Behavioral intervention strategies with child abusive parents: A home intervention program

This article describes a therapeutic program for child abusive parents that is psychoeducationally based and is conducted through home visits by trained behavioral interventionists. The immediate goals of the intervention are to teach abusive parents effective child management procedures based on social learning therapy and to modify faulty or excessive expectations these parents have toward the behavior of their children. The general model is discussed as well as criteria for selection of parents for home intervention services, the differences between home intervention with abusive and non-abusive parents and the procedures used in home intervention services. A general discussion is also provided of the various goals and stages through which parents progress.     

The effect of Alaska's home visitation program for high-risk families on trends in abuse and neglect

OBJECTIVES: At 6 sites serving 21 communities, Alaska implemented Healthy Families Alaska, a home visitation program using paraprofessionals designed to decrease child abuse and neglect. The primary study objective was to compare changes over time in Child Protective Services outcomes by Healthy Families Alaska enrollment status. METHODS: Enrollment status was linked to birth certificates for birth years 1996-2002 which in turn was linked to the Alaska Child Protective Services database for outcome years 1996-2004. All children were followed through the study databases until age 2 years. RESULTS: There were 40,099 children born during 1996-2002 to residents of Healthy Families Alaska communities and 985 were enrolled in the program. Physical abuse referrals among enrolled children decreased from 73 to 42 per 1000 child-years of follow-up from 1996-1998 to 2000-2002 (p=.005); all of this decrease occurred among children who received 20 or more home visitations. This decrease may have been unrelated to program impact as a similar decrease in referral was seen among unenrolled high-risk children. Compared to unenrolled high-risk children, enrolled children had a modest decrease in the proportion with substantiated neglect but no difference in the proportion with neglect referral or physical abuse referral or substantiation. CONCLUSIONS: Little evidence exists that Alaska's home visitation program had a measurable impact on child maltreatment outcomes. PRACTICE IMPLICATIONS: Within Alaskan communities that had a home visitation program targeting families at high risk for child abuse, changes in Child Protective Services outcomes among children less than 2 years of age were followed over time by program enrollment status. Enrollment was associated with a substantial decrease in physical abuse referrals, but a similar decrease was seen among unenrolled high-risk children. No improvement was seen in physical abuse substantiation. A greater number of home visitations was not associated with fewer abuse outcomes. This work supports most of the recent literature, which questions the field effectiveness of home visitation programs. In combination with other studies, the current work may lead decision-makers and funding agencies to re-examine the usefulness of home visitation programs, particularly those using a methodology similar to that implemented in Alaska.     

Changes in depressive symptoms in first time mothers in home visitation

ObjectiveThe expansion of Home Visitation Programs for at-risk, first-time mothers and their young children has drawn attention to the potential impact of depression on program outcomes, yet little research has examined depression in the context of home visitation. The purpose of this study was to determine the prevalence of and changes in depressive symptoms in mothers enrolled in home visitation and identify predictors of change in symptoms over the first 9 months of service.MethodsSubjects consisted of 806 at-risk, first-time mothers enrolled in a Home Visitation Program. Self-reported depression was measured at enrollment and again 9 months later. Established clinical cutoffs were used to identify clinically elevated levels of depression. Additional measures were taken of interpersonal trauma history, concurrent intimate partner violence, and social support.ResultsResults indicated that: (1) 45.3% of mothers had clinically elevated symptoms of depression at some point during the first 9 months of service, (2) 25.9% of mothers had elevated symptoms at both time points or at the 9-month assessment, and (3) 74.1% experienced an interpersonal trauma prior to enrollment. Lack of improvement or worsening of depressive symptoms from enrollment to 9 months was best predicted by pre-enrollment interpersonal trauma history, young maternal age, being African American, and symptoms severe enough to have led to mental health treatment.ConclusionsFindings suggest that maternal depressive symptoms are a significant problem in home visitation. The role of interpersonal trauma in depressive symptoms, and how to best address these clinical issues in home visitation, warrants further examination.Practice implicationsMaternal depression is prevalent in Home Visitation Programs, and many mothers exhibit elevated symptoms at multiple time points over the first year of service. Interpersonal trauma history is also prevalent, and is predictive of increased depressive symptoms over time. Home Visitation Programs should note that mothers with interpersonal trauma history, young maternal age, and being African American have an increased likelihood of persistent depressive symptoms, which may in turn pose significant challenges to providing services.     

