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Eckenrode J, Ganzel B, Henderson, Jr CR, et al. Preventing Child Abuse and Neglect With a Program of Nurse Home Visitation: The Limiting Effects of Domestic Violence. JAMA. 2000;284(11):1385–1391. doi:10.1001/jama.284.11.1385
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
Conclusions The presence of domestic violence may limit the effectiveness of interventions
to reduce incidence of child abuse and neglect.
The prevention of child abuse and neglect is an urgent public health
concern. Annually, about 1 million abused children—15 of every 1000
children—are identified in the United States.1
Home visitation has been widely promoted in recent years as a promising approach
to preventing health and developmental problems among children, and thousands
of home visitation programs have been started during the past decade.2 The role of visitation in preventing child abuse and
neglect perhaps has received the most attention. This emphasis stems in part
from the magnitude of this social problem and the limited success of prevention
efforts in the past. Policy makers and child advocates have actively promoted
home-visitation services3,4 despite
limited evidence supporting their effectiveness in reducing child maltreatment.5
Much of the enthusiasm for home visitation as a tool to prevent child
abuse stems from the early findings of a randomized trial conducted more than
20 years ago in Elmira, NY. Home visitation by nurses prenatally and for 2
years postnatally resulted in a significant reduction in the rate of verified
Child Protective Services (CPS) cases among a subsample of poor, unmarried
teenaged mothers when the children were aged 2 years.6
Four percent of the nurse-visited families had a verified maltreatment report
before the child's second birthday, in contrast to 19% in a comparison group
receiving routine perinatal care. Support continued for home visitation despite
the fact that differences in child maltreatment were no longer significant
by the time the children in the Elmira trial reached age 4 years,7 perhaps because of increased surveillance of the families
by the nurses.8
A recent review offers ambiguous support for the relation between home
visitation and reductions in child maltreatment.2
The findings from several large-scale home-visitation efforts have shown disappointing
short-term results in reducing family violence and child maltreatment.4,9 A 15-year follow-up study of the Elmira
trial families, however, provided the first evidence from a randomized trial
for the long-term effects of home visitation on reducing child maltreatment.10 Results from the follow-up showed that nurse-visited
families had half as many child maltreatment reports as families in the comparison
In addition to assessing the impact of home-visitation services on child
maltreatment, it is also important to specify for whom and under what conditions
these services are effective. Preventive interventions often find that treatment
effects for certain outcomes vary across subgroups of study participants.11,12 In this study, we examine how domestic
violence limits the effectiveness of the home-visitation program in preventing
maltreatment. There are several reasons why domestic violence might interfere
with the success of a home-visitation intervention. Research suggests that
children in households with domestic violence may be at an increased risk
for child maltreatment.13-16
Although some child maltreatment may be caused directly by the male perpetrators
of domestic violence, other incidents may result from the effects of domestic
violence on the mothers' caregiving capacities (eg, through injury, mental
distress, and restricted mobility). Data17
also suggest that mothers who are in violent relationships often act violently
themselves, either as initiators of the violence or in self-defense. Such
reciprocally violent relationships may place children at even greater risk
as violence spreads throughout the household. Children witnessing domestic
violence may also exhibit more internalizing and externalizing problems,18,19 which, in turn, may make them more
difficult to parent. We predicted that the intervention would be less effective
in reducing child maltreatment in the presence of domestic violence.
Details of the design of the original intervention can be found in earlier
A summary of the design is given here.
The original study was conducted in Elmira, a small, semirural community
in upstate New York with a population of 40,000. Pregnant women were recruited
from a free antepartum clinic sponsored by the county health department and
from the offices of private obstetricians. From April 1978 through September
1980, 500 consecutive eligible women were invited to participate. Women were
actively recruited for the study if they had no previous live births, registered
in the study prior to the 25th week of gestation, and were either young (<19
years at registration), unmarried, or of low socioeconomic status (Medicaid
status or no private insurance). Exactly 400 of the 500 eligible women enrolled
in the study. Eighty-five percent of the final sample had at least 1 of the
3 risk characteristics used for recruitment: 47% were younger than age 19
years, 62% were unmarried, and 61% came from households classified as of low
There were no differences in the age, education, or marital status of
those women who chose to enroll vs those who declined, except that 80% of
the whites agreed to participate vs 96% of the nonwhites (almost all African-Americans).
