Home visiting intervention for vulnerable families with newborns: follow-up results of a randomized controlled trial

Abstract

Objective: This study aimed to: (1) Assess the community utility of a screening tool to identify families with child abuse or neglect risk factors in the immediate postnatal period (2) Determine the social validity and effectiveness of a home visiting program using community child health nurses and offering social work services for identified families, and (3) Identify factors in the immediate postnatal period associated with the child’s environment that predict poor adjustment to the parenting role.

Method: A randomized controlled trial using a cohort of 181 families was undertaken to evaluate the impact of a home visiting program. Mothers were recruited in the immediate postnatal period and allocated either into the home visiting program or into a comparison group. The research design required self-identification into the study by providing positive responses to a range of risk factors. A repeated measures design was used to test parenting stress and maternal depression from the immediate postnatal period to 12-month follow-up and physical child abuse potential to 18-month follow-up. To test whether measures taken in the immediate postnatal period were predictive for poor adjustment to the parenting role, a linear regression model was used.

Results: The screening procedure was shown to have utility in the context of recruitment to a research trial and mothers were willing to accept the home visiting program examined by this study from the immediate postnatal period. From as early as 6 weeks the program demonstrated ability to impact positively on maternal, infant, family, and home environment variables (testing 90 randomly allocated intervention vs. 91 comparison families). At follow-up, parental adjustment variables were not significantly different between groups (testing the remaining 68 (75.5%) intervention vs. 70 (76.9%) comparison families) and home environment assessment scores had converged. Predictive analysis of factors measured in the immediate postnatal period revealed an absence of any predictive value to demographic characteristics, which secondary prevention efforts typically target.

Conclusions: Follow-up evaluation did not demonstrate a positive impact on parenting stress, parenting competence, or quality of the home environment confirming the need to test early program success on longer term outcomes. Further, the study not only demonstrated that there was a relationship between maternal, family and environmental factors identified in the immediate postnatal period, and adjustment to the parenting role, but also challenged demographic targeting for child abuse and neglect risk. At the same time, the immediate postnatal period presented an exciting window of opportunity to access high-risk families who may otherwise have become marginalized from traditional services.

Introduction

EFFORTS TO ADDRESS child abuse and neglect range from prevention and early intervention programs, to out-of-home care services for children removed from dangerous environments. Although treatment for parents and their children remains an important and necessary part of comprehensive service delivery, a broader approach is needed due to the inevitable limitations of interventions that take place after child abuse and neglect have occurred. In comparison, early intervention and prevention strategies seek to assist families in developing skills and knowledge that, over time, may prevent the emergence of dysfunctional parenting behaviors. As such, preventive and early intervention programs are valued not just for their potential to avoid human suffering, but to reduce need for the wide range of services required to address the consequences of child abuse and neglect (James, 1994).

During the past three decades researchers and clinicians alike have attempted to determine appropriate and effective methods for the prevention of child abuse and neglect. The approach used by child protection services is usually to operate at different levels of prevention due to the complexity of personal and social systems factors that predispose families to intrafamilial violence (Browne & Herbert, 1997) and the scarcity of resources available to service providers. Many programs aimed at preventing abuse and neglect (by improving parenting competence, knowledge, skills, and parent-child attachment) have been home-based and controlled trials have demonstrated the value of home-visiting by nurses. Although program diversity has precluded formal meta-analyses of the published literature, substantive and methodological conclusions can be drawn. The more successful preventive interventions tested to date have been conducted with selected, targeted populations MacMillan et al 1994, Olds and Kitzman 1993, Roberts et al 1996, Wekerle and Wolfe 1993. In particular, the home visiting strategy appears to be most effective when targeted to families with a range of characteristics placing them at risk for parenting dysfunction, child abuse, or neglect. Follow-up studies of a successful early trial conducted in the United States (Olds, Henderson, Tatelbaum, & Chamberlin, 1986) examined a diverse range of outcomes from maternal life course, child abuse, and neglect, to children’s criminal and antisocial behavior Olds et al 1997, Olds et al 1998. These longitudinal studies indicated that for disadvantaged families in the United States, intensive home visiting by nurses in the first 2 years of life effectively improved both short and longer term child, parent, and family well-being.

In Australia, program evaluation has been constrained by a number of factors, foremost being the relative low incidence of and difficulty measuring child abuse and neglect and the lack of built-in evaluation of otherwise well-meaning interventions (Vimpani, Frederico, & Barclay, 1996). Furthermore, it has been difficult to control for improved outcomes brought about by changes in wider social family policies (Vimpani et al., 1996). Finally, although the ability to identify and engage appropriate target populations underpins the success of preventive strategies, one of the most consistent themes of the child abuse and neglect literature has been the challenge of recruiting and retaining higher-risk families. Specifically, the problem for community health service providers is that families at risk for child abuse and neglect are frequently among those least likely to access health services. These families are often isolated and marginalized from traditional services due to their personal and/or socioenvironmental characteristics Ferguson et al 1984, Ford et al 1990, Hart 1971. Thus, screening families for potential child abuse and neglect characteristics requires careful assessment based on empirical evidence for risk.

This study sought to address identified limitations within the literature with respect to home visiting. The overall aim of this study was to evaluate the effectiveness of home visiting as a prevention and early intervention strategy using child health nurses, social workers, and parent aides. In accordance with this aim, the hypothesis that the home visiting program would be associated with more favorable adjustment to the parenting role compared with nonintervention, or clinic-based service delivery was tested. Specifically, the following research questions and hypotheses were put:

• Would a screening instrument used during the immediate postnatal period to identify families with child abuse or neglect risk factors demonstrate community utility?

• Would a home visiting intervention program beginning in the immediate postnatal period and targeted to families with child abuse or neglect risk factors demonstrate high social validity?

• The hypothesis was tested that more favorable adjustment to the parenting role would be associated with a home visiting intervention program compared with nonintervention or clinic based service provision only and would be evidenced by: (a) lower rates of maternal depression, parenting stress, and child abuse potential; (b) higher scores for home environment and parent-child interactions observed in the home; and (c) higher levels of parental knowledge and practice of child safety and preventive health care.

• The hypothesis that maternal, family and environmental factors identified in the immediate postnatal period would be predictive of adjustment to the parenting role at follow-up was tested.