Violence: Early Childhood Home Visitation To Prevent – Child Maltreatment

The CPSTF finding is based on evidence from a systematic review of 21 studies (search period through December 2001). The review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to violence prevention.

In this review, maltreatment includes all forms of child abuse and neglect.

Detailed results from the systematic review are available in the CPSTF finding [PDF - 150 kB].

Twenty-one studies were included in the review.

• Child maltreatment in high-risk families: median reduction of 38.9% in episodes (interquartile interval: –74.1% to 24.0%; 21 studies, 26 study arms)
  • Longer-duration programs produced larger effects; programs of less than 2 years duration did not appear to be effective.
  • Professional home visitors may be more effective than trained paraprofessionals, but longer-duration programs with trained paraprofessionals can also be effective.

Detailed results from the systematic review are available in the CPSTF finding [PDF - 150 kB].

• One study qualified for the review of economic evidence. Estimates are reported in 1997 U.S. dollars.
• The study evaluated the net benefits of a nurse home visitation program provided to first-time mothers in a semi-rural county.
• The costs and benefits analyzed for this intervention were limited to government costs and benefits, not those of program participants, the healthcare system, or society at large.
  • Program costs considered were through the child’s second birthday and included nurse salaries and fringe benefits; nurse training; part-time secretary; part-time supervisor; taxicab; linked services such as the Women, Infants, and Children (WIC) nutritional supplementation program; supplies; and overhead.
  • The benefits considered were through the child’s fourth birthday and included reduced use of government services (i.e., AFDC, Child Protective Services, Food Stamps, and Medic aid) and newly generated tax revenues from mothers returning to work.
• For a subsample of low-income families, governmental benefits more than offset program costs, for a net benefit to government of $350.61 per low-income family.
• For the whole sample, governmental costs exceeded benefits, which resulted in a net benefit of –$3,081 per family.

These programs should be applicable to most families considered to be at high risk of child maltreatment (e.g., single or young mothers, low-income households, families with low birth weight infants).

Each Community Preventive Services Task Force (CPSTF) review identifies critical evidence gaps—areas where information is lacking. Evidence gaps can exist whether or not a recommendation is made. In cases when the CPSTF finds insufficient evidence to determine whether an intervention strategy works, evidence gaps encourage researchers and program evaluators to conduct more effectiveness studies. When the CPSTF recommends an intervention, evidence gaps highlight missing information that would help users determine if the intervention could meet their particular needs. For example, evidence may be needed to determine where the intervention will work, with which populations, how much it will cost to implement, whether it will provide adequate return on investment, or how users should structure or deliver the intervention to ensure effectiveness. Finally, evidence may be missing for outcomes different from those on which the CPSTF recommendation is based.

Identified Evidence Gaps

The following outlines evidence gaps from reviews of early childhood home visitation programs to prevent child maltreatment, intimate partner violence, violence by children participating in the program, and violence by parents (other than child maltreatment or intimate partner violence)

Although we have demonstrated the effectiveness of home visitation in the prevention of child maltreatment, evidence on the other outcomes assessed (violence by children, violence by parents, and intimate partner violence) was insufficient to determine effectiveness. Further research on the effectiveness of home visitation in the prevention of these outcomes would clarify other possible benefits of this intervention. Findings of large, but statistically nonsignificant, effect sizes for some of these outcomes suggest that studies may be of low statistical power; we believe that larger sample sizes should be considered. Suicidal behavior by visited children and diverse forms of victimization should also be assessed as outcomes in home visitation programs. Follow-up studies should determine long-term as well as short-term effects.

The evidence we reviewed indicates a benefit of home visitation for the reduction of child maltreatment in populations that have been shown to be at elevated risk of maltreatment. The population that might benefit is a large one. In 1999, 33% of the 3.6 million births in the United States were to single mothers, 12% were to teen mothers, and 22% were to mothers with less than a high school education (Eberhardt et al., 2001); 43% of births—approximately 1.7 million—were to mothers with at least one of these characteristics (B. Hamilton, National Center for Health Statistics, “personal communication,” Sept. 9, 2002). Given such a large need, it will be useful to conduct research, perhaps in the form of demonstration projects, to make the intervention more effective. Because the visitation programs reviewed are heterogeneous and differ in content, organization, personnel, intensity, and other characteristics, questions that should be addressed include:

