ChrldAbuse & N&w, Vol. IS, pp. 363-375, Printed in the U.S.A. All rights reserved.

0145-2134/91 $3.00 + .oO copyright 0 1991 Pergaman Press plc

1991

AN EXPERIMENTAL CHILD ABUSE

EVALUATION OF IN-HOME PREVENTION SERVICES

RICHARDP.BARTH Associate Director, Family Welfare Research Group, and Associate Professor, School of Social Welfare, University of California at Berkeley

Abstract-Petinatal child abuse prevention projects are rarely rigorously evaluated. Women were referred to the Child Parent Enrichment Project (CPEP) project during or just after pregnancy if identified as at-risk of engaging in child abuse by community professionals. Clients were randomly assigned to CPEP services (n = 97) or traditional community services (n = 94). CPEP services are based on ecological theory and involve six months of home visiting by paraprofessional women and linkage to other formal and informal community resources. No advantages on self-report measures for the CPEP group were measured at posttest, and follow-up reports of child abuse were similar for both groups. Consumer satisfaction indicates that clients highly valued the program. Some indication of greater success with families with less serious probiems was observed. The results argue for caution regarding the capacities of perinatal child abuse prevention services to serve the high-risk clientele they often receive. Key Words-Child

abuse, Prevention, Home visiting, Paraprofessionals, Perinatal.

IN-HOME SERVICES to prevent child abuse are frequently delivered but infrequently evaluated. Socioecologically based services to high-risk families during the perinatal period are a sensible approach to child abuse prevention. These services address stressors arising from di~culties in housing, family life, and the sho~comings of extent services which otherwise aggravate personal vulnerabilities toward abuse (Barth & Blythe, 1983; Olds, 1982). Prenatal education and support, early and extended postpartum contact, parent education, and home visitation by professionals, paraprofessionals, or volunteers are often part of the child abuse prevention package (Gray, 1982; Payne, 1983). Despite their sensibility and popularity, research on perinatal child abuse prevention programs provides more promise than persuasion of their effectiveness (Helfer, 1982; Olds, 1988a). Although many evaluations have been completed (see Daro, 1988 for a review), few include random assignment to groups and report self-report and archival records of subsequent parental care and child abuse. An early evaluation of a home-visiting program involved 100 children from families identified as “high risk.” Biweekly meetings with pediatricians and weekly lay home visitor visits comprised the intervention. None of the 50 children in the randomly assigned intervention group suffered serious injury while five children in the randomly assigned non-intervention group were hospitalized for serious injury and one for failure-to-thrive (Gray, Cutler, Dean, & Kempe, 1979). The groups did not differ in child abuse reports (8% of families were reported), on parenting scales, or on screening tests of children’s development. Funding was provided by Bio-Medical Research Support Grant 2-507-RR07006 Resources from the Division of Research National Institute of Health, State of California Office of Child Abuse Prevention Grant CB 3301 S-AI, and Administration on Children, Youth, and Families, OHDS, DHHS Grants, 90-CA-0988 and 90-PJ-000101. Received for publication September 8, 1989; final revision received May 17, 1990; accepted May 18, 1990. Requests for reprints should be sent to Richard P. Barth, Ph.D., Berkeley Child Welfare Research Center, School of Social Welfare, 120 Haviland Hall, University of California, Berkeley, CA 94720. 363

