The Effectiveness of Early Childhood Home Visitation in the Prevention of Child Abuse

1. 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)

2. The Guide to Community Preventive Services Systematic reviews and evidence-based recommendations regarding community level interventions Already published: Vaccine-Preventable Diseases Tobacco Use Prevention and Control Motor Vehicle Occupant Injury Prevention Social Environment Diabetes Physical Activity Oral Health http://www.thecommunityguide.org

3. 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.

4. 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

5. Descriptions (1) Sampling (1) Measurement (2) Exposure Outcome Data Analysis (1) Interpretation (3) Follow-up Confounding Other Biases Other (1) Community Guide Methods: Quality of Execution (penalties) Total of 9 points possible. Studies with 5 flaws are excluded.

6. Community Guide Methods: Criteria for Evidence of Effectiveness

7. Child maltreatment reports in the US Approximately 4.3% of children (<18 years) in 1996 Source: National Center for Juvenile Justice, 1999

8. 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

9. 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

10. 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.

11. 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

12. Analytic Framework: Early Childhood Home Visitation Violence by adolescent parent(s) Parent Knowledge Skills Self-confidence Access to resources Parenting Home visitation program Partner abuse by adolescent parent Child Development Skills Health/ well-being Child maltreatment Violent act by juvenile

13. 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 • Child maltreatment- effective:recommended, strong evidence

14. Child Maltreatment Child maltreatment (or victimization) includes abuse and neglect

15. Direct Measures CPS reports Parent’s reports Other report or observation of abuse, neglect, or victimization Proxy Measures ER visits/ hospitalization for injury or ingestion Injury Out-of-home placement Measures of Child Maltreatment Direct measures chosen over proxy measures

16. Study Ratings Number of intervention arms (number of studies)

17. Effect size measure Effect size = Relative change in intervention group compared with relative change in intervention group

18. Maltreatment Results: Overall

19. Effectiveness of Home Visitation Barth Brayden Brooten Caruso Dawson Duggan Flynn Gray Hardy Honig1 Honig2 Huxley Katzev Kitzman Larson1 Larson2 Marcenko Muslow Olds Siegel1 Siegel2 Siegel3 Velasquez Wagner1 Wagner2 Wagner3

20. Results: By Outcome

21. Results: By Outcome Barth Brayden Brooten Caruso Dawson Duggan Flynn Hardy Honig1 Honig2 Huxley Katzev Muslow Olds Siegel1 Siegel2 Siegel3 Velasquez Wagner1 Wagner2 Gray Kitzman Larson1 Larson2 Wagner3 Marcenko Abuse/ neglect Trauma/ injury Placement

22. Study Bias: Presence of Home Visitor Leads to Increased Reporting of Child Abuse + visitor/-visitor: 1.8 (Brayden) – 2.5 (Dawson)

23. Results: By Outcome (Adjusted for Reporting Bias, Factor 1.5)

24. Results: By Outcome (Adjusted for Reporting Bias, Factor 1.5) Barth Brayden Brooten Caruso Dawson Duggan Flynn Hardy Honig1 Honig2 Huxley Katzev Muslow Olds Siegel1 Siegel2 Siegel3 Velasquez Wagner1 Wagner2 Gray Kitzman Larson1 Larson2 Wagner3 Marcenko Abuse/ neglect Trauma/ injury Placement

25. Results: By Visitor Type

26. Results: By Visitor Type Brooten Gray Kitzman Olds Velasquez Barth Brayden Dawson Duggan Flynn Hardy Honig1 Honig2 Huxley Katzev Marcenko Muslow Siegel1 Siegel2 Siegel3 Wagner1 Wagner2 Wagner3 Caruso Larson1 Larson2 Nurse Para-professional Mental health worker

27. Home Visitation Effects by Duration of Program Spearman correlation: Whole sample: -0.52 (p=0.01) Paraprofessionals: -0.63 (p<0.01) Professionals: -0.32 (NS)

28. Other stratified analyses 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

29. 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

30. 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

31. (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 Children: Mixed Effects

32. (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 Benefits and Harms for Mothers: Beneficial Effects

33. 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 Benefits

34. 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) Other Reported and Potential Harms

35. 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 Reported Barriers

36. 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. Applicability

37. 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

38. 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

39. End

40. Results: Initiation time (Prenatal, Postnatal, or Either)

41. Effects of Home Visitation on Child Maltreatment by Program Initiation Time Caruso Dawson Barth Kitzman Larson1 Marcenko Olds Brayden Brooten Duggan Gray Hardy Honig1 Honig2 Katzev Larson2 Muslow Siegel1 Siegel2 Siegel3 Velasquez Wagner3 Flynn Huxley Wagner1 Wagner2 Prenatal Postnatal Either

42. Results: Single vs. Multicomponent

43. Effects of Home Visitation on Child Maltreatment, Single vs. Multicomponent Barth Duggan Flynn Hardy Honig1 Honig2 Huxley Larson1 Larson2 Marcenko Muslow Siegel1 Siegel2 Siegel3 Brayden Brooten Caruso Dawson Gray Katzev Kitzman Olds Velasquez Wagner1 Wagner2 Wagner3 Single component Multi- component

44. Home Visitation Effects by Study Execution Score

45. Results: Randomized vs. Non-randomized

46. Effects of Home Visitation on Child Maltreatment, by Randomization Barth Brayden Brooten Dawson Duggan Gray Hardy Kitzman Larson1 Larson2 Marcenko Olds Siegel1 Siegel2 Siegel3 Wagner1 Wagner2 Wagner3 Caruso Flynn Honig1 Honig2 Huxley Katzev Muslow Velasquez Random Non- random