Supplementation of urban home visitation with a series of group meetings for parents and infants: results of a "real-world" randomized, controlled trial

OBJECTIVE: Home visitation has been shown to be effective in reducing rates of child maltreatment and in enhancing psychosocial outcomes in children and their parents. Even when available, however, it is underutilized by parents in some urban settings. We tested a supplemental 10-session group intervention for its ability to increase active participation in home visitation, enhance the quality of caregiving behavior of parents, and improve social developmental outcome in children. METHOD: A randomized controlled design was utilized, involving two separate cohorts of parents of 3- to 18-month old infants, totaling 148 parent-child dyads. The intervention focused on practical experience in promoting parent-infant attachment relationships. RESULTS: At 6 months follow-up, there was a substantial increase in the proportion of intervention group parents participating in home visitation, compared to parents in the control group (Fisher's exact p = .008). Parents in the intervention group exhibited a trend for improvement in their capacity to appropriately interpret infants' emotional cues (p = .08), independent of the effects of home visitation itself. Attrition in both the treatment and control groups was inversely associated with income and level of education. CONCLUSIONS: Group meetings may constitute an effective means of engaging stressed urban families in home visitation.     

Improving the quality of home visitation: an exploratory study of difficult situations

OBJECTIVE: The primary purpose of this study was to use an ecological assessment model to obtain a better understanding of difficult situations that home visitors confront when implementing home visitation services. METHOD: A mixed method study was used which included conducting focus groups to identify specific situations faced by home visitors who implement the Healthy Families America model of child abuse and neglect prevention. The results of the focus groups were used to design a survey. The survey had 91 Healthy Families home visitors rate situations according to frequency and difficulty. RESULTS: The results revealed that situations that were ranked most difficult included working with families where there are limited resources, where family mental illness is present (e.g., threatening suicide), where there is substance use in the home, and where families are unmotivated. A factor analysis of the situations produced five factors that reflect the difficulty of doing home visitation: having a lack of clinical skill, addressing family difficulties, addressing parenting difficulties, resolving personal difficulties, and having a lack of experience. CONCLUSION: The situations identified in this study can assist in developing the competencies needed by home visitors. The factor analysis results can be conceptualized into an inventory for staff supervision, with workers completing the inventory to identify individual areas of training needs.     

Flexible and inexpensive: Improving learning transfer and program evaluation through participant action plans

Action plans have been shown to improve transfer of learning and have proven an effective tool in training evaluation. This study describes how action planning was simply and successfully adapted to a preexisting curriculum with few additional resources. The decision to use participant action planning, the administration of it, and the participants' and the sponsor's responses are discussed, along with suggestions for future human performance technology research.     

Characteristics of volunteers and families in a neonatal home visitation project: the Kempe Community Caring Program

OBJECTIVE: The purpose of this paper is to review literature related to home visitation support for new families using volunteer visitors and to describe characteristics of volunteers of the Kempe Community Caring Program, a home visitor support program for first time parents. Suggestions for effectively utilizing volunteers in family support programs are made. METHOD: Program data was collected and reviewed on 592 volunteer home visitors and the 1,144 families they served. Several evaluations and assessments were performed in order to attempt to measure the success of the intervention. Motivation for volunteering, longevity with program, and the extent of sociodemographic match between visitor and client were reviewed and discussed. RESULTS: Information on matched volunteer-client pairs was limited; however, speculations were made that neither motivation to participate nor sociodemographic match were critical factors in determining success of the intervention. Duration of volunteer participation was influenced by marital status, but not by age. Married volunteers stayed with the program significantly longer than unmarried volunteers. Low risk families demonstrated slightly improved confidence in parental function after receiving home visitation by a volunteer. CONCLUSION: This program suggests that new mothers may benefit from receiving the services of a volunteer home visitor; specifically, their confidence as parents and ability to establish positive relationships show slight improvement. Likewise, volunteers and families felt satisfied with the supportive relationships generated. In addition, a volunteer profile emerged which may be beneficial to similar programs' recruiting efforts.     

