Strengths and Limitations of Home Visiting to Prevent Child Maltreatment by Teen Parents
By Marita K. Herkert
The use of home visiting services to prevent child maltreatment has been widely studied with adult parents, but few studies examine their use among teen parents. In 1991 the U.S. Advisory Board on Child Abuse and Neglect recommended implementation of universal, voluntary home visiting for pregnant women. This article examines a sample of current models of home visiting as they affect the risk of child maltreatment among teen parents. Programs reviewed include the Nurse Home Visiting Program, Healthy Families America, Parents as Teachers, and the Colorado Adolescent Maternity Program. Evaluations of existing home visiting programs are reviewed and recommendations are made for future research.
Several promising programs have been developed to prevent child abuse and neglect. Home visiting with new parents is one of the most widely studied and utilized intervention methods (e.g., Bilukha et al., 2005; Guterman, 2001; Murphey and Braner, 2000). The underlying goal of this method is to reduce child abuse rates by providing support and education to new parents (Daro and Harding, 1999; Krugman, 1993; Wagner and Clayton, 1999). Research shows that home visiting improves home safety, infant-parent attachment, and parent understanding of child development; however, program evaluations identify mixed results, often with minimal change in rates of child abuse and neglect (Britner and Reppucci 1997; Chaffin, Bonner, and Hill, 2001; Gomby, Cubross, and Behrman, 1999; Roberts, Kramer, and Suissa, 1996). These programs are often difficult to evaluate because of the subjective nature of the home visits. Three challenges in the evaluation of home visiting programs are attrition rates, consistency in delivery of curriculum, and the impact of multiple goals on the visits. These challenges are considered in the following review of program effectiveness.
Program effectiveness is especially important to consider in working with adolescent parents because of the unique challenges and stressors that teen parents face. Programs to prevent child abuse are particularly relevant for adolescent parents because, in theory, early intervention will reduce risk of future child abuse by addressing child and parent risk factors. However, traditional home visiting programs cannot always be used with adolescent populations in the same way that they are used with adult parents.
This article explores the effectiveness of several current intervention and prevention models of home visiting on the risk of child abuse and neglect among adolescent parents. In this article, the term “teen parent” refers to an adolescent parent between the ages of 15 and 19. Programs for very young teens are not examined here because those parents face a unique set of challenges. Child abuse and neglect here refer primarily to physical and emotional abuse, as sexual abuse is not addressed specifically. The abuse rates described below reflect the U.S. Department of Health and Human Services’ (2007, p. xiii) definition of abuse: “Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act which presents an imminent risk of serious harm.” The term “child maltreatment” is used interchangeably with the phrase “child abuse and neglect.”
Teen Pregnancy and Child Maltreatment Rates
In 2004, there were 415,262 live births to U.S. mothers between the ages of 15 and 19; these births represent nearly 10 percent of live births recorded in the United States. The rate of births to teen mothers was 4.1 live births per 1,000 (Martin et al., 2006). In 1991, the birth rate for 15- to 19-year-old mothers of all races was 61.7 per 1,000. By 2005, the rate was 40.5 per 1,000. Among African American teenagers, the decline was greater: from 118.2 per 1,000 in 1991 to 60.9 per 1,000 in 2005 (Martin et al., 2007). These rates indicate that the teen birth rate has been in decline since 1990, but teen mothers are a highly vulnerable population, often in need of concrete resources and parenting education. Such vulnerability increases risk for child maltreatment.
Rates of child abuse and neglect are high among the parents of children under 4 years old. In 2005, 30.4 percent of child maltreatment victims were under the age of 4 (USDHHS [U.S. Department of Health and Human Services], 2007). Vulnerability of both the parents and children increases the risk of abuse and neglect dramatically, intensifying the need for prevention efforts. In 2005, there were 42,640 reports of child abuse committed by U.S.
parents 19 years or younger. These reports represent 5.1 percent of child abuse reports (USDHHS, 2007). The rates suggest that a significant number of child abuse and neglect cases are associated with teen parents. Specific prevention efforts are needed to address the issue.
Several additional factors increase the risk for abuse and neglect by teen parents. These include subsequent pregnancies, socioeconomic stressors, and low educational attainment (Klass, 2003; Middlemiss and McGuigan, 2005). Each of these issues is related to the struggles (and success) of a teen parent. The wide variety of risk factors suggests the need for an approach to child maltreatment prevention that considers the teen parent’s developmental phase and unique needs while working to address heightened risk.
