Child maltreatment and the early onset of problem behaviors: can a program of nurse home visitation break the link?

This study investigated the relationship between child maltreatment and the early onset of problem behaviors in the Elmira Nurse Home Visitation Program. Participants were predominantly low-income and unmarried mothers and their first-born children who were randomized either to receive over 2 years of home-visitation services by nurses or to be placed in a comparison group. Data were drawn from a follow-up study that took place when the children were 15 years of age. Results demonstrated that, in the comparison group. child maltreatment was associated with significant increases in the number of early onset problem behaviors reported by the youth. For the youth in the nurse-visited group there was no relationship between maltreatment and early onset problem behaviors. We suggest that this finding was due to the effects of the intervention in reducing the number as well as the developmental timing of the maltreatment incidents. Results suggest that prenatal and infancy home visiting by nurses can moderate the risk of child maltreatment as a predictor of conduct problems and antisocial behavior among children and youth born into at-risk families.

Preventing child abuse and neglect with a program of nurse home visitation: the limiting effects of domestic violence.

CONTEXT: Home visitation to families with young children has been promoted as an effective way to prevent child maltreatment, but few studies have examined the conditions under which such programs meet this goal. OBJECTIVE: To investigate whether the presence of domestic violence limits the effects of nurse home visitation interventions in reducing substantiated reports of child abuse and neglect. DESIGN: Fifteen-year follow-up study of a randomized trial. SETTING: Semirural community in upstate New York. PARTICIPANTS: Of 400 socially disadvantaged pregnant women with no previous live births enrolled consecutively between April 1978 and September 1980, 324 mothers and their children participated in the follow-up study. INTERVENTIONS: Families were randomly assigned to receive routine perinatal care (control group; n = 184 participated in follow-up), routine care plus nurse home visits during pregnancy only (n = 100), or routine care plus nurse home visits during pregnancy and through the child's second birthday (n = 116). MAIN OUTCOME MEASURES: Number of substantiated reports over the entire 15-year period involving the study child as subject regardless of the identity of the perpetrator or involving the mother as perpetrator regardless of the identity of the child abstracted from state records and analyzed by treatment group and level of domestic violence in the home as measured by the Conflict Tactics Scale. RESULTS: Families receiving home visitation during pregnancy and infancy had significantly fewer child maltreatment reports involving the mother as perpetrator (P =. 01) or the study child as subject (P =.04) than families not receiving home visitation. The number of maltreatment reports for mothers who received home visitation during pregnancy only was not different from the control group. For mothers who received visits through the child's second birthday, the treatment effect decreased as the level of domestic violence increased. Of women who reported 28 or fewer incidents of domestic violence (79% of sample), home-visited mothers had significantly fewer child maltreatment reports during the 15-year period than mothers not receiving the longer-term intervention (P =.01). However, this intervention did not significantly reduce child maltreatment among mothers reporting more than 28 incidents of domestic violence (21% of sample). CONCLUSIONS: The presence of domestic violence may limit the effectiveness of interventions to reduce incidence of child abuse and neglect. JAMA. 2000;284:1385-1391.

Enduring effects of nurse home visitation on maternal life course: a 3-year follow-up of a randomized trial.

CONTEXT: A home visitation program using nurses to improve maternal and child outcomes had favorable results in a randomized trial with a primarily white, semirural population. Many of the short-term findings have been replicated with urban blacks, but whether the program will continue to demonstrate effectiveness after its conclusion is uncertain. OBJECTIVE: To determine the effectiveness of a prenatal and infancy home visitation program on the maternal life course of women in an urban environment 3 years after the program ended. DESIGN AND SETTING: Three-year follow-up of a randomized controlled trial of women seen consecutively between June 1990 and August 1991 at an obstetrical clinic in Memphis, Tenn, who were enrolled in a visitation program for 2 years after the birth of their first child. PARTICIPANTS: A cohort of 743 women who were primarily black, were pregnant for less than 29 weeks, had no previous live births, and had at least 2 sociodemographic risk factors (unmarried, <12 years of education, or unemployed). INTERVENTION: An average of 7 (range, 0-18) home visits during pregnancy and 26 (range, 0-71) from birth to the child's second birthday. MAIN OUTCOME MEASURES: Rate of subsequent pregnancy, mean interval between first and second birth, and mean number of months of welfare use. RESULTS: Compared with the control group, women who received home visits by nurses had fewer subsequent pregnancies (1.15 vs 1.34; P=.03), fewer closely spaced subsequent pregnancies (0.22 vs 0.32; P=.03), longer intervals between the birth of the first and second child (30.25 vs 26.60 months; P=.004), and fewer months of using Aid to Families with Dependent Children (32.55 vs 36.19; P=.01) and food stamps (41.57 vs 45.04; P=.005). Compared with the effect of the program while the program was in operation, the effect after it ended was essentially equal for Aid to Families with Dependent Children, greater for food stamps, greater for rates of closely spaced subsequent pregnancies, and smaller for rates of subsequent pregnancy overall. CONCLUSIONS: We found enduring effects of a home visitation program on the lives of black women living in an urban setting. While these results were smaller in magnitude than those achieved in a previous trial with white women living in a semirural setting, the direction of the effects was consistent across the 2 studies.

