Are home visiting programs effective in reducing child maltreatment?

Becoming a new mother usually is a time of great joy. But for young mothers who may be struggling with poverty, addiction, and postpartum depression, the experience also can feel overwhelming and isolating. For agencies serving children and families, the time also marks a powerful opportunity to offer prevention and early intervention supports, as new and expectant mothers are especially motivated during this period to learn about how best to care for their child and keep them safe.

Home visiting programs provide parents with the necessary tools, support, and knowledge to create a safe home environment and establish a secure bond with their infants. Services generally include regular visits, spanning several months to several years, from a professional (such as a nurse or social worker) or paraprofessional to pregnant women and mothers of young children. Goals may include enhanced parenting skills, better maternal and child health, achievement of maternal education and employment goals, and enhanced child development.

More than a quarter million families in the U.S. received in excess of 2 million visits from evidence-based home visiting services in 2015.1 Some programs, such as Nurse‐Family Partnership and Healthy Families America, are built on nationally designed curricula and approaches, while others are locally designed or represent unique local variants of a national approach. Other programs, such as Early Head Start and Head Start, offer home visiting in conjunction with other services (such as center‐based early childhood classes) either as an option or as one element of a program.

By implementing evidence-based home visiting programs that complement the work of child protective services, agency leaders reduce the potential for future harm, leverage the talent and expertise of professionals trained in infant and child development, and expand the network of partners that can help keep children safe. Home visiting programs also can contribute significantly to effective and safe reduction of the use of out-of-home placement. They help parents access the services they need, such as parenting skills and child development education, supporting them to raise their children competently in nurturing, caring, and supportive environments.2

Evidence of effectiveness

Home visiting has a strong evidence base for promoting positive outcomes for mothers and young children in such areas as:

  • Prevention of child abuse and neglect: Studies have demonstrated that high-quality home visiting has led to a decrease in child maltreatment. The 15-year study of Nurse- Family Partnership programs found a 48 percent reduction in rates of child abuse and neglect among low-income families.3
  • Child and maternal health. Research shows that home visiting programs effectively support healthy child development, beginning in the prenatal period. Pregnant women who participate in the programs have better birth outcomes, and the programs have been found to have a positive impact on breast-feeding and immunization rates as well as lower depressive symptoms and stress.4
  • Child development and school readiness. Studies of various home visiting programs have shown positive impacts on children’s cognitive development and behavior, higher grade point averages and achievement scores at age 9, and higher graduation rates from high school.5
  • Family economic self‐sufficiency. Studies have found that compared with a control group, more parents participating in home visiting programs work, are enrolled in education or training, and have higher monthly incomes.6
  • Positive parenting practices. Research shows that home visiting programs help parents increase positive parenting actions and reduce negative ones, have more responsive interactions, create more developmentally stimulating home environments, engage in activities that promote early language and literacy, and know more about child development.7

In addition, a 2014 study found that children whose mothers received home visits during pregnancy and throughout their first two years of life were less likely to have died from preventable causes when compared with their counterparts in the control group.8 Although more research is needed, home visiting is a promising means to reduce preventable child fatalities for children at-risk of abuse and neglect by teaching parents how to engage with their children in positive, nurturing, and responsive ways.

Research also shows that home visiting saves money that otherwise would be spent later on more costly programs and services. Cost-benefit analyses show that high-quality home visiting programs offer a triple return on investment of $3.13 for every dollar spent, due to reduced costs of child protection, K-12 special education and grade retention, health care, and criminal justice expenses.9

Home visiting models that reduce child maltreatment

While each home visiting program is structured differently, essential components common to the models include:

  • Teaching parenting skills and modeling effective parenting techniques;
  • Assistance with referrals to address postpartum depression;
  • Navigation of community resources;
  • Screening children for developmental delays; and
  • Facilitating early diagnosis and appropriate interventions.10

Home visiting models vary based on factors such as their target population, the education level required of the home visitors, and the duration and frequency of home visits.

As of June 2017, 20 home visiting models met the U.S. Department of Health and Human Services criteria for evidence of effectiveness.11 Five evidence-based home visiting models have demonstrated reduction of child maltreatment in one or more outcome studies:12

  1. Child First
  2. Health Access Nurturing Development Services (HANDS)
  3. Nurse-Family Partnership
  4. Parents as Teachers
  5. SafeCare

Of these models, Nurse-Family Partnership has the highest number of favorable findings related to reducing child maltreatment. Primary outcome measures include evidence of substantiated child maltreatment from administrative records and counts taken from medical records of encounters with health care providers for injuries or ingestions.