Reducing maltreatment recurrence through home visitation: A promising intervention for child welfare involved families

Maltreatment of children is a key predictor of a range of problematic health and developmental outcomes. Not only are affected children at high risk for recurrence of maltreatment, but effective interventions with known long term impact are few and limited. While home visiting is one of the most tested secondary prevention models for improving parenting, its primary focus on young primiparous mothers underemphasizes one of the most important risk groups: child welfare involved multiparous mothers. This study's focus is a randomized controlled trial of Healthy Families New York that included a subgroup of mothers (n = 104) who had at least one substantiated child protective services (CPS) report before enrolling in the program. By the child’s seventh birthday, mothers in the home visited group were as half as likely as mothers in the control group to be confirmed subjects for physical abuse or neglect (AOR = .46, p = .08). The number of substantiated reports for mothers in the control group was twice as high as for those in the home visited group (1.59 vs. 79 p = .02, ES = .44). Group differences were only observed after the child's third birthday, suggesting the possible effect of surveillance in early years. Post-hoc analyses indicate that home visited mothers had fewer subsequent births that may have contributed to less parenting stress and improved life course development for mothers. In light of our findings, we suggest considering and further testing home visiting programs as a tertiary prevention strategy for child welfare-involved mothers.     

Enhancing quality: Listening to participant voices to improve our Master's program in special education

Newly inducted special education teachers must be well-prepared to address changes in today's schools, including increased student diversity, implementation of tiered systems of support, and the need for increased collaboration with general education teachers and specialists. The purpose of this qualitative study was to develop and implement a data-based continual improvement approach to identify the strengths of our special education Master's program and address changes needed to ensure that graduates are ready to engage with the demands of their chosen profession. Using data gathered from 24 recent graduates and 20 field mentors, we describe our model and what we have done with our results over two years. An important finding is that our students greatly value the relationships they form during the program and the relationships the faculty model, and participants attribute our graduates' skills in collaboration to our program's modeling of collaborative processes and positive relationships. Implications for effective approaches to continuous improvement of special education teacher preparation programs are discussed.     

Supplementation of urban home visitation with a series of group meetings for parents and infants: results of a “real-world” randomized, controlled trial

Objective: Home visitation has been shown to be effective in reducing rates of child maltreatment and in enhancing psychosocial outcomes in children and their parents. Even when available, however, it is underutilized by parents in some urban settings. We tested a supplemental 10-session group intervention for its ability to increase active participation in home visitation, enhance the quality of caregiving behavior of parents, and improve social developmental outcome in children.Method: A randomized controlled design was utilized, involving two separate cohorts of parents of 3- to 18-month old infants, totaling 148 parent-child dyads. The intervention focused on practical experience in promoting parent-infant attachment relationships.Results: At 6 months follow-up, there was a substantial increase in the proportion of intervention group parents participating in home visitation, compared to parents in the control group (Fisher’s exact p = .008). Parents in the intervention group exhibited a trend for improvement in their capacity to appropriately interpret infants’ emotional cues (p = .08), independent of the effects of home visitation itself. Attrition in both the treatment and control groups was inversely associated with income and level of education.Conclusions: Group meetings may constitute an effective means of engaging stressed urban families in home visitation.     

Activity centers in the home: Ideas for family day care providers and parents

The home is where young children spend most of their time. Whether it is the home of the day care provider or their own home, it is the place where much of their learning takes place during their early years. Providers and parents can arrange the home environment to maximize learning for infants, toddlers, preschoolers, and school-agers. Setting up activity centers is a good way to organize space, ensure optimum learning opportunities, and facilitate supervision.Jean Billman is Professor of Early Childhood Education at Winona State University in Minnesota. She has been a center director and now directs a laboratory preschool on campus.     