• What number, spacing, and duration of home visits is optimal for cost-effective programs that are acceptable to visited families?
• What training for professional and paraprofessional home visitors maximizes cost-effectiveness?
• What circumstances enhance the effectiveness of paraprofessional visitors (e.g., educational background and origin)?
• How should the curriculum of home visits be organized, in terms of:
  • Structure?
  • Specific components and contents?
• How strong is the need for program fidelity (i.e., degree of adherence to initially proposed curriculum and schedule) for the reduction of violent behaviors?
• What is the utility of additional components, such as parent support groups, child daycare, enhanced pediatric care, free transportation to appointments, and linkage with social support services?
• What are the essential components of home visitation programs, and what components are dispensable?
• What populations are most likely to benefit from home visitation programs and what program characteristics are most important for specific populations?

Applicability

The effectiveness of home visitation for child maltreatment prevention has been demonstrated in a variety of geographic areas and "at-risk" populations. Although we found insufficient evidence to determine the effectiveness of home visitation on child violence, parental violence, and other outcomes among both visited children and parents, evidence from the Elmira study indicated beneficial effects for these outcomes among visited low SES households with single parents. It is still unclear whether other specific subgroups (e.g., racial/ethnic populations) within the general category of "population at-risk" are likely to benefit more than other subgroups.

Studies of the effectiveness of home visitation in preventing violence by visited children have examined diverse populations, but too few studies are available, and they provide inconsistent evidence. Evidence about parental violence outcomes is limited to a mostly white population from the northeastern United States, principally from the study by Olds et al (1997; 1998). If found to be effective, the applicability of early home visitation for these outcomes in different populations should also be determined. In addition, it will be useful to determine if home visitation is effective in the general population (as well as in "at-risk" populations), and if so, if benefits exceed costs.

Other Positive or Negative Effects

As noted, this review did not systematically summarize evidence of the effectiveness of home visitation programs on nonviolent outcomes. Such outcomes might include children's cognitive, emotional, and physical development; school achievement; substance use; sexual activity; access to health care; immunization coverage; quality and safety of the home environment; employment of parents; educational achievement of parents; and family planning, including spacing and number of subsequent pregnancies. We are hopeful that the research questions that we have just developed for home visiting and violence might also inform additional studies or reviews of home visiting to achieve other outcomes as well. Concerning negative effects, questions that should be addressed include:

• How serious is the problem of stigmatization by risk criteria when home visitation programs are directed at "at-risk" populations?
• If stigmatization is an important problem (under some or all circumstances), what can be done in program design to minimize the negative effects of stigmatization?
• What role can community coalitions play in preventing or alleviating stigmatization?

Economic Evidence

The available economic evidence was limited. Considerable research is warranted on the following questions:

• What is the cost and cost effectiveness of the various alternative home visitation programs?
• How can effectiveness in terms of health outcomes or quality-adjusted health outcomes be better measured, estimated, or modeled?
• How can the cost benefit of this program be estimated from a societal perspective?
• How do specific characteristics of this approach contribute to economic efficiency?

Barriers

Several important barriers may adversely affect implementation and outcomes of home visitation programs. Addressing the following research questions may help to avoid or overcome these barriers:

• What program components or design features improve the retention of program participants?
• Can baseline characteristics of families that are more likely to drop out of home visitation programs be identified? Might such identification improve efforts to retain participants in the programs?
• What design characteristics of home visitation programs improve the work satisfaction and retention of home visitors?
• What background characteristics of visitors and required pre-program training minimize visitor dropout and maximize program performance?
• What features of service systems are essential for efficient implementation and sustainability of home visitation programs?
• What is the minimum level of services infrastructure needed to support adequate supervision of lay home visitors?
• What combination of community characteristics provides optimal community readiness for implementation and sustainability of home visitation programs?

References

Eberhardt MS, Ingram DD, Makuc DM, et al. Health, United States, 2001, with urban and rural chartbook. Hyattsville MD: National Center for Health Statistics, 2001.

Olds DL, Henderson CR Jr, Cole R, et al. Long-term effects of nurse home visitation on children's criminal and antisocial behavior: 15-year follow-up of a randomized controlled trial.JAMA 1998;280:1238–44.

Olds DL, Eckenrode J, Henderson CR Jr, et al. 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;278:637–43.

• All studies were conducted in the United States, except for one in Canada.
• Home visitation programs were conducted with teenage parents; single mothers; families of low socioeconomic status (SES); families with very-low-birth weight infants; parents previously investigated for child maltreatment; and parents with alcohol, drug, or mental health problems.