Prenatal and infancy home visitation by nurses: recent findings.

This article describes a 20-year program of research on the Nurse Home Visitation Program, a model in which nurses visit mothers beginning during pregnancy and continuing through their children's second birthdays to improve pregnancy outcomes, to promote children's health and development, and to strengthen families' economic self-sufficiency. The results of two randomized trials (one in Elmira, New York, and the second in Memphis, Tennessee) are summarized, and an ongoing trial in Denver, Colorado, is briefly described. Results of the Elmira and Memphis trials suggest the following: The program benefits the neediest families (low-income unmarried women) but provides little benefit for the broader population. Among low-income unmarried women, the program helps reduce rates of childhood injuries and ingestions that may be associated with child abuse and neglect, and helps mothers defer subsequent pregnancies and move into the workforce. Long-term follow-up of families in Elmira indicates that nurse-visited mothers were less likely to abuse or neglect their children or to have rapid successive pregnancies. Having fewer children enabled women to find work, become economically self-sufficient, and eventually avoid substance abuse and criminal behavior. Their children benefitted too. By the time the children were 15 years of age, they had had fewer arrests and convictions, smoked and drank less, and had had fewer sexual partners. The program produced few effects on children's development or on birth outcomes, except for children born to women who smoked cigarettes when they registered during pregnancy. The positive effects of the program on child abuse and injuries to children were most pronounced among mothers who, at registration, had the lowest psychological resources (defined as high levels of mental health symptoms, limited intellectual functioning, and little belief in their control of their lives). Generally, effects in Elmira were of greater magnitude and covered a broader range of outcomes than in Memphis, perhaps because of differences between the populations studied, community contexts, or a higher rate of turnover among home visitors in Memphis than in Elmira. The article concludes that the use of nurses as home visitors is key; that services should be targeted to the neediest populations, rather than being offered on a universal basis; that clinically tested methods of changing health and behavioral risks should be incorporated into program protocols; and that services must be implemented with fidelity to the model tested if program benefits found in scientifically controlled studies are to be reproduced as the program is replicated in new communities.

Long-term effects of home visitation on maternal life course and child abuse and neglect. Fifteen-year follow-up of a randomized trial.

CONTEXT: Home-visitation services have been promoted as a means of improving maternal and child health and functioning. However, long-term effects have not been examined. OBJECTIVE: To examine the long-term effects of a program of prenatal and early childhood home visitation by nurses on women's life course and child abuse and neglect. DESIGN: Randomized trial. SETTING: Semirural community in New York. PARTICIPANTS: Of 400 consecutive pregnant women with no previous live births enrolled, 324 participated in a follow-up study when their children were 15 years old. INTERVENTION: Families received a mean of 9 home visits during pregnancy and 23 home visits from the child's birth through the second birthday. DATA SOURCES AND MEASURES: Women's use of welfare and number of subsequent children were based on self-report; their arrests and convictions were based on self-report and archived data from New York State. Verified reports of child abuse and neglect were abstracted from state records. MAIN RESULTS: During the 15-year period after the birth of their first child, in contrast to women in the comparison group, women who were visited by nurses during pregnancy and infancy were identified as perpetrators of child abuse and neglect in 0.29 vs 0.54 verified reports (P<.001). Among women who were unmarried and from households of low socioeconomic status at initial enrollment, in contrast to those in the comparison group, nurse-visited women had 1.3 vs 1.6 subsequent births (P=.02), 65 vs 37 months between the birth of the first and a second child (P=.001), 60 vs 90 months' receiving Aid to Families With Dependent Children (P=.005), 0.41 vs 0.73 behavioral impairments due to use of alcohol and other drugs (P=.03), 0.18 vs 0.58 arrests by self-report (P<.001), and 0.16 vs 0.90 arrests disclosed by New York State records (P<.001). CONCLUSIONS: This program of prenatal and early childhood home visitation by nurses can reduce the number of subsequent pregnancies, the use of welfare, child abuse and neglect, and criminal behavior on the part of low-income, unmarried mothers for up to 15 years after the birth of the first child.

Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing. A randomized controlled trial.

CONTEXT: Interest in home-visitation services as a way of improving maternal and child outcomes has grown out of the favorable results of a trial in semirural New York. The findings have not been replicated in other populations. OBJECTIVE: To test the effect of prenatal and infancy home visits by nurses on pregnancy-induced hypertension, preterm delivery, and low birth weight; on children's injuries, immunizations, mental development, and behavioral problems; and on maternal life course. DESIGN: Randomized controlled trial. SETTING: Public system of obstetric care in Memphis, Tenn. PARTICIPANTS: A total of 1139 primarily African-American women at less than 29 weeks' gestation, with no previous live births, and with at least 2 sociodemographic risk characteristics (unmarried, <12 years of education, unemployed). INTERVENTION: Nurses made an average of 7 (range, 0-18) home visits during pregnancy and 26 (range, 0-71) visits from birth to the children's second birthdays. MAIN OUTCOME MEASURES: Pregnancy-induced hypertension, preterm delivery, low birth weight, children's injuries, ingestions, and immunizations abstracted from medical records; mothers' reports of children's behavioral problems; tests of children's mental development; mothers' reports of subsequent pregnancy, educational achievement, and labor-force participation; and use of welfare derived from state records. MAIN RESULTS: In contrast to counterparts assigned to the comparison condition, fewer women visited by nurses during pregnancy had pregnancy-induced hypertension (13% vs 20%; P=.009). During the first 2 years after delivery, women visited by nurses during pregnancy and the first 2 years of the child's life had fewer health care encounters for children in which injuries or ingestions were detected (0.43 vs 0.55; P=.05); days that children were hospitalized with injuries or ingestions (0.03 vs 0.16; P<.001); and second pregnancies (36% vs 47%; P=.006). There were no program effects on preterm delivery or low birth weight; children's immunization rates, mental development, or behavioral problems; or mothers' education and employment. CONCLUSION: This program of home visitation by nurses can reduce pregnancy-induced hypertension, childhood injuries, and subsequent pregnancies among low-income women with no previous live births.

Child rearing beliefs in the African-American community: implications for culturally competent pediatric care.

Cultural competence is increasingly acknowledged as an essential component of nursing care within the heterogeneous society our nation has become. A necessary antecedent to competence is an understanding of, and respect for, the beliefs and priorities of the families being served. Literature from a variety of disciplines in the areas of attachment, socialization agendas, discipline, and parental teaching is reviewed to provide a description of the cultural context for child rearing in African-American families. Implications for clinical practice are discussed.

Intellectual impairment in children of women who smoke cigarettes during pregnancy.

OBJECTIVE: To examine the relationship between maternal cigarette smoking during pregnancy and children's intellectual functioning during the first 4 years of life. DESIGN: Prospective follow-up of participants in a randomized trial of pregnancy and infancy nurse home visitation. SETTING: Semi-rural community in Upstate New York. PARTICIPANTS: 400 families in which the mothers registered before the 30th week of pregnancy and had no previous live births. Eighty-five percent of the mothers were either teenagers (< 19 years at registration), unmarried, or poor. Analysis limited to whites who comprised 89% of the sample. MAIN RESULTS: Children in the comparison group whose mothers smoked 10 or more cigarettes per day during pregnancy had Stanford-Binet scores at 3 and 4 years of age that were 4.35 (95% CI: 0.02, 8.68) points lower (after controlling for a wide range of variables) than their counterparts whose mothers did not smoke during pregnancy. CONCLUSIONS: The results of this study add to the increasingly consistent evidence that maternal cigarette smoking during pregnancy poses a unique risk for neurodevelopmental impairment among children and provide an additional reason for pregnant women not to smoke cigarettes.

Prevention of intellectual impairment in children of women who smoke cigarettes during pregnancy.