344

Richard P. Barth

Alternately, the evaluation of a program providing early and extended postpartum contact and paraprofessional home visits to women (n = 357) in their third trimester found no significant relationship between services and maternal attachment, child maltreatment, or greater health care utilization than women randomly assigned to less complete services (Siegel, Bauman, Schaefer, Saunders, & Ingram, 1980). The authors conclude that their failure to screen for the highest-risk families minimized the impact of their preventive intervention as did delaying the onset of services until after mothers left the hospital. In another experimental child abuse prevention evaluation, 80 pregnant women were randomly assigned to receive visits from paraprofessionals (Larson, 1980). Women were divided into three conditions receiving (1) a prenatal home visit, a postpartum hospital visit, and home visits during the first six weeks of the infant’s life and for the subsequent year; (2) home visits canning during the child’s sixth week and continuing until the 15th week; or (3) no visits. Accident rates were significantly higher for Groups 2 and 3, and immunizations were more common in Group 1. No reports of child abuse were described. Perhaps the best known and evaluated in-home, perinatal, child abuse prevention project -and one which the author carefully reviewed in the planning stage of the current project-is Old’s Prenatal/Early Infancy Project ( 1988b). The project actively recruited women (N = 400) in their first six months of gestation if they had no prior children and had any one of the conditions of being a teenager, a single parent, or poor. The key service was nurse home visitation during the pregnancy and the subsequent two years. The theoretical basis for the program was a social ecological model (which emphasizes connecting women to formal and informal services) and naive parental psychology (which holds that parents do what they think is approp~ate and if they are doing some~ing that is wrong it is because they do not know the harm it could cause to their child). For research purposes, the women were followed for two years after the service period. In contrast to the randomly assigned control group (but excluding all non-white clients), they found positive effects on birthweight, use of formal services, ease of reported care, emergency room use, repeat pregnancies, and the rate of substantiated cases of child abuse and neglect (19% in the control group; 4% in the service group). In sum, few programs have used random assignment to groups, and their results have varied from the spectacular to the disappointing. The project described in this paper adds to that select set.

METHOD Evidence about three possible ameliorates of child abuse-social support, bonding, and goal setting and problem solving-governed the development ofthe Child Parent Enrichment Project &PEP). Many investigators have shown a link between social isolation and child maltreatment (e.g., Salzinger, Kaplan, & Artemyeff, 1983). Having the emotional, informational, and material resources that often accompany participation in a socially supportive network is often assumed to lessen the risk of maltreatment. A few investigations (e.g., Klaus & Kennel, 1982) have shown that the relationship that develops between the mother and infant during the first days after birth may influence the health of their latter relationships. Bonding is no longer thought to be an event that occurs at the instant of birth, when motherinfant contact is made (Goldberg, 1983) but is instead viewed as a by-product of a healthy pregnancy and labor and an overall experience of wanting the child and knowing that caring for the child will be manageable. Goal setting and problem solving have been associated with effective parenting (Enos & Hisanga, 1979; Shure & Spivak, 1978). The ability to establish and accomplish goals may encourage attainment of comprehensive prenatal care as well as provide a partial antidote to the wear and tear of caring for an infant (Barth, 1986). These concepts under~rded the CPEP service delivery program.

Prevention services

365

As the previous studies showed, perinatal child abuse prevention services often employ paraprofessionals and volunteers (see also, Miller, Fein, Howe, Gaudio, & Bishop, 1984; Whitey, Anderson, & Lauderdale, 1980). The use of people indigenous to the local community is largely compatible with the goals of perinatal programs. Paraprofessionals provide feasible service to the many clients who might have problems rather than those who already do. They may encourage at-risk clients to accept home visits that are not typically considered a privilege. Paraprofessionals may also be more likely to offer information, tangible aid, and problem-solving in a way that is acceptable to clients. Research and practice suggest that across child abuse prevention programs, experienced mothers serving as paraprofessionals have a better chance of developing a helpful relationship to high-risk mothers (Barth, Hacking, & Ash, 1986). Paraprofessionals, known as parenting consultants, delivered CPEP services. Parenting consultants were recruited to represent ethnic (white, black, Latino, and native American) and geographic communities in the service region ofcontra Costa County, California (population 630,000). Over 100 hours of training spanned topics concerning the perinatal period, community resources, child abuse and child abuse reporting, and team building. During that time, paraprofessionals also learned the basics of a task-centered approach (Reid & Epstein, 1972; Fortune, 1985) which focuses on the identification of goals for improved self and child care and enhances clients’ ability to identify and complete tasks that forward goal attainment. Assignment of a parenting consultant to CPEP clients was based on ethnic or geographic considerations. Services were provided for about six months. The average number of home visits was 11 with a range from 5 to 20 (Barth, 1989). Each of eight parenting consultants worked about 20 hours per week and followed about 10 families. Two parenting consultants left the project at midterm and two additional parenting consultants were trained. Group supervision was used to try to ensure similar service delivery by parenting consultants. The use of the task-centered approach provided paraprofessionals and clients with a focal point for their work to reduce the risk of parenting problems. Tasks were recorded on sheets for clients and paraprofessionals to use as prompts and for accountability of task achievement (Barth, 1986). On the average, the parenting consultant and client completed 17 tasks per case. These were distributed between those done by the parenting consultant alone (M = 49%) and client alone (M = 4 1%), and the two together (M = 9%). Tasks that clients completed in pursuit of their goals included attending prenatal care, eating two good meals per day, preparing one clean room for the baby to come home to, visiting the labor room, using a respite care program one-half day per week, visiting a thrift shop in pursuit of a crib, and making appointments to visit three apartments with the paraprofessional. During and between visits with clients, parental consultants completed tasks including providing transportation, support, and assistance with client needs, advocating on client’s behalf, modeling positive parenting and homecare skills, and discussing the care of a colicky baby. Typical conjointly completed tasks were driving together to church to pick up food, giving information regarding whom to contact at the Housing Authority, and teaming up to repair a refrigerator. (See Barth, 1989, for additional analysis of task accomplishment, goal attainment, and client satisfaction.) Participants