Early home intervention with low-birth-weight infants and their parents

We investigated the effects of a year-long home intervention with a sample of preterm infants randomly assigned to 1 of 3 groups: a developmental intervention, a parent-infant intervention, and a no-treatment control group. A full-term no-treatment control was also used. Both intervention approaches focused on the parent-child unit, providing training for parents to improve observational skills, emotional support, and information about community resources. However, whereas specific tasks to facilitate the child's development were provided in the developmental intervention group, the quality of the parent-infant interaction was the target for treatment in the other group. All infants were assessed at 4, 8, 12, and 16 months of age corrected for prematurity. The results suggest that although both intervention approaches were effective in modifying some aspects of the home environment and, to a lesser degree, in improving infants' cognitive development, the parent-infant interaction approach seemed to have the greater impact. These findings confirm previous observations regarding the cognitive development of preterm and full-term infants during the first 18 months of life and demonstrate changes in behavior and behavior styles in both pre- and full-term infants as they become older.     

Randomized trial of a statewide home visiting program to prevent child abuse: impact in reducing parental risk factors

OBJECTIVES: To assess the impact of a home visiting program in reducing malleable parental risk factors for child abuse in families of newborns identified, through population-based screening, as at-risk of child abuse. METHODS: This randomized trial focused on Healthy Start Program (HSP) sites operated by three community-based organizations on Oahu, HI, USA. From 11/94 to 12/95, 643 families were enrolled and randomly assigned to intervention and control groups. Mothers in both groups were interviewed annually for 3 years (88% follow-up each year) to measure mental health, substance use, and partner violence. HSP records were reviewed to measure home visiting services provided. Home visitors were surveyed annually to measure their perceived competence. RESULTS: Malleable parental risks for child abuse were common at baseline. There was no significant overall program effect on any risk or on at-risk mothers' desire for and use of community services to address risks. There was a significant reduction in one measure of poor mental health at one agency and a significant reduction in maternal problem alcohol use and repeated incidents of physical partner violence for families receiving > or =75% of visits called for in the model. Home visitors often failed to recognize parental risks and seldom linked families with community resources. HSP training programs were under-developed in preparing staff to address risks and to link families with community resources. CONCLUSIONS: Overall, the home visiting program did not reduce major risk factors for child abuse that made families eligible for service. Research is needed to develop and test strategies to improve home visiting effectiveness in reducing parental risks for child abuse.     

Social media and gamification: Engaging vulnerable parents in an online evidence-based parenting program

The aim of this study was to examine the feasibility (accessibility, engagement and impact) of adding social media and gaming features (e.g., social sharing with anonymity, badges to incentivize skills practice, an accredited facilitator for support) and access via smartphones to an evidenced-based parenting program, Triple P Online. The highly vulnerable population included 155 disadvantaged, high-risk parents (e.g., 76% had a family annual income of less than $15,000; 41% had been incarcerated; 38% were in drug/alcohol treatment; and 24% had had a child removed due to maltreatment). The ethnic groups most commonly identified were African American (24%) and Hispanic (66%). Respondents were primarily mothers (86%) from five community programs in Los Angeles. The study used a single group repeated measures design (pre, post, 6-month follow-up). Data collected included standardized self-report measures, post-intervention focus groups and interviews, website usage reports, and Google Analytics. Significant multivariate ANOVA time effects were found, demonstrating reductions in child behavioral problems, reduced lax/permissive and over-reactive parenting, and decreased parental stress. No effects were found for parental confidence, attributions, or depression and anxiety (which were in the normal range at baseline). Positive effects were maintained or improved at 6-month follow-up. The participants engaged in the online community and valued its flexibility, anonymity, and shared learning. This foundational implementation trial provides support for future rigorous evaluation of social media and gaming features as a medium for increasing parental engagement in evidence-based parenting programs online—a public health approach to protect and improve the development of vulnerable children.