To learn more, see Which home visiting programs are effective in reducing child maltreatment?

Funding

Home visiting services are provided to families at no cost to them. Most agencies that offer home visiting blend funding from a variety of sources at the federal, state, and county levels to cover program costs. At the federal level in 2017, the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program awarded $372.4 million in grants to all 50 states, the District of Columbia, U.S. territories, Indian tribes, and tribal organizations to fund evidence-based home visiting programs.13

Aside from MIECHV, states may allocate federal dollars toward home visiting from Title V of the Maternal and Child Health Block Grant program, Temporary Assistance for Needy Families, Medicaid, and Healthy Start. States also draw on a mix of general and dedicated funds to support home visiting, such as tobacco lawsuit settlements and taxes, lotteries, birth certificate fees, and budget line items. Although currently a small percentage of total funding, private dollars also may be leveraged to develop, implement, and expand home visiting services. States also have approved legislation to continue expanding and investing in home visiting.

Child welfare agencies also can allocate federal dollars dedicated to child welfare services and prevention, such as the Promoting Safe and Stable Families program and the Community-Based Child Abuse Prevention program. States also have used their Title IV-E waivers to fund evidence-based home visiting models, such as Nurse-Family Partnership and Safe Care.

1 National Home Visiting Resource Center. (2017). 2017 Home Visiting Yearbook. Arlington, VA: James Bell Associates and the Urban Institute. Retrieved from: https://www.nhvrc.org/wp-content/uploads/NHVRC_Yearbook_2017_Final.pdf
2 Commission to Eliminate Child Abuse and Neglect. (2016). Within our reach: A national strategy to eliminate child abuse and neglect fatalities. Washington, DC: Government Printing Office. Retrieved from: https://www.acf.hhs.gov/cb/report/within-our-reach-national-strategy-eliminate-child-abuse-and-neglect-fatalities
3 Olds, D., Henderson, C., Cole, R. (1998). Long-Term Effects of Nurse Home Visitation on Children’s Criminal and Antisocial Behavior: 15-Year Follow-up of a Randomized Controlled Trial. JAMA, 280, 1238-44.
4 Healthy Families America. (2008). Research Spotlight on Success: Healthy Families America Promotes Child Health and Development. Retrieved from: www.healthyfamiliesamerica.org
5 Healthy Families America. (2008). Research Spotlight on Success: Healthy Families America Promotes Child Health and Development. Retrieved from: www.healthyfamiliesamerica.org
6 Olds, D., Henderson, C., Tatelbaum, R. (1998). Improving the Life-Course Development of Socially Disadvantaged Mothers: A Randomized Trial of Nurse Home Visitation. American Journal of Public Health, 78(11),1436–1445.
7 Healthy Families America. (2008). Research Spotlight on Success: Healthy Families America Promotes Child Health and Development. Retrieved from: www.healthyfamiliesamerica.org
8 Olds,D., Kitzman, H., Knudtson, M., Anson, E., Smith, J., Cole, R. (2014). Effect of Home Visiting by Nurses on Maternal and Child Mortality. JAMA.168(9), 800–806. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4235164/
9 Washington State Institute for Public Policy. (2017). Benefit-cost technical documentation. Olympia, WA: Author. Retrieved from: http://www.wsipp.wa.gov/TechnicalDocumentation/WsippBenefitCostTechnicalDocumentation.pdf
10 Dodge, K.A., et al. (2014). Implementation and randomized controlled trial evaluation of universal postnatal nurse home visiting. American Journal of Public Health, 104(S1), S136-S143. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4011097/pdf/AJPH.2013.301361.pdf
11 For more information, see: https://homvee.acf.hhs.gov/outcomes
12 Two programs that are included on the Department of Health and Human Services evidence-based child maltreatment list were not included in this brief. Early Head Start New Zealand was not included because it is not a U.S. Program and Healthy Families America was not included because the primary outcome measure effect was “mother was a confirmed victim of sexual abuse.” For more information, see: https://homvee.acf.hhs.gov/
13 For more information, see: https://mchb.hrsa.gov/maternal-child-health-initiatives/home-visiting-overview