OBJECTIVE: To analyze the influence of a comprehensive program of nurse home visitation on the intellectual functioning of children born to women who smoked cigarettes during pregnancy. DESIGN: Randomized clinical trial. Treatment 1: sensory and developmental screening at ages 1 and 2 years; treatment 2: screening plus free transportation for prenatal and well-child care; treatment 3: screening, transportation, plus prenatal home visitation; treatment 4: screening, transportation, prenatal home visitation, plus postnatal home visitation through the children's second birthdays. SETTING: Semi-rural community in Upstate New York. PARTICIPANTS: 400 families in which the mothers registered before the 30th week of pregnancy and had no previous live births. Eighty-five percent of the mothers were either teenagers, unmarried, or poor. Analysis was limited to whites, who constituted 89% of sample. INTERVENTION: Nurse home visitation during pregnancy (treatments 3 and 4) or during pregnancy and the first 2 years of the child's life (treatment 4). During pregnancy, the nurses helped women improve their health-related behaviors, informal social support, and linkage with needed community services. MAIN FINDINGS: Children born to women who smoked 10 or more cigarettes per day at registration during pregnancy and who were assigned to treatments 3 and 4 had IQs (averaging across the 3rd and 4th years of life) that were 4.86 (95% CI: 0.47, 9.26) points higher after adjustment for covariates than did children born to women who smoked 10+ cigarettes per day and who were assigned to treatments 1 and 2. The positive influence of the home-visiting program on reducing the harmful effect of smoking appears to be due to prenatal visitation. CONCLUSION: Comprehensive prenatal home-visitation services can offset the impairment in intellectual functioning associated with substantial maternal smoking during pregnancy.

Does prenatal and infancy nurse home visitation have enduring effects on qualities of parental caregiving and child health at 25 to 50 months of life?

OBJECTIVE: To examine, during the 3rd and 4th years of life, the health, development, rates of child maltreatment, and living conditions of children who had been enrolled in a randomized trial of nurse home visitation during pregnancy and first 2 years of their lives. DESIGN: Prospective follow-up of families who had been randomly assigned to nurse-visited and comparison conditions. SETTING: Study conducted in semirural community in upstate New York. Families dispersed among 14 other states during 2-year period after children's second birthdays. PARTICIPANTS: Four hundred women were recruited through a health department antepartum clinic and offices of private obstetricians and were registered before 30th week of pregnancy. All women had no previous live births and 85% were either teenaged (< 18 years at registration), unmarried, or from Hollingshead social classes IV or V. Analysis focused on whites, who comprised 89% of sample. INTERVENTION: Nurse home visitation from pregnancy through second year of the child's life. MAIN RESULTS: There were no treatment differences in the rates of child abuse and neglect or children's intellectual functioning from 25 to 48 months of age. Nurse-visited children, nevertheless, lived in homes with fewer hazards for children; they had 40% fewer injuries and ingestions and 45% fewer behavioral and parental coping problems noted in the physician record; and they made 35% fewer visits to the emergency department than did children in the comparison group. Nurse-visited mothers were observed to be more involved with and to punish their children to a greater extent than were mothers in the comparison group. The functional meaning of punishment differed between the nurse-visited and comparison families. CONCLUSIONS: The program does have enduring effects on certain aspects of parental caregiving, safety of the home, and children's use of the health care system, but it may be necessary to extend the length of the program for families at highest risk to produce lasting reductions in child abuse and neglect.

Effect of prenatal and infancy nurse home visitation on government spending.

A completed series of reports on a randomized trial (N = 400) indicated that, in contrast to comparison services, prenatal and infancy nurse home visitation improved a wide range of maternal and child health outcomes among poor, unmarried, and teenaged women bearing first children in a semirural county in upstate New York. Eighty-nine percent of the sample was white, and all analyses focused on this group. In this article, an analysis of the net cost of the home-visitation program from the perspective of government spending is presented. The average per-family cost of the program in 1980 dollars was $3,246 for the sample as a whole, and $3,133 for low-income families. Treatment differences in government expenditures for Aid to Families with Dependent Children, Food Stamps, Medicaid, and Child Protective Services, minus tax revenues due to maternal employment (also expressed in 1980 dollars), were conceived as government savings. By the time the children were 4 years of age, government savings were $1,772 (95% confidence interval [CI]: -$557, $4,102) for the sample as a whole, and $3,498 (95% CI: $569, $6,427) for low-income families. Within 2 years after the program ended, after discounting, the net cost of the program (program costs minus savings) for the sample as a whole was $1,582 per family. For low-income families, the cost of the program was recovered with a dividend of $180 per family.

Home visitation for pregnant women and parents of young children.

