Are home visiting programs effective in reducing child maltreatment?
Becoming a new parent can be a time of great joy. But for young parents who may be struggling with poverty, addiction, or postpartum depression, the experience also can feel overwhelming and isolating. For agencies serving children and families, this time is a powerful window 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 baby and keep their child 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 to pregnant women and mothers of young children, spanning several months to several years, from a professional (such as a nurse or social worker) or paraprofessional. Goals may include enhanced parenting skills, better maternal and child health, achievement of maternal education and employment goals, and enhanced child development.
In 2020, almost 300,000 families in the U.S. received over 3.2 million visits from evidence-based home visiting services,1 representing 12 evidence-based and nine emerging models.2 Some programs, such as Nurse-Family Partnership and Healthy Families America, are nationally designed approaches, while others are locally designed or represent unique local variants of national approaches. 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). Several states are working to scale home visiting access through initiatives, like Family Connects Texas and New Jersey’s continuum of services.
Implementing evidence-based home visiting programs can complement the work of child protective services by supporting family well-being and preventing harm, leveraging the talent and expertise of professionals trained in infant and child development, and expanding the network of partners that can support families. Home visiting programs help parents access the services they need, such as parenting skills and child development education, supporting them to raise their children in nurturing, caring, and supportive environments.
Evidence of effectiveness
Home visiting has a strong evidence base for promoting positive outcomes for parents and young children. In addition, positive effects of home visiting have been found across different types of families and across different settings,3 which is critical given that issues of race and ethnicity must be considered when choosing interventions.4 Key outcome areas include:
- Preventing child maltreatment. Studies have demonstrated that high-quality home visiting has led to decreases in child maltreatment. A 15-year study of Nurse-Family Partnership found a 48% reduction in rates of substantiated reports of child abuse and neglect among low-income families.5 For parents already involved with child welfare, participation in Healthy Families America reduced recurrence of maltreatment by one-third, as measured by substantiated reports of maltreatment and hospitalizations for abuse.
- Child and maternal health. Research shows that home visiting effectively supports both child and maternal health, beginning in the prenatal period. For example, pregnant women who participated in Healthy Families America had fewer low-birth-weight infants, and the program has been found to have a positive impact on breast-feeding and child immunization rates, as well as mental health and parenting stress.
- Child development and school readiness. Studies of various home visiting models have found positive effects on children’s cognitive development, behavior, and school performance, including Healthy Families America, Child First6 and Parents as Teachers.7
- Family economic self-qsufficiency. Studies have found that parents participating in home visiting programs are more likely than similar parents in a control group to work or be enrolled in education or vocational training,8 and have higher monthly incomes.
- Positive parenting practices. Research shows that many evidence-based home visiting models help parents improve parenting interactions, increase their confidence, and create more developmentally stimulating home environments while also decreasing the use of physical punishment and yelling.
In addition, a 2014 study of Nurse-Family Partnership found that children whose mothers received home visits from nurses 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. Although more research is needed, home visiting is a promising means to reduce preventable child fatalities for children at-risk of abuse or neglect by teaching parents how to engage with their children in positive, nurturing, and responsive ways.
Research also shows that home visiting is cost-effective, saving 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 return on investment ranging from $1.80 to $5.70 for every dollar spent (though costs vary across programs), due to reduced expenditures on child protection, K-12 special education and grade retention, health care, and criminal justice.
Home visiting models that reduce child maltreatment
Of the many home visiting models with evidence of effectiveness, several have specifically demonstrated a reduction of child maltreatment in one or more outcomes studies. These include the following models:8
- Health Access Nurturing Development Services, also known as HANDS, includes developmental and social-emotional screenings for children, and domestic violence and perinatal depression screening for parents. Visitors work with families to establish high-quality, comprehensive, coordinated health care, and maintain up-to-date immunizations and well-child checks. A registered nurse or social worker provides quarterly visits to focus on mother’s pre- and post-natal health needs, and the needs of the infant.
