the effectiveness of early childhood home visitation in the prevention of child abuse
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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 PresentationTRANSCRIPT
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)
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)
• Descriptions (1) • Sampling (1)• Measurement (2)
ExposureOutcome
• Data Analysis (1)
• 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
• Child maltreatment- effective: recommended, strong evidence
Child Maltreatment
Child maltreatment (or victimization) includes abuse
and neglect
Measures of Child Maltreatment
Direct Measures • CPS reports• Parent’s reports• Other report or
observation of abuse, neglect, orvictimization
Proxy Measures • ER visits/
hospitalization for injury or ingestion
• Injury • Out-of-home
placement
Direct measures chosen over proxy measures
Study Ratings
Quality ofExecution
Suitability of study design
Greatest Moderate Least
Good(0 - 1)
4(4)
Fair(2 – 4)
21(16) 1(1)
Limited( 5)
1(1)
Number of intervention arms (number of studies)
Effect size measure
Effect size = Relative change in intervention group compared with relative change in intervention group
Maltreatment Results: Overall
Total intervention arms 26
Negative 19
Positive 7
Median -38.9
IQ range: lower -74.1
upper +24.0
Range: lower -100.0
upper +228.4
Effectiveness of Home Visitation
0
1
2
3
4
5
6
7
8
9
1 0
1 1
1 2
1 3
1 4
1 5
1 6
1 7
1 8
1 9
2 0
2 1
2 2
2 3
2 4
2 5
2 6
2 7
-120 -80 -40 0 40 80 120 160 200 240
BarthBraydenBrootenCarusoDawsonDugganFlynnGrayHardyHonig1Honig2HuxleyKatzevKitzmanLarson1Larson2MarcenkoMuslowOldsSiegel1Siegel2Siegel3VelasquezWagner1Wagner2Wagner3
Results: By Outcome
Abuse/ neglect
Injury Place-ment
Total intervention arms 20 5 1Negative 14 5 0Positive 6 0 1
Median -39.6 -31.9 +13.0IQ range: lower -74.6 -72.2 N/A upper +37.2 -10.8 N/ARange: lower -100.0 -100.0 N/A upper +228.4 -2.9 N/A
Results: By Outcome
0
1
2
3
4
5
6
7
8
9
1 0
1 1
1 2
1 3
1 4
1 5
1 6
1 7
1 8
1 9
2 0
2 1
2 2
2 3
2 4
2 5
2 6
2 7
-120 -80 -40 0 40 80 120 160 200 240Percent Change from Baseline
BarthBraydenBrootenCarusoDawsonDugganFlynnHardyHonig1Honig2HuxleyKatzevMuslowOldsSiegel1Siegel2Siegel3VelasquezWagner1Wagner2GrayKitzmanLarson1Larson2 Wagner3Marcenko
Abuse/neglect
Trauma/injury
Placement
Study Bias: Presence of Home Visitor Leads to Increased Reporting of Child Abuse
0123456789
10
ab
us
e c
as
es
, %
of
the
s
am
ple
Dawson '89 Brayden '93
Incl. visitorsExcl. visitorsControls
+ visitor/-visitor: 1.8 (Brayden) – 2.5 (Dawson)
Results: By Outcome (Adjusted for Reporting Bias, Factor 1.5)
Abuse/neglect
Injury Place-ment
Total intervention arms 20 5 1
Negative 17 5 1
Positive 3 0 0
Median -59.7 -54.6 -24.7
IQ range: lower -83.1 -81.5 N/A
upper -8.5 -40.6 N/A
Range: lower -100.0 -100.0 N/A
upper +118.9 -35.3 N/A
Results: By Outcome (Adjusted for Reporting Bias, Factor 1.5)
0
1
2
3
4
5
6
7
8
9
1 0
1 1
1 2
1 3
1 4
1 5
1 6
1 7
1 8
1 9
2 0
2 1
2 2
2 3
2 4
2 5
2 6
2 7
-120 -80 -40 0 40 80 120 160 200 240Percent Change from Baseline
BarthBraydenBrootenCarusoDawsonDugganFlynnHardyHonig1Honig2HuxleyKatzevMuslowOldsSiegel1Siegel2Siegel3VelasquezWagner1Wagner2GrayKitzmanLarson1Larson2 Wagner3Marcenko
