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)
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The Effectiveness of Early Childhood Home Visitation in the Prevention of Child Abuse
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) - PowerPoint PPT Presentation
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The Effectiveness of Early Childhood Home Visitation in the Prevention of Child Abuse
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)
• 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
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)