Considerations in Working with Teen Parents
Evidence from the home visiting evaluations reviewed below suggests that it is difficult to create a model to successfully reduce risk and rates of child maltreatment. Regardless of the program model, working with teen parents poses additional challenges not present in interventions with at-risk adult parents. These challenges stem from the teen’s vulnerable situation and developmental stage (Klass, 2003). Teen parents are often difficult to engage, so delivery of the curriculum may not be effective. Moreover, teen parents may have difficulty understanding the purpose of the program, connecting with a home visitor and working with him or her. These difficulties may be related to the significant psychological and biological changes that occur during this stage of the teen parent’s life. Carol Klass (2003, p. 27) explains, “The serotonin level declines in most adolescents, leading to increased impulsivity and the inability to process information in a mature way.” The developmental stage along with the responsibility of caring for a new baby increases the teenager’s risk of maltreating the child. This combination also makes it difficult for the home visitor to connect with the teen parent, share resources, and provide education (Klass, 2003).
The teen parent’s stage of development affects his or her area of interest and may lead to a narcissistic focus. Klass (2003) points out that the teenager may be more focused on his or her own needs than on the child’s. This focus increases the risk of child maltreatment and neglect. Klass suggests that the home visitor should begin the relationship by focusing on the teen’s needs rather than on those of the baby. By attending to the parent’s potential for feelings of loneliness and isolation, the worker can help improve the teen parent’s focus on the child and his or her self-esteem in the parenting role.
The home visitor’s relationship with the teen is another important factor in working with teen parents to prevent child maltreatment. Wendy Middlemiss and William McGuigan (2005) explain the importance of this relationship and the program curriculum, observing that “enhanced parent interactions [with the visitor] are also suggestive of more secure attachments between high-risk adolescent mothers and infants who receive home visits” (p. 222). The relationship is at least partially developed through the amount of time spent with the teen and the number of visits conducted (Klass, 2003). The strength of the relationship between the home visitor and the teen parent has a direct effect on the success of the prevention program (Klass, 2003).
A final consideration in working with teen parents is the fact that they often have more concrete needs than adult parents do. These needs include limited education, little or no income, and difficulty accessing resources (Klass, 2003). Klass (2003) notes that all of these factors increase the likelihood of child maltreatment and must be considered by home visiting programs. Addressing these needs must be attended to for child maltreatment prevention. Parents of all ages have concrete needs, but teen parents are more likely than adult parents to have such needs and limited access to assistance (Klass, 2003).
The Rise of Home Visiting Programs
Home visiting has been used in various helping professions, including social work and nursing, for over a century (Weiss, 1993). It has been utilized as a means to reach at-risk clients for a variety of reasons. Child maltreatment prevention is one of the most widely researched uses of home visiting. In 1991, the U.S. Advisory Board on Child Abuse and Neglect recommended home visiting as an effective secondary prevention strategy for child abuse and neglect. It also recommended focusing on families most at risk for child maltreatment (Krugman, 1993).
The advisory board specifically recommended home visiting programs that were universal, voluntary, lasted for the first 2 years of the child’s life, and used both professional and paraprofessional visitors. The programs were intended to provide support and parenting education to new parents, reducing the risk of child abuse and neglect (Krugman, 1993). Although the entire board supported the recommendation, it was not implemented federally. Federal funding and support for home visiting were lacking. Nevertheless, thousands of local and state home visiting programs were created as a result of the recommendation. By 1993, as many as 550,000 children were served by one of six program models (Gomby et al., 1999). Since then, home visiting programs have continued to grow, although research questions their effectiveness in reducing child maltreatment rates (Chaffin et al., 2001; Daro and Harding, 1999; Middlemiss and McGuigan, 2005; Murphey and Braner, 2000; Roberts et al., 1996). These evaluations assess home visiting programs across parent age groups. Because of teen parents’ high-risk status, a few programs are designed specifically for them, although programs often include teen parents in the high-risk families that they serve.
Types of Home Visiting Programs
Home visiting programs are often one component of an agency’s intervention services, although not all home visiting programs are used in conjunction with other child maltreatment prevention services. These additional prevention services often include parenting education classes, support groups, doula services (pregnancy and birthing support), and child care (Middlemiss and McGuigan, 2005). Although home visiting programs vary, three factors define and are present in such programs: (1) regular home visits intended to ensure access to services; (2) initiation of services perinatally and continuation of them for at least 2 years; and (3) a focus on parenting skills, child development, and encouraging developmentally appropriate parent-child interactions (Middlemiss and McGuigan, 2005).