Abuse/neglect
Trauma/injuryPlacement
Results: By Visitor Type
Nurse Para-prof
Mental health worker
Total intervention arms 5 18 3Negative 5 11 3Positive 0 7 0
Median -48.7 -17.7 -44.5IQ range: lower -89.0 -65.7 N/A upper -24.6 +41.2 N/ARange: lower -100.0 -100.0 N/A upper -2.9 +228.4 N/A
Results: By Visitor Type
0
1
2
3
4
5
6
7
8
9
1 0
1 1
1 2
1 3
1 4
1 5
1 6
1 7
1 8
1 9
2 0
2 1
2 2
2 3
2 4
2 5
2 6
2 7
-120 -80 -40 0 40 80 120 160 200 240Percent Change from Baseline
BrootenGrayKitzman OldsVelasquez BarthBraydenDawsonDugganFlynnHardyHonig1Honig2HuxleyKatzevMarcenkoMuslowSiegel1Siegel2Siegel3Wagner1Wagner2Wagner3 CarusoLarson1Larson2
Nurse
Para-professional
Mentalhealth worker
Home Visitation Effects by Duration of Program
-120
-60
0
60
120
180
240
0 1 2 3 4
Duration of the program, yrs
Rela
tive p
ct
ch
an
ge
ParaprofessionalsProfessionals
Spearman correlation:Whole sample: -0.52 (p=0.01)Paraprofessionals: -0.63 (p<0.01)Professionals: -0.32 (NS)
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
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)
Pre Post Either
Total intervention arms 6 16 4Negative 4 11 4Positive 2 5 0
Median -23.7 -20.9 -74.3IQ range: lower -58.0 -59.5 N/A upper +66.8 +37.2 N/ARange: lower -93.2 -100.0 N/A upper +228.4 +127.6 N/A
Effects of Home Visitation on Child Maltreatment by Program Initiation Time
0
1
2
3
4
5
6
7
8
9
1 0
1 1
1 2
1 3
1 4
1 5
1 6
1 7
1 8
1 9
2 0
2 1
2 2
2 3
2 4
2 5
2 6
2 7
-120 -80 -40 0 40 80 120 160 200 240Percent Change from Baseline
CarusoDawsonBarthKitzmanLarson1MarcenkoOldsBraydenBrootenDugganGrayHardyHonig1Honig2KatzevLarson2MuslowSiegel1Siegel2Siegel3VelasquezWagner3FlynnHuxleyWagner1Wagner2
Prenatal
Either
Postnatal
Results: Single vs. Multicomponent
Single Multi
Total intervention arms 14 12Negative 10 9Positive 4 3
Median -20.9 -46.0IQ range: lower -65.7 -89.4 upper +21.4 +22.4Range: lower -87.4 -100.0 upper +127.6 +228.4
Effects of Home Visitation on Child Maltreatment, Single vs. Multicomponent
0
1
2
3
4
5
6
7
8
9
1 0
1 1
1 2
1 3
1 4
1 5
1 6
1 7
1 8
1 9
2 0
2 1
2 2
2 3
2 4
2 5
2 6
2 7
-120 -80 -40 0 40 80 120 160 200 240Percent Change from Baseline
BarthDugganFlynnHardyHonig1Honig2HuxleyLarson1Larson2MarcenkoMuslowSiegel1Siegel2Siegel3BraydenBrootenCarusoDawson Gray Katzev Kitzman Olds Velasquez Wagner1 Wagner2Wagner3
Singlecomponent
Multi-component
Home Visitation Effects by Study Execution Score
-120
-60
0
60
120
180
240
0 1 2 3 4 5
Execution score (i.e., # penalties)
Rel
ativ
e p
ct c
han
ge
Results: Randomized vs. Non-randomized
Random Not Random
Total intervention arms 18 8Negative 13 6Positive 5 2
Median -27.5 -68.3IQ range: lower -46.9 -77.3 upper +19.6 +20.0Range: lower -100.0 -93.2 upper +228.4 +94.1
Effects of Home Visitation on Child Maltreatment, by Randomization
0
1
2
3
4
5
6
7
8
9
1 0
1 1
1 2
1 3
1 4
1 5
1 6
1 7
1 8
1 9
2 0
2 1
2 2
2 3
2 4
2 5
2 6
2 7
-120 -80 -40 0 40 80 120 160 200 240Percent Change from Baseline
BarthBraydenBrootenDawsonDugganGrayHardyKitzmanLarson1Larson2MarcenkoOldsSiegel1Siegel2Siegel3Wagner1Wagner2Wagner3CarusoFlynnHonig1Honig2HuxleyKatzevMuslow Velasquez
Random
Non-random