiated neglect.¹⁶ Across a number of HFA studies there was no evidence of near-term effects on substantiated reports, but there was one study from Oregon that found a favorable impact on substantiated physical or sexual abuse reports after two years.¹⁷ One study of Early Start New Zealand and a few studies of NFP showed positive effects on emergency room or doctor visits for injuries or ingestions.^18,19,20 

Studies of HFA showed mixed but mostly no impacts on a parent-reported measure of a range of abusive parenting behaviors over follow-up periods ranging from one to seven years in four different jurisdictions. 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 punishment and abuse.^21,22,23,24 Studies of Early Start New Zealand and SafeCare Augmented found impacts on the same parent report measure in the areas of severe or very severe physical assault and nonviolent discipline, respectively.^18,25

MIHOPE’s findings on maltreatment are consistent with the overall pattern of the evaluation’s findings of few small impacts and little variation across models and family characteristics. Among the 12 primary outcome measures assessed when the children were 15 months old, only four were statistically significant. Two of the four were frequency of psychological aggression toward the child and the number of emergency department visits paid for by Medicaid. However, after controlling for the large number of statistical tests, none of the observed impacts were found to be significant.¹³

What is the evidence of effectiveness of home visiting to increase protective factors associated with reductions in the risk of child maltreatment?

Thirteen of the nineteen models meeting the HHS evidence criteria and eligible for implementation as “evidence-based” 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.²⁶ Four of the thirteen with positive impacts (Family Check-Up for Children, HFA, PAT, and Play and Learn Strategies Infant) also have at least one unfavorable or ambiguous impact. 

MIHOPE’s findings on increasing protective factors include one positive impact on the quality of the home environment when the children were 15 months old. However, after controlling for the large number of statistical tests, none of the observed impacts were found to be significant.¹³

Research Gaps

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 and measures that support drawing causal inferences about effectiveness. In fact, many studies of home visiting models that focus primarily on childhood education 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.

Much 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, a 2011 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.²⁷ Since then, a few additional studies have been contributed to the evidence needed to guide Tribal home visiting programs and policy.^28,29

The rapid shift to providing virtual services in 2020 as a result of COVID-19 precautions has the potential to revolutionize home visiting. However, there is scant evidence to guide policy and programmatic decisions about alternative modes of service delivery ranging from all virtual to hybrid versions of in-home and virtual visits. PAT is one model that has some information available about implementation of virtual visits from a feasibility study with 84 parents and children. The study found an increase in parent engagement compared to previous program data, but the research design did not support include a study of effectiveness.³⁰ Essentially, decision makers in 2022 and beyond are proceeding with delivering services using “evidence-based” models in modes that do not have any evidence of effectiveness. As research proceeds, policy makers, program managers, and families have an opportunity to revisit home visiting’s fundamental assumptions about how services that support parents can best meet the needs of communities and be informed by evidence.

Conclusions

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 some 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, but in light of COVID-19 and the racial reckoning that swelled in 2020, a number of issues need to be addressed, including the lack of access to virtual services for many most affected by the digital divide.

Overall, the research on home visiting to prevent child maltreatment could be improved with use of rigorous methods, appropriate measures, longer follow-up periods, inclusion of and reporting on important subgroups, and incorporation of family and community participation in identifying outcomes of relevance to guide local decision making. New studies of modifications to the existing “evidence-based” models and those focused on providing virtual or hybrid services should be funded to take advantage of the natural experiments that have happened in response to COVID-19. They should be resourced to be large enough to improve our understanding of what modes of service delivery work for which populations. Evidence-based decision-making and implementation of services that appeal to and reach all families requires high-quality evidence and an investment in the research-practice-community pipeline.³¹

Implications for Parents, Services and Policy

The approach taken by HHS in using the HomVEE systematic review process to attach state funding to the quality of the evidence, has increased 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 HomVEE and HHS evidence requirements and the resulting information about effectiveness are public, researchers are using them to increase the rigor of their evaluations. 

In light of the dearth of evidence, of effectiveness, approaches emphasizing innovation and improvement that center families and communities are needed. These include expanding the reach and research on existing Collaborative Improvement and Innovation Networks and learning more about how universal home visiting systems can help engage families in home visiting and improve child and family well-being.

References

1. U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child maltreatment 2019. Washington, DC: U.S. Department of Health and Human Services; 2021.

2. Casanueva C, Tueller S, Smith K, Dolan M, Ringeisen. NSCAW II Wave 3 Tables. OPRE Report #2013-43. Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services; 2014.

3. Casanueva C, Smith K, Ringeisen H, Dolan M, Testa M, Burfeind C. NSCAW Child Well-Being Spotlight: Children Living in Kinship Care and Nonrelative Foster Care Are Unlikely to Receive Needed Early Intervention or Special Education Services. Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services; 2020.

4. Casanueva C, Dolan M, Smith KR. Disconnected youth involved in child welfare. Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services; 2014.

5. Peterson C, Florence C, Klevens J. The economic burden of child maltreatment in the United States. Child Abuse & Neglect 2018;86:178-183. 

6. Paulsell D, Avellar S, Sama Miller E, Del Grosso P. Home Visiting Evidence of Effectiveness: Executive summary. Princeton, NJ: Mathematica Policy Research; 2011.

7. U.S. Department of Health and Human Services, Administration for Children and Families, Office of Planning, Research and Evaluation. Early childhood home visiting models: Reviewing evidence of effectiveness. Washington, DC: Office of Planning, Research and Evaluation; 2021.