This article reviews three of the most widely studied and implemented home visiting programs: the Nurse Home Visitation Program, Healthy Families America, and Parents as Teachers. It also examines the Colorado Adolescent Maternity Program as a model that works specifically with teen mothers. Home visiting programs have had successful outcomes with a wide range of populations, but, according to Middlemiss and McGuigan (2005, p. 213), “outcome research for adolescent mothers has not been entirely consistent.”
Nurse Home Visitation Program
The Nurse Home Visitation Program (NHVP), a family support model developed by David Olds, has been evaluated extensively over the past two decades. Olds and colleagues have implemented and are evaluating pilot programs in Elmira, NY, Memphis, TN, and Denver, CO. These programs serve a wide variety of populations, and results are promising (Olds et al., 1999). In the NHVP, visits are initiated at the end of the second trimester of pregnancy and continue for the first 24 months of the child’s life. Initially, visits are frequent (often weekly) and become less so as the child grows. Monthly visits conclude when the child nears the age of 2 years. Visits last approximately 75–90 minutes. All home visits in the NHVP are made by nurses with professional training, while many other programs use paraprofessional home visitors (Olds et al., 1999). The NHVP uses a structured curriculum in which the focus of the visits falls on health, relationships, and building community resources.
Findings from the Elmira, NY, site indicate that program participants are the subjects of “fewer verified child abuse and neglect reports” (Olds et al., 1999, p. 52) than are members of a control group. An evaluation of another site suggests that NHVP participation decreases child abuse and neglect by adolescent parents (Murphy and Braner, 2000). Four percent of parents in the home visiting group were reported for abuse or neglect; the rate among the control group parents was 19 percent (Murphey and Braner, 2000). All participants were identified as high-risk parents; participants included both adolescent and adult parents. Ian Roberts and colleagues (1996) review a wide range of home visiting programs, including the NHVP. Despite the promising findings mentioned above, Roberts and associates (1996) note that many programs, including the NHVP, did not reduce rates of reported child abuse and neglect. By contrast, Oleg Bilukha and associates (2005) find that prevention programs, including the NHVP, have some effect on reducing child abuse and neglect. These studies demonstrate the ongoing debate concerning the most extensively researched home visiting program.
Healthy Families America
Healthy Families America (HFA) is a home visiting and family support program modeled after the Hawaii Healthy Start Program, which initial evaluations found to be highly successful at affecting child maltreatment rates (Guterman, 2001). The HFA program “seeks to expand the availability of high-quality, intensive home visitation services and to create communitywide commitments to these services and others that promote a supportive atmosphere for all new parents” (Daro and Harding, 1999, p. 154). These services are provided primarily to high-risk families and are initiated perinatally. In this, HFA differs from the NHVP, which begins services prenatally. The HFA program has been widely implemented. By 1997, over 270 HFA programs served nearly 18,000 families in 38 states (Daro and Harding, 1999, p. 157). Evaluations suggest that HFA programs have mixed results in reducing child maltreatment risk and rates. Less than 6 percent of parents in HFA programs are the subject of a maltreatment report, but the national average is 4.6 percent, a rate higher than that found for the Hawaii Healthy Start Program (Daro and Harding, 1999). These differences are significant, although it is important to keep in mind that HFA programs often serve high-risk families, and these families are vulnerable to many external factors not addressed in the home visiting programs. This vulnerability may suggest that it is problematic to compare HFA program parents with parents in the general population.
The format of HFA differs from that of the NHVP but has the same basic goals: to reduce child maltreatment and promote positive parenting. The HFA program does not limit services to first-time parents. It uses screenings and assessments to identify high-risk families, targeting them with services and a flexible curriculum. Home visits are made by trained paraprofessionals, rather than by nurses (Guterman, 2001). The issue of staff training levels is an area of debate within the home visitation research, but some argue that engagement and relationship-building are beneficial when done by paraprofessionals who can connect with the parents on a relational level (Guterman, 2001).
In an evaluation of an HFA program with adolescent mothers, the risk of child abuse and neglect was “reduced when mothers increase their parenting skills and their ability to cope with stress” (Middlemiss and McGuigan, 2005,
p. 220). Middlemiss and McGuigan (2005) find that the HFA program encourages parent-infant attachment and parent responsiveness to their child’s needs. They suggest that the skills taught in the home visiting program are empowering to the teen mothers, and they note that empowerment is important in reducing risk for child maltreatment. Mothers with improved coping and parenting skills had a lower risk of child maltreatment than that found for a control group. Concerns over the use of HFA with teen parents include difficulty in engagement with the teen parent, attrition, and the absence of a direct effect on abuse and neglect rates (Middlemiss and McGuigan, 2005).