After completing the informed consent and baseline interviews, women were
stratified by sociodemographic characteristics and randomized to 1 of 4 treatment
Families in treatment group 1 (n = 94) were provided with sensory and
developmental screening for the study child at ages 12 and 24 months. Based
on these screenings, the children were referred for further clinical evaluation
and treatment when needed. Families in treatment group 2 (n = 90) received
the same screening services offered to those in treatment 1, plus free transportation
for prenatal and well-child care through the child's second birthday. Because
there were no differences between those in the 2 treatment groups in use of
prenatal and well-child care (both groups had high rates of completed appointments),
they were combined to form a single comparison group. Families in treatment
group 3 (n = 100) were provided with the screening and transportation services
offered to treatment 2, but were also assigned a nurse who visited them during
pregnancy. Families in treatment group 4 (n = 116) were provided the same
services as those in treatment group 3 except that the nurse continued to
visit through the child's second birthday.
During home visits, the nurses promoted 3 aspects of maternal functioning:
health-related behaviors during pregnancy and the early years of the child's
life, the care parents provide to their children, and maternal life-course
development (family planning, educational achievement, and participation in
the work force). Visits were held once every other week during pregnancy,
once a week for the first 6 weeks postpartum, and then on a diminishing schedule
until the children reached age 2 years. Further details on the intervention
can be found in earlier publications.6,10,20,21
Nurses completed an average of 9 (range, 0-16) visits during the mother's
pregnancy and 23 (range, 0-59) visits from the child's birth to second birthday.
Of the 400 original mothers and their children, in 49 mother-child pairs
either the child (n = 26) or mother (n = 2) had died, the child had been adopted
(n = 15), or the parents had requested no additional participation (n = 6).
This left 351 eligible mother-child pairs for the follow-up study. Assessments
were completed for 324 of these pairs, representing 81% of those women who
were originally randomized and 92% of those eligible for follow-up. The number
of completed interviews did not differ by treatment group. Interviews were
conducted with the mothers, adolescents, and custodial parents of the adolescents
(if the biological mother no longer had custody). Mothers were offered $75
and children $25 for completion of the 15-year assessments. Data gatherers
were blinded to treatment assignment. Social service, school, and criminal
justice records provided additional sources of data. Written consent for all
study procedures was obtained from the mothers and children. All research
procedures were reviewed and approved by the institutional review boards of
Cornell University and the University of Rochester.
Assessment procedures are described in previous publications.6,7,22 Registration information
collected prior to randomization included assessments of the women's sociodemographic
and personality characteristics, health-related behaviors, and health conditions.
Women's household socioeconomic status was estimated with the Hollingshead
4-factor method (August Hollingshead, PhD, unpublished data, 1976). Families
were classified into lower (levels III and IV) and higher household economic
(levels I and II) status.
At the 15-year follow-up, mothers were interviewed using a life-history
calendar designed to help them recall major life events (including births
of subsequent children, marriages and partnerships, education, employment,
moves, and housing arrangements). Women were also asked to estimate the total
number of months that they received Aid to Families with Dependent Children,
Medicaid benefits, and food stamps.
Mothers reported their exposure to domestic violence using the violence
subscales of the Conflict Tactics Scale.23
For the purpose of these analyses, we used a measure that consisted of the
total number of times the mother reported having experienced any form of partner-perpetrated
violence since the birth of the study child. Variables were also constructed
reflecting frequency of major and minor violence as defined by Straus.24 Minor violence included throwing items, pushing,
and slapping. Major violence included kicking, biting, hitting with a hand
or an object, beating, choking, threatening with a knife or gun, or use of
a knife or gun.
Mothers provided consent for the research staff to review CPS records.
Because program effects were hypothesized to be concentrated on the mother
and her first-born child, only reports involving either the mother as perpetrator
or the study child as subject were coded. Substantiated reports were abstracted
to ascertain key features of the maltreatment incident. All New York State
CPS records were searched, as well as those of most other states in which
families resided during the 15-year period. Out-of-state CPS record reviews
were not as complete owing to varying state policies on expunging records
and releasing case-level information. Nevertheless, our search covered an
average of 13.4 years of the 15-year period. There were no treatment differences
in the amount of time searched.
The primary outcome variables for this analysis were the number of substantiated
reports over the entire 15-year period involving the study child regardless
of the identity of the perpetrator or involving the mother as perpetrator
regardless of the identity of the child. These 2 outcomes are not independent.
We present both, not as distinct findings, but as alternative ways of understanding
maltreatment. Finally, we constructed separate measures distinguishing type
of maltreatment reports involving neglect only and reports including abuse
only. There were not enough abuse cases to examine sexual and physical abuse
Analyses were conducted on all cases in which data were available, irrespective
of degree of program participation. The model included a 3 × 2 ×
2 factorial structure: treatment (groups 1 and 2 vs 3 vs 4), maternal marital
status (married vs unmarried at study registration), and social class (Hollingshead
levels III or IV vs I or II at registration) and all interactions among these
classification factors. It also included the covariates maternal age and educational
level at registration and level of domestic violence in the family (number
of incidents of violence) measured over the 15-year study period.