- Healthy Families America includes home visiting and ongoing screening to determine whether families are at increased risk for child abuse or neglect, or other adverse childhood experiences. As Healthy Families America is implemented locally, some locations include additional services such as support groups, father involvement programs, and services that support the needs of that specific community. The program has been found to be effective for children and families from many different racial and ethnic backgrounds. A similar program, Family Spirit, is culturally tailored for young American Indian mothers. Both programs are considered promising, based on initial studies.
- Nurse-Family Partnership features home visits by registered nurses who teach positive health-related behaviors and competent care of children, and support personal development of the mother through means such as family planning, educational achievement, and participation in the workforce. Nurses help build the confidence of mothers, provide tools to promote a healthy start for their babies, and help mothers envision a life of stability and success for their family. The program has demonstrated effectiveness diverse populations, including Black and Latinx families.
- Parents as Teachers delivers culturally sensitive services that emphasize parent-child interaction, development-centered parenting, goal setting, and family well-being. Parent educators focus on the link between child development and parenting on key developmental topics. Parent educators work with families to identify, set, and achieve goals that lead to positive outcomes. The program has demonstrated effectiveness with diverse populations, including Black and Latinx families.
- Promoting First Relationships® offers a home visiting model that focuses on building parents’ skills for developing healthy relationships with their child. Home visitors provide positive feedback to build parents’ confidence and focus on the emotional needs of both parents and children. Home visitors may record interactions between parents and children to provide real-time feedback and offer opportunities for improvement.
- SafeCare® is an in-home parenting skills training program teaching child behavior management, home safety, and child healthcare skills that has demonstrated effectiveness with families from many backgrounds, including Black, Latinx, and American Indian/Alaska Native. Program modules begin with an assessment to determine parents’ skills and areas for improvement. Home visitors provide training and work with parents until they show a mastery of skills. SafeCare® Augmented is a modified version in which staff are also trained in the techniques of motivational interviewing and on risk factors related to domestic violence.
While each home visiting program is structured differently, five essential components common to each model include:
- Teaching parenting skills and modeling effective parenting techniques.
- Assistance with referrals to address postpartum depression.
- Referral to and navigation of community resources.
- Screening children for developmental delays.
- Facilitating early diagnosis and appropriate interventions.
Home visiting models vary based on factors such as target population and the duration and frequency of home visits. The table below illustrates how the 5 programs that have demonstrated effectiveness in reducing child maltreatment compare.
Healthy Access Nurturing Development Services
First-time parents beginning during pregnancy or before a child is 3 months old. Eligible families face multiple challenges, which may include poverty, substance abuse, and domestic violence.
- Based on the needs of an individual family.
- Has been found to lead to a decrease in substantiated reports of child maltreatment for participating families.
Healthy Families America
Families at risk of child abuse or neglect. Services begin either prior to the birth of a child or within three months of birth.
- Visits are offered weekly until children are 6 months old, with less frequent visits three to five years after birth of baby
- Maltreatment recurrence was reduced by one-third for families that already had been involved with child protective services.
First-time, low-income mothers and their children. Mothers must be enrolled and receive a home visit prior to 28th week of pregnancy.
- Nurses begin weekly visits at 16 weeks gestation, and during the first month after enrollment. Visits become bi-weekly until the baby is born, weekly for the first six weeks after birth, and return to bi-weekly until the baby is 20 months old. Visits occur monthly until the child is 2.
- Led to decreases in the onset of neglect, as well as decreases in substantiated reports of child abuse and neglect, number of days hospitalized, outpatient visits due to injuries, and a range of other health care encounters due to injuries.
Parents as Teachers
Low-income pregnant women and families with children from birth to age 3, most of whom are at or below the federal poverty level.
- Personal visits of about an hour are delivered at least once a month, depending on family needs.
- Parents as Teachers led to a decrease in the percentage of children suspected to be abused or neglected.
Promoting First Relationships®
Parents and families with children birth to age 3.