Parents as Teachers
The Parents as Teachers (PAT) program, started in 1981, is an education-based model that is designed to increase parent knowledge, child school readiness, parent competence, and parent confidence (Gomby et al., 1999). It now has over 2,000 sites and serves over 500,000 families (Wagner and Clayton, 1999). The program is a universal access model that uses a standard, perinatally implemented curriculum and serves the family until the child’s third birthday. Parenting support groups, also available through PAT, are designed to complement the home visiting services (Wagner and Clayton, 1999).
In addition, Mary Wagner and Serena Clayton (1999) describe the Teen PAT program, a two-generational approach that combines PAT with case management services for teen parents. The unique goals of the Teen PAT program are to increase the educational achievement of parents and to postpone additional pregnancies. Additional pregnancies and lack of such achievement are risk factors for child maltreatment that are especially relevant to teen parents (Wagner and Clayton, 1999). Wagner and Clayton (1999) also note that concerns with the Teen PAT include high attrition rates (48 percent) and workers’ difficulty in engagement or initial relationship-building with the teen parents. The outcomes of the Teen PAT program have not been promising: “Analyses showed little or no benefit on most outcome measures for either parents or children from PAT services” among teen parents (Wagner and Clayton, 1999, p. 111). However, “fewer child abuse and neglect cases were opened among the group that received both PAT home visiting and comprehensive case management services” (Gomby et al., 1999, p. 14). The PAT program’s use of comprehensive services and services directed toward teen mothers, (e.g., case management) is unique among home visiting programs, but the program has not demonstrated consistent success in addressing child abuse rates.
Colorado Adolescent Maternity Program
The Colorado Adolescent Maternity Program (CAMP) is a “comprehensive, multidisciplinary prenatal, delivery, and postnatal care program” designed for mothers between the ages of 13 and 19 (Stevens-Simon, Nelligan, and Kelly, 2001, p. 756). This model is unique among home visiting programs because it was designed specifically for teen parents. They are screened into the program, and home visits are offered by trained paraprofessionals at least two times per month. The admission screening uses the Family Stress Checklist to assess teen parents’ risk for mistreating their children (Stevens-Simon et al., 2001), and the assessment is made in a clinic or hospital setting. The CAMP home visiting program is designed to meet the individual needs of participating families. Services are centered on building parental self-efficacy, providing informal support, offering education on infant temperament and development, and coordinating services (Stevens-Simon et al., 2001). An evaluation of the CAMP program finds that the child maltreatment rates for parents receiving home visiting services do not differ from those for the comparison group. Catherine Stevens-Simon and colleagues (2001, p. 753) find that “the incidence of maltreatment rose in tandem with the predicted risk status of the mother.” Similar to the other home visiting programs reviewed above, the CAMP program, although designed specifically for teen parents, is not shown to be significantly effective at reducing risk for child abuse and neglect.
Benefits of Home Visiting Programs
Research fails to show that the programs outlined consistently reduce child maltreatment rates; however, home visiting programs have some benefits that indirectly affect risk for child abuse and neglect. These benefits may accrue through such other program features as parenting education, emotional support for the parent, and home safety lessons (Stevens-Simon et al., 2001). A philosophy behind home visiting support programs is that addressing parent needs, both concrete and psychological, will reduce risk of child maltreatment. For example, programs designed specifically for teen parents may alleviate the transportation concerns that prevent teen parent participation, help with motivation to follow through with services, and provide support to isolated parents (Middlemiss and McGuigan, 2005). Teen parents are often isolated from friends, and this isolation can increase the risk for child maltreatment. By meeting with the teen parents in their home, home visitors are able to understand the teen’s living situation and address issues that may concern the mother or father. Understanding the home environment can also help the home visitor become aware of the teens’ relationships with parents or other family members. Such knowledge can also reveal economic concerns, home safety concerns, and the general family environment (Gomby et al., 1999).
By addressing both concrete and relational needs, the home visitor is able to work with the teen parent to reduce the stress in the home. As Klass (2003) points out, the home can be seen as neutral territory for the teen parent, a space where the home visitor is able to collaborate with the teen rather than appear to be the expert. The home environment is also generally comfortable for the teen parent. The home visitor can work with him or her on parenting skills, attachment concerns, and boundary issues within the setting in which the parent and child most frequently interact (Klass, 2003).