Regressions of maltreatment on violence were specified separately by
levels of treatment (ie, the model included the interaction of treatment with
violence). This model is an extension of that presented in our earlier analysis
of abuse and neglect.10 Regressions of violence
specified separately by marital status and social class, in addition to treatment,
were also examined. These regressions were essentially homogeneous, and for
reasons of parsimony, we present only the interactions of violence with treatment.
Homogeneity of regressions was also examined for age and education.25
Race of the mother and sex of the child were additional classification
factors examined in deriving the final model. We also examined several other
covariates for possible inclusion in the model, such as father employment
status at study registration, but did not include these in the final model
because they had no unique relationship to the outcomes.
The abuse and neglect outcomes are in the form of count data. Results
are reported as incidence and log incidence. We examined the distribution
of the outcomes and, as in our earlier research,10
used a Poisson log-linear model, which best represents these data. Variables
with a Poisson distribution have variance equal to the mean. In Poisson log-linear
models, this assumption is frequently not met. When the variance is larger
than the mean, the data are said to be overdispersed. Correction for overdispersion
by scaling the SEs from overstating significance in statistical tests.26,27 All tests were corrected for overdispersion.
In the linear model in which tests of mean differences depend on the
value of a covariate (ie, when regressions are nonhomogeneous), the situation
can be shown pictorially by graphing the estimated regression lines for groups
being compared. With the effects of other covariates and the classification
effects subsumed in the intercept of the equations, the vertical distance
between the regression lines represents the estimated mean difference at a
given covariate value on the abscissa. A test of the mean difference can be
carried out for any single specific value. Alternatively, a simultaneous region
of significance over which the means differ statistically can be computed.
Because the region provides information about a continuum of covariate values,
the use of simultaneous statistical inference is required.28-30
In an approach similar to that taken by Olds et al,6
we have extended the methods for simultaneous regions of significance to the
generalized case, with log-link functions and Poisson error.
As previously reported, there were no differences at registration in
background characteristics of those assigned to the treatment and control
Table 1 shows the incidence
rates for each of the maltreatment outcomes for the entire sample, without
adjusting for violence and its interactions. Consistent with our earlier report,10 there were significantly fewer child maltreatment
reports involving the mother as perpetrator (P =
.01) or involving the study child (P = .04) for families
receiving home visitations during pregnancy and infancy vs families not receiving
home visitation. For both outcomes, the number of maltreatment reports for
the group receiving home visitation only during pregnancy (treatment group
3) fell between the other groups and was not significantly different from
the comparison group. Therefore, the remaining analyses focus on contrasts
from the overall model involving treatment groups 1 and 2 vs treatment group
Almost half (48%) of the mothers in this sample reported some form of
domestic violence since the birth of the study child (range, 0-225 incidents).
For all women in the sample, the mean number of incidents over the 15 years
was 22.2 (median, 1.0). For those women reporting any domestic violence, the
mean number of incidents was 43.1 (median, 11.7). Home visitation had no impact
on the incidence of domestic violence.
Prior to estimating the interaction between treatment group and domestic
violence, we examined the co-occurrence of domestic violence and child maltreatment.
Because the intervention affected the incidence of child maltreatment, the
best estimate of the underlying level of co-occurrence in this population
is obtained for families in the control group. For these women, 22.7% experienced
domestic violence in the past 15 years and were also in families with at least
1 confirmed child maltreatment report. Although we found that the number of
domestic violence incidents was positively associated with child maltreatment
reports (Figure 1), this effect
was not statistically significant in the models we estimated.
Table 2 summarizes the results
of a model that includes the interaction of treatment with domestic violence
for 13 outcome variables. The interaction is shown as the difference in the
regressions of maltreatment on domestic violence for treatment groups 1 and
2 vs treatment group 4. For each of the 4 maltreatment outcomes listed in Table 2, there was a significant difference
in the regressions on domestic violence across treatment conditions (P = .04-.001). To illustrate this interaction, the Figure 1 shows separate estimated regression
lines for these 2 treatment groups for maltreatment involving the study child.
The treatment effect decreases as the level of domestic violence increases.
There were significantly fewer cases of child maltreatment in the home-visited
group among mothers who reported 28 or fewer incidents of violence over the
15-year period. Of the 112 women who reported at least 1 incident of domestic
violence, 71 (63.4%) had 28 or fewer incidents. Treatment effects were nonsignificant
for mothers reporting more than 28 incidents of domestic violence over 15
years (21% of the entire sample of mothers in treatment groups 1, 2, and 4,
and 36.4% of those who had reported at least 1 domestic violence incident).
We examined the robustness of the interaction effect, tested a number
of alternative explanations, and investigated possible underlying mechanisms.