Participants were pregnant women referred to the Child Parent Enrichment Project (CPEP) by public health, education, or social service professionals (n = 19) working in 17 different agencies. Professionals gathered information about clients’ conditions that might presage child abuse on a screening instrument adapted from Gray, et al. ( 1979) and Murphy, Orkow, and Nicola ( 1985) that included underuse of needed community services, criminal or mental illness record, suspicion of previous abuse by mother, low self-esteem, chaotic lifestyle, lack of social support from father or family, low intelligence or poor health of mother, unplanned or

366

Richard Table 1. Characteristics

P. Barth

of CPEP and Control Groups at Intake

Risk Checklist Mother is underusing needed services Mother has history of criminal or mentally ill behavior Mother suspected of physical abuse in the past Mother has low self-esteem, is socially depressed or isolated Mother has generally chaotic life There is a lack of support from father and/or family The mother’s intelligence or health is not good The baby was not planned or wanted The mother was or is abused Child is difficult to care for Total Proportion of Risks Present Age Ethnicity Income Education Completed Supportive Relationship Number of Children a Modal

with Father

CPEP (n = 97)

(n = 94)

.61 .08 .05 .83 .43 .65 .32 .46 .27 .36 .51 23.25 White” $4-6000 Less than H.S.” .40 I .52

.74 .lO .03 .82 .58 .63 .33 .50 .2_5 .39 .54 23.75 White” $4-6000’ Less than H.S.” .39 I .42

Control

values given.

unwanted pregnancy, previous/ongoing abuse of mother, and difficult child to care for. If mothers had two or more risk factors, they were considered eligible for referral although considerable discretion for screening was granted to referrers. The typical participant had more than four of the known risk factors (see Table 1). When referrers determined that clients might benefit from program services, they described the program to interviewees. If interviewees were interested, they indicated their consent to be contacted by CPEP staff or to have the referrer contact CPEP at that time. (See Barth et al., 1986, for a more complete description of CPEP referral and recruitment practices.) Random assignment to groups occurred at the central office before the in-home assessment interviews. All interviewers knew the clients’ assignment when they went into the homes to interview them. Families were informed of the procedure before the interview and provided written consent to being randomly assigned to either conventional or CPEP services. Informed consent also included access to medical and social service records but did not include access to the state’s central child abuse registry. To minimize bias in responses to the interview that might occur if clients believed that identifying more serious needs would result in the receipt of more comprehensive services, clients were informed that the random assignment had been made at the central office and could not be changed by the interviewer. Clients were also informed that the referring agency knew that they were not guaranteed any additional services and that the client and the referring agency should, in any event, continue to work together to address the family’s needs as if there had been no CPEP project. Of all clients referred to the project (n = 3 13), 34 ( 10.8%) could not be located for even a first contact by CPEP staff, 39 (12.5%) refused to participate once contacted, and 49 participants (21 service and 28 control, 15.6%) could not be reached for posttest. Thus, 6 1% of all referrals completed pre- and posttesting. The demographic breakdown for participants shows that mothers were, on the average, 5.7 months pregnant at the time they began the program. Among the clients, 44% were primaparas; 24% were pregnant and had one child; 16% had two children; and 16% had 3 or more children. Of the participants, 45% were white, 3 1% were Latin0 (primarily Chicano), 17% were black, 7% were other. The median age of the entire sample was 23.5 years old. Of the participants, 40% were on AFDC and 70% had family incomes less than $10,000; 45% of