Finally, home visiting services can be beneficial in working with teen parents to reduce risk of child maltreatment because the visits can complement services offered by family support agencies and other programs (Daro and Harding, 1999). Home visiting is often an individualized, relationship-based program that focuses directly on the parent’s needs. The home visitor can work with the parent to apply what is learned in parenting classes or support groups to the parent’s relationship with his or her child. Overall, there are significant intrinsic benefits to home visiting services that indirectly target child maltreatment risk among adolescent parents. Research suggests that the evaluated programs do not reduce rates of child abuse and neglect, but findings do associate participation in those programs with improvements in such other program goals as understanding of child development, parent self-esteem, and parent-child relationship-building (Daro and Harding, 1999; Gomby et al., 1999; Middlemiss and McGuigan, 2005; Olds et al., 1999). These benefits are important to consider, despite the limitations of home visiting programs for teen parents.
Challenges of Home Visiting Programs
Significant challenges and limitations impede the success of home visiting programs in reducing risk of child maltreatment. These challenges make evaluation findings difficult to generalize, and it has even been suggested that trends in child abuse rates over time are not appropriate measures of success (Daro and Harding, 1999). Reduction of child maltreatment rates is the primary goal of these programs, but they also have other goals. Such goals can be beneficial for the overall intervention, but program goals may be too ambitious or may contain too many objectives to effectively target child maltreatment risk (Gomby, 1999; Murphey and Braner, 2000). Inclusion of multiple goals is particularly difficult with programs for teen parents, because goals in teen parent visiting programs include parenting skills and child development, as well as parent education and prevention of additional pregnancies (Stevens-Simon et al., 2001).
In many studies of home visiting programs, attrition rates are found to be high. They are particularly high among teen parents (Middlemiss and McGuigan, 2005; Wagner and Clayton, 1999). For example, Middlemiss and McGuigan (1999) reported a 48 percent attrition rate among the teen parents evaluated in the Teen PAT program. Programs are often intensive and serve high-risk populations. Attrition may impede evaluation efforts and, if it prevents delivery of the curriculum or services offered, may impede attainment of program goals. Attrition may also jeopardize consistency of curriculum delivery and intensity of visits. These challenges may particularly affect programs (such as HFA) that have a flexible curriculum, because it is not always clear as to whether or not the curriculum is being delivered, so the parents may not always receive the program content.
In addition, concerns over staffing, caseloads, and use of evaluation may impede the effectiveness of home visiting programs in meeting the goal of reducing risk of child maltreatment. There has been an ongoing debate about whether home visits should be conducted by paraprofessional staff (e.g., Daro and Harding, 1999; Guterman, 2001; Olds et al., 1999). The NHVP model only uses professional nursing staff as home visitors, and rates of abuse or neglect by participants are lower than the rates among nonparticipants (Olds et al., 1999). However, Neil Guterman (2001) argues that trained paraprofessional staff, such as those in the HFA programs, can be effective at delivering home visiting programs because they often have personal experience and ties to the community. He also suggests that they are able to relate more effectively with the parents. Finally, high caseloads and the intensity of working with teen parents on multiple needs in high-risk situations can reduce potential effectiveness of home visiting programs, adding yet another challenge to home visiting services (Guterman, 2001).
Child maltreatment prevention among teen parents poses important challenges. The teenage years are a time of both high risk and great opportunity for parents and their very young children. Teen parents are at a higher risk for concrete and developmental stressors than are nonparenting teens, and children are most vulnerable to be abused during early childhood (Neil Guterman, personal communication, September 25, 2007). The risk for child maltreatment is thus high among teen parents. Many programs have been developed to prevent child abuse by teen parents, but evaluations of home visiting programs have not shown promising results. This may be because the programs work with a high-risk population, because home visitors are mandated reporters and may have a surveillance bias, or because child maltreatment is difficult to conceptualize and measure (Stevens-Simon et al., 2001).
Suggestions for future research and evaluation of home visiting programs include the use of home visiting programs in conjunction with other interventions, such as doula services during pregnancy and childbirth, parenting classes, and work and education programs. Future research should evaluate maltreatment rates over time and consider additional interventions that affect child abuse and neglect rates. Established home visiting programs may be beneficial to teen parents, but research suggests that they fall short of preventing child maltreatment.
Teen parents present significant challenges to the home visitor. If these programs are to have lasting effects on the rates of child abuse and neglect by teen parents, methods must be developed to address the unique issues and needs faced by these parents, as existing services may fail to address the population’s unique needs. The teenage years are a time of risk and opportunity; research must continue to work to develop effective interventions that address the specific and unique needs of teen parents and their children.
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About the Author
MARITA K. HERKERT is a second-year clinical student at the School of Social Service Administration, concentrating in family support and violence prevention. She received her bachelor’s degree in social work from Luther College in Decorah, IA. She is currently an intern at the Infant Welfare Society of Evanston’s Family Support Program, doing home visiting with teen parents. After graduation, Marita plans to do advocacy and research on issues facing young children and families.