- Home visitors meet with parents for an hour each week, for 10 weeks
- Improvement in parental sensitivity and knowledge of child’s social and emotional needs. Children were less likely to be placed in foster care compared to a comparison group.
SafeCare® and SafeCare® Augmented
Families with children from birth to age 5 with a history of child maltreatment, or families with children at risk for maltreatment.
- Providers conduct 60- to 90-minute weekly or biweekly home visits for 18 to 22 weeks.
- Participation led to reductions in non-violent discipline strategies and a decrease in referrals to child welfare.
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 2021, the Maternal, Infant, and Early Childhood Home Visiting Program awarded $342 million in grants to 56 states, territories, Tribal entities, and non-profit organizations to fund evidence-based home visiting programs. In addition, federal Title IV-E dollars can fund evidence-based home visiting programs that prevent children from entering foster care, due to the passage of the Family First Prevention Services Act. Child welfare agencies can allocate other federal dollars dedicated to child welfare services and prevention programs, such as the Promoting Safe and Stable Families and Community-Based Child Abuse Prevention. 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 have drawn on a mix of general and dedicated funds to support home visiting programs, such as proceeds from tobacco lawsuit settlements, taxes, lotteries, birth certificate fees, and budget line items. Although private dollars currently account for a small percentage of total funding, they may be leveraged to develop, implement, and expand home visiting services. States also have passed specific laws to expand and invest in home visiting.
1 As a result of the COVID-19 pandemic, more than half of these visits were provided virtually.
2 National Home Visiting Resource Center. (2021). 2021 Home Visiting Yearbook. James Bell Associates and the Urban Institute. Retrieved from: https://nhvrc.org/yearbook/2021-yearbook/
3 Michalopoulos, C., Faucetta, K., Hill, C.J., Portilla, X.A., Burrell, L., Lee, H., Duggan, A., and Knox, V. (2019). Impacts on Family Outcomes of Evidence-Based Early Childhood Home Visiting: Results from the Mother and Infant Home Visiting Program Evaluation. OPRE Report 2019-07. Washington, DC: Office of Planning, Research, and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services. Retrieved from: https://www.acf.hhs.gov/opre/report/impacts-family-outcomes-evidence-based-early-childhood-home-visiting-results-mother-and
4 Casey Family Programs. (n.d.) Interventions shown to be effective with children and families of color being served with Family First funding. Research Brief Executive Summary (First Edition).
5 Olds DL, Eckenrode J, Henderson CR Jr, Kitzman H, Powers J, Cole R, Sidora K, Morris P, Pettitt LM, Luckey D. Long-term effects of home visitation on maternal life course and child abuse and neglect. Fifteen-year follow-up of a randomized trial. JAMA. 1997 Aug 27;278(8):637-43.
6 Lowell, D.I., Carter, A.S., Godoy, L., Paulicin, B., and Briggs-Gowan. M.J. A randomized controlled trial of Child FIRST: a comprehensive home-based intervention translating research into early childhood practice. Child Dev. 2011 Jan-Feb;82(1):193-208.
7 Drotar D, Robinson J, Jeavons L, Lester Kirchner H. A randomized, controlled evaluation of early intervention: the Born to Learn curriculum. Child Care Health Dev. 2009 Sep;35(5):643-9. doi: 10.1111/j.1365-2214.2008.00915.x. PMID: 19689569.
8 For this brief, we draw research from both the Home Visiting Evidence of Effectiveness clearinghouse and the Title IV-E Prevention Services Clearinghouse, which was developed in accordance with the Family First Prevention Services Act.
9 Love, J., Kisker, E., Ross, C. M., Schochet, P. Z., Brooks-Gunn, J., Paulsell, D., et al. (2002). Making a difference in the lives of infants and toddlers and their families: The impacts of Early Head Start. Volumes I-III: Final technical report. Washington, DC: U.S. Department of Health and Human Services, Head Start Bureau. Retrieved from: https://www.acf.hhs.gov/opre/report/making-difference-lives-infants-and-toddlers-and-their-families-impacts-early-head-2