Many of the most pervasive, intractable, and costly problems faced by high-risk women and young children in our society today are a consequence of adverse maternal health-related behaviors (such as cigarette smoking, drinking, and drug use during pregnancy), dysfunctional infant care giving, and stressful environmental conditions that interfere with individual and family functioning. These problems include low birth weight, child abuse and neglect, childhood injuries, unintended and closely spaced pregnancy, and reduced economic self-sufficiency on the part of parents. Evidence is accumulating that these problems can be reduced with comprehensive programs of prenatal and infancy home visitation by nurses. While we are witnessing a renaissance of interest in home visitation as a means of addressing these problems, the recommendations of various health and human service advisory groups about the structure of proposed home-visitation initiatives are uncoordinated and frequently inconsistent with the empirical evidence. Home visitation is a promising strategy, but only when the program meets certain standards. The more successful programs contain the following: (1) a focus on families at greater need for the service, (2) the use of nurses who begin during pregnancy and follow the family at least through the second year of the child's life, (3) the promotion of positive health-related behaviors and qualities of infant care giving, and (4) provisions to reduce family stress by improving the social and physical environments in which families live.

Can home visitation improve the health of women and children at environmental risk?

We reviewed randomized trials of prenatal and infancy home-visitation programs for socially disadvantaged women and children. Some home-visitation programs were effective in improving women's health-related behaviors during pregnancy, the birth weight and length of gestation of babies born to smokers and young adolescents, parents' interaction with their children, and children's developmental status; reducing the incidence of child abuse and neglect, childhood behavioral problems, emergency department visits and hospitalizations for injury, and unintended subsequent pregnancies; and increasing mothers' participation in the work force. The more effective programs employed nurses who began visiting during pregnancy, who visited frequently and long enough to establish a therapeutic alliance with families, and who addressed the systems of behavioral and psychosocial factors that influence maternal and child outcomes. They also targeted families at greater risk for health problems by virtue of the parents' poverty and lack of personal and social resources.

Improving the life-course development of socially disadvantaged mothers: a randomized trial of nurse home visitation.

We evaluated a comprehensive program of prenatal and postpartum nurse home visitation for socially disadvantaged women bearing first children. Eighty-five per cent of the participating women were either teenagers (less than 19 years at registration), unmarried, or of low socioeconomic status. Women were randomly assigned to either nurse home visitation or comparison services (free transportation for prenatal and well-child care and/or sensory and developmental screening for the child). During the first four years after delivery of their first child, in contrast to their counterparts in the comparison group, nurse-visited White women who had not graduated from high school when they registered in the study returned to school more rapidly; nurse-visited, poor, unmarried White women showed an 82 per cent increase in the number of months they were employed, had 43 per cent fewer subsequent pregnancies, and postponed the birth of second children an average of 12 months longer.

Preventing child abuse and neglect: a randomized trial of nurse home visitation.

A program of prenatal and infancy home visitation by nurses was tested as a method of preventing a wide range of health and developmental problems in children born to primiparas who were either teenagers, unmarried, or of low socioeconomic status. Among the women at highest risk for care-giving dysfunction, those who were visited by a nurse had fewer instances of verified child abuse and neglect during the first 2 years of their children's lives (P = .07); they were observed in their homes to restrict and punish their children less frequently, and they provided more appropriate play materials; their babies were seen in the emergency room less frequently during the first year of life. During the second year of life, the babies of all nurse-visited women, regardless of the families' risk status, were seen in the emergency room fewer times, and they were seen by physicians less frequently for accidents and poisonings than comparison group babies (P less than or equal to .05 for all findings, except where indicated.) Treatment differences for child abuse and neglect and emergency room visits were more significant among women who had a lower sense of control over their lives.

Improving the delivery of prenatal care and outcomes of pregnancy: a randomized trial of nurse home visitation.

We evaluated a comprehensive program of prenatal and postpartum nurse home visitation. The program was designed to prevent a wide range of health and developmental problems in children born to primiparous women who were either teenagers, unmarried, or of low socioeconomic status. During pregnancy, women who were visited by nurses, compared with women randomly assigned to comparison groups, became aware of more community services; attended childbirth classes more frequently; made more extensive use of the nutritional supplementation program for women, infants, and children; made greater dietary improvements; reported that their babies' fathers became more interested in their pregnancies; were accompanied to the hospital by a support person during labor more frequently; reported talking more frequently to family members, friends, and service providers about their pregnancies and personal problems; and had fewer kidney infections. Positive effects of the program on birth weight and length of gestation were present for the offspring of young adolescents (less than 17 years of age) and smokers. In contrast to their comparison-group counterparts, young adolescents who were visited by nurses gave birth to newborns who were an average of 395 g heavier, and women who smoked and were visited by nurses exhibited a 75% reduction in the incidence of preterm delivery. (P less than or equal to .05 for all findings.)