8. Supplee L, Paulsell D, Avellar S. What works in home visiting programs? In: Nelson K, Scheitzer D, eds. What Works in Child Welfare. Washington, DC: Child Welfare League of America Press 2012;39-61.

9. Gomby DS. Home visitation in 2005: Outcomes for children and parents. Invest in kids working paper no. 7. Washington, DC: Committee on Economic Development; 2005.

10. Sweet MA, Applebaum MI. Is home visiting an effective strategy? A meta-analytic review of home visiting programs for families with young children. Child Development 2004;75: 1435-1456.

11. Howard  KS, Brooks-Gunn J. The role of home-visiting programs in preventing child abuse and neglect. The Future of Children 2009;19:119-146.

12. Sama-Miller E, Lugo-Gil J, Harding J, Akers L, Coughlin R. Home visiting evidence of effectiveness (HomVEE) systematic review: Handbook of procedures and evidence standards, Version 2.1. Washington, DC: Office of Planning, Research, and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services; 2021.

13. Michalopoulos C, Faucetta K, Hill CJ, Portilla XA, Burrell L, Lee H, Duggan A, Knox V. Impacts on family outcomes of evidence-based early childhood home visiting: Results from the mother and infant home visiting program evaluation. Washington, DC: Office of Planning, Research, and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services; 2019.

14. Home Visiting Evidence of Effectiveness. Reductions in child maltreatment. 2021a. https://homvee.acf.hhs.gov/outcomes/reductions%20in%20child%20maltreatment/In%20brief. Accessed January 28, 2022.

15. Olds DL, Eckenrode J, Henderson CR, Kitzman H, Powers J, Cole R, Sidora K, Morris P, Pettitt LM, Luckey D. 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(8):637-643. 

16. Eckenrode J, Zielinski D, Smith E, Marcynyszyn LA, Henderson CR, Kitzman H, Cole R, Powers J, Olds DL. Child maltreatment and the early onset of problem behaviors: Can a program of nurse home visitation break the link? Development and Psychopathology 2001;13(4):873-890.

17. Green BL, Sanders MB, Tarte J. Using administrative data to evaluate the effectiveness of the Healthy Families Oregon home visiting program: 2–year impacts on child maltreatment & service utilization. Children and Youth Services Review 2017;75:77-86.

18. Fergusson DM, Horwood LJ, Grant H, Ridder EM. Early start evaluation report. Christchurch, NZ: Early Start Project Ltd. 2005.

19. Olds DL, Henderson Jr CR, Chamberlin R, Tatelbaum R. Preventing child abuse and neglect: A randomized trial of nurse home visitation. Pediatrics 1986;78:65-78.

20. Olds DL, Henderson CR, Kitzman H. 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 1994;93(1):89-98.

21. Duggan A, McFarlane E, Fuddy L, Burrell L, Higman SM, Windham A, Sia C. Randomized trial of a statewide home visiting program: Impact in preventing child abuse and neglect. Child Abuse & Neglect 2004;28(6):597-622.

22. Duggan A, Caldera D, Rodriguez K, Burrell L, Rohde C, Crowne SS. Impact of a statewide home visiting program to prevent child abuse. Child Abuse & Neglect 2007;31(8):801-827.

23. DuMont K, Mitchell-Herzfeld S, Greene R, Lee E, Lowenfels A, Rodriguez M, Dorabawila V. Healthy Families New York (HFNY) randomized trial: Effects on early child abuse and neglect. Child Abuse & Neglect 2008;32(3):295-315.

24. DuMont K, Kirkland K, Mitchell-Herzfeld S, Ehrhard-Dietzel S, Rodriguez ML, Lee E, Layne C, Greene R. A randomized trial of Healthy Families New York (HFNY): Does home visiting prevent child maltreatment? Rensselaer, NY: New York State Office of Children & Family Services and Albany, NY: University of Albany, State University of New York; 2010.

25. Silovsky JF, Bard D, Chaffin M, Hecht D, Burris L, Owora A, Beasley L, Doughty D, Lutzker J. Prevention of child maltreatment in high-risk rural families: A randomized clinical trial with child welfare outcomes. Children and Youth Services Review 2011;33(8):1435-1444.

26. Home Visiting Evidence of Effectiveness. Positive parenting practices. 2021b. https://homvee.acf.hhs.gov/outcomes/Positive%20Parenting%20Practices/In%20Brief. Accessed January 28, 2022.

27. Del Grosso P, Kleinman R, Esposito AM, Sama Martin E, Paulsell D. Assessing the evidence of effectiveness of home visiting program models implemented in tribal communities. Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services; 2011.

28. Coughlin R, Argueta I, Mraz Esposito A, SamaMiller E. Assessing the research on early childhood home visiting models implemented with tribal populations—Part 1: Evidence of effectiveness. Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services; 2020.

29. Mraz Esposito A, Yanez A, Coughlin R, Sama-Miller E. Assessing the research on early childhood home visiting models implemented with tribal populations—Part 2: Lessons learned about implementation and evaluation. Washington, DC: Office of Planning, Research, and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services; 2020.

30. Traube DE, Hsiao HY, Rau A, Hunt-O’Brien D, Lu L, Islam N. Advancing home-based parenting programs through the use of telehealth technology. Journal of Child and Family Studies. 2020;29:44-53.

31. Daro D. A shift in perspective: A universal approach to child protection. Future of Children. 2019;29(1):17-40.