We examined whether the effects of domestic violence varied as a function
of its severity. Separate models were tested using measures of minor and major
domestic violence as defined in the "Assessments" subsection. In each model,
the interaction effect remained significant (P =
.01 for both), indicating that the limiting effect of domestic violence was
not restricted to the most severe forms of violence.
Finding a significant interaction effect when the maltreatment outcome
focused on reports involving only mothers as perpetrators rules out the possibility
that the effects observed were the result of the same partners committing
violence against both the mothers and the children. We also examined whether
the same effect held across types of maltreatment by estimating models in
which the dependent variable was restricted to cases of neglect only, and
cases where physical or sexual abuse (but no neglect) occurred. As shown in Table 2, domestic violence significantly
moderated treatment effects for both sets of outcomes.
We also determined whether type of treatment interacted with domestic
violence when predicting outcomes other than child maltreatment. We estimated
models by using dependent variables previously associated with significant
treatment effects in the follow-up study.10,20
These included life-course outcomes for the mother, such as number of subsequent
children, months on welfare, impairments due to substance use, and number
of arrests, as well as life-course outcomes for the study children, such as
number of runaway episodes and number of arrests or convictions. As shown
in Table 2, there was little evidence
that the presence of domestic violence had an impact on treatment effects
for any other maternal or child outcomes.
We next examined whether women experiencing domestic violence may have
been less engaged with the intervention, which, in turn, could have led to
a diminished program effect. To the contrary, we found that for the women
visited during pregnancy and their child's infancy, there was a small and
nonsignificant positive correlation between domestic violence and number of
prenatal and postnatal nurse visits (r = 0.13), indicating
that the presence of domestic violence was associated with slightly more,
rather than fewer, nurse visits.
Finally, we examined possible mechanisms that may underlie the interaction
effect. The approach was to identify variables representing changes that occurred
as a result of the intervention and that might help to explain why domestic
violence limited the effectiveness of the home-visitation program in preventing
maltreatment. These are the same maternal life-course outcomes shown in Table 2. Adding these variables to the
model for maltreatment that contained the interaction with violence did not
significantly reduce the differences in the regressions. As such, these maternal
life-course variables do not explain the observed interaction effects.
Our findings show that domestic violence represents an important part
of the context for understanding the conditions under which a home-visitation
intervention prevented child maltreatment. The interaction effect appears
to be robust across alternative measures of both domestic violence and child
maltreatment. It does not appear to reflect less engagement in the intervention
on the part of women reporting domestic violence, nor does it reflect the
perpetration of domestic violence and child maltreatment by the same individuals.
The impact of the intervention on other maternal life-course and child outcomes
was not affected in the same way by the level of domestic violence.
The data available to us did not yield further insight into the mechanisms
that may explain the moderating effects of domestic violence. It is likely
that domestic violence sets in motion a number of processes that compromise
the parenting of the mother or other caretakers. Some may involve the mother's
physical or psychological health at the time she is caring for her children.
Domestic violence may also result in a more chaotic or a less predictable
environment for children, placing them at increased risk. Future research
will be needed to clarify these alternative mechanisms.
There are important limitations of the present study. The intervention
occurred during the late 1970s and early 1980s in a semirural New York State
community. Care must be taken in generalizing our results to current interventions
in other communities and with different populations. We enrolled a high-risk
sample that may have experienced higher lifetime rates of domestic violence
than samples drawn from lower-risk or more heterogeneous populations. For
example, the National Violence Against Women Survey31
of a nationally representative sample of 8000 women used a modified version
of the Conflict Tactics Scale and found that 22.1% of the women reported intimate
partner violence at some time during their adult lives, about half the rate
we have reported. Furthermore, the increased awareness in recent years of
domestic violence as a social problem and the increased availability of services
for battered women and their children may alter the relationships we have
observed in our trial.
This report illustrates 1 element of a more general strategy for improving
health and human services. By identifying groups of individuals for whom the
program fails to affect targeted outcomes, approaches can be devised that
may strengthen services. In the current case, we have learned that this program
failed to prevent child abuse and neglect for 21% of the sample who experienced
relatively higher levels of domestic violence. While issues of domestic violence
have been addressed more systematically as the program evolved during the
years, the current findings have led to the incorporation of even more explicit
methods of addressing domestic violence32,33
and partner relationships34 in the most recent
generation of the program protocols. The promotion of partner communication
is designed to strengthen the mother-partner relationship, while a domestic
violence assessment and education program is designed to address domestic
violence effectively if it emerges. Both of these strategies have been tested
previously in separate controlled studies.35,36
Whether such modifications will strengthen the impact of the program on child
abuse and neglect will not be known until future trials of this program are
conducted. Meanwhile, careful analyses that examine groups for which the program
is more and less effective will enable policy makers to focus scarce resources
on those who benefit the most and encourage the continuous search for more
effective ways of serving those who fail to respond as expected.
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