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Johns Hopkins Medicine
Office of Corporate Communications
Media Contact: Jessica Collins
June 15, 2004
Study Calls for Better Training for Home Visitors and More Coordination with Community Resources

A highly lauded and widely adopted program that relies on home visits by paraprofessionals to promote effective parenting in families at risk of child abuse succeeded in building trust, but neither prevented abuse nor reduced known risk factors, according to results of a study directed by researchers at Johns Hopkins Children's Center.

Working with the Hawaii State Department of Health and the University of Hawaii's John Burns School of Medicine, the Hopkins researchers studied mostly poor households on Oahu who participated in the state's Healthy Start Program.  These families made up about 20 percent of Hawaii's child-bearing population.  The Healthy Start Program in 1991 was cited by the U.S. Advisory Board on Child Abuse and Neglect as the most promising strategy for child abuse prevention and has since inspired hundreds of similar programs in 39 states.

The study, published in the June issue of the journal Child Abuse & Neglect, identified maternal depression and participation in domestic violence with a spouse or partner as the factors most likely to predict a mother's physical abuse of a child, but found that home visitors failed both to identify these and other risk factors and to direct families to community resources that could help, said principal investigator Anne Duggan, Sc.D., associate professor of pediatrics and of health policy and management at Hopkins.

"Program leaders and staff were very passionate about their work and really believed they were preventing child abuse," she said.  "But even the home visitors gave themselves better marks for promoting a positive outlook and building on strengths than on developing mothers' ability to solve problems, set and work toward goals, and establish support networks."

"We know from these results that addressing the physical difficulties related to living in poverty is not enough," she added.  "Parental behavioral and mental health problems also must be addressed in order to make lasting improvements in child health and development."

Duggan called for reform of training programs that prepare home visitors to identify family risk factors, motivate families to address them, and enable families to access treatment services.

"Training programs were insufficient to prepare home visitors for the job," she said.  "In some cases, supervisors didn't have enough experience."  Other factors contributing to failure may include a lack of formal coordination between the home visit programs and community resource organizations, and poor record keeping.

Duggan maintains that, with some revisions, home visiting programs "have great potential."  In her study, employees did well in both earning the mothers' trust among the families they worked with and in linking families to primary care providers for the children, she said.

Added Loretta Fuddy, chief of the Hawaii State Department of Health's Family Health Division, "In response to problems identified by the study, the Hawaii State Department of Health, the Hopkins researchers and the network of community-based organizations that provide Healthy Start home visiting in Hawaii have revised the service model, training programs and supervision to address the increasing complexity of the families served.  The impact of these changes is the focus of current research."

The research team assigned 643 families at risk for child maltreatment at random to either an intervention or control group.  They interviewed mothers in both groups annually for three years to measure mental health, substance abuse and partner violence.  They also reviewed Healthy Start Program records to evaluate the home visiting services provided and surveyed home visitors annually to measure their perceived competence.

Child abuse and neglect were measured by observed and self-reported parenting behaviors, hospitalizations for trauma and conditions that might have been avoided with adequate preventive care, a mother's relinquishment of her role as primary caregiver, and reports from Child Protective Services.

The researchers found that mothers with higher levels of depression were up to three times more likely to severely physically assault their children than those with little or no depression. Mothers with no partner and those in violent relationships were up to six times more likely to severely assault their children compared to those in nonviolent relationships.  Physical assault varied over time, with 2-year-olds incurring the highest risk of abuse.  Infants born small for their gestational age were nearly six times as likely to be physically abused than normal weight babies.  Mothers who were depressed, who used illegal drugs, who did not have a partner or who were involved in violent relationships were at increased risk of mental abuse of their children.
The study team found no significant difference between the groups in terms of mothers' desire for and use of community services available.  But home visitors often failed to recognize parental risks and seldom linked families with community resources.

Researchers did observe a reduction in poor mental health among mothers being visited by one agency; a modest reduction in maternal problem alcohol use and repeated incidents of physical violence from a partner in some of the families; and a modest impact in preventing neglect.

The study was funded by the Robert Wood Johnson Foundation, the Annie E. Casey Foundation, the David and Lucille Packard Foundation, the Hawaii State Department of Health, the U.S. Maternal and Child Health Bureau, and the National Institute of Mental Health.

Coauthors were Lori Burrell, M.A.; Susan M. Higman, Ph.D.; Elizabeth McFarlane, M.P.H.; and Amy Windham, Ph.D., of Hopkins; Loretta Fuddy, L.C.S.W., M.P.H., of the Hawaii State Department of Health; and Calvin Sia, M.D., of the University of Hawaii - John Burns School of Medicine.

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Duggan, Anne et al, "Randomized Trial of a Statewide Home Visiting Program: Impact in Preventing Child Abuse and Neglect," Child Abuse & Neglect, June 2004, Vol. 28, Issue 6.

Duggan, Anne, et al, "Randomized Trial of a Statewide Home Visiting Program to Prevent Child Abuse: Impact in Reducing Parental Risk Factors," Child Abuse & Neglect, June 2004, Vol. 28, Issue 6.

Windham, Amy M., et al, "Risk of Mother-reported Child Abuse in the First Three Years of Life," Child Abuse & Neglect, June 2004, Vol. 28, Issue 6.

Johns Hopkins Children's Center

Child Abuse & Neglect