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367

moms reported a steady relationship. Table 1 shows that the CPEP and control groups did not differ significantly on any preassessment demographic variables. The research design was similar to that used by Olds (1988a) to preempt concerns about the ethics of random assignment. The control group received referrals to social and health services indicated by the two-hour assessment interview. In a few cases, a second interview was needed to complete the assessment and referral process. In all cases, this was the extent of contact with control group clients. Provision of these services to the control group has the potential to undermine the detection of differences between CPEP and no CPEP services. These services were, however, fewer than those provided by the Prenatal/Early Infancy Project which showed program impact despite providing control families with transportation for regular prenatal and well-child care (Olds, 1988a). When families assigned to the CPEP group refused services or accepted less than five visits (there were only six such families, and their mean number of visits was 2.1) they were reassigned to the control group. While adding these uninterested families to the control group may have slightly biased the results in favor of the intervention group, the fact that they received a bit of additional service may have had an offsetting effect. Only three of these families were in the final sample, so their impact was probably quite modest. Nonparametric tests found no pretest differences when comparing (1) CPEP, (2) control, (3) could not contact, (4) reassigned to control group, and (5) could not recontact groups. Pre- and Posttest Measures Posttest measures were collected at each assessment point by trained interviewers speaking the client’s native language and aware of the client’s status in the CPEP or control group. SelJreports of mother’s well-being. Four measures of well-being were completed by participating mothers. The Child Abuse Potential Inventory (CAPI, Milner, 1980; Milner & Wimberly, 1979, 1980) was given to every mother. The CAP1 has been shown to correctly classify a high percentage of the cases of abusers and nonabusers. Items from the three subscales most able to predict abuse (distress, rigidity, and unhappiness) were used, reducing the number of items from 77 to 35, which reduced the total possible score from 475 to 22 1. The Centerfor Epidemiologic Studies Depression Scale (CES-D, Radloff, 1977) was developed for use in epidemiologic surveys to assess symptoms of depression. Evaluative evidence suggests that the 20-item (4 points per item) CES-D has high reliability and validity (Radloff, 1977). Scores higher that 16 are considered to be in the clinical range. The State-Trait Anxiety Inventory (STAI, Spielberger, Gorsuch, & Lushene, 1970) asks respondents to rate their anxiety level. The mean scores for females is 37.5. Other investigators report STAI alpha coefficients ranging from .83 to .92. The Pearlin Mastery Scale is a 6-item scale adapted from Pearlin and Schooler (1978) that assesses the client’s mastery and locus of responsibility for events. Each item has four points. A sample is “There is really no way I can solve some of the problems I have.” Previous research with a similar population shows adequate reliability as evinced by an alpha coefficient of .8 1 (Barth, Schinke, & Maxwell, 1985). Higher scores indicate less mastery. Formal and informal support. In respect for its multiple dimensions, support was assessed with multiple measures. Clients completed the Community Resources Use Scale (CRUS) in an interview with the assessor. Clients were asked about their current use and their possible need for each of 19 possible formal and informal community services. The score on this measure indicates the discrepancy between the services that clients are eligible to use and report that they might benefit from and their actual use of those services. The Social Supports

368

Richard P. Barth

and Preparation Scale (SSP) is a IO-item checklist that queries participants about the availability of informal helping resources before, during, and after birth. The SSP also inquires about the mother’s preparation of the home for the arrival of the infant. Higher scores (scores ranged from 2 to 9) indicate more ways that mothers are not prepared. The Inventory of Social Supportive Behaviors (ISSB) is a 40-item (5 points per item) self-report measure standardized on pregnant and adolescent mothers (Barrera, 198 1). The ISSB asks for counts of behaviors characterizing social support (e.g., Did anyone give you over $25 in the last month?). Higher scores are better on this scale. The Social Support Inventory (SSI) matches Habif and Lahey’s ( 1980) measure of social support-except that their dichotomous response options were expanded to four per item (high scores indicate more support.) A sample is “My relationships with others are steady and close.” The alpha coefficient for this scale is .76. Additional Posttest Measures Participants completed additional items about pregnancy and postpregnancy outcomes six months after the initial assessment or when their child was 4 months old-whichever came first. Prenatal care. Clients were asked about the frequency of ingesting healthy (i.e., protein, grains, dairy products, fruit, and vegetables) and unhealthy (e.g., tobacco, alcoholic or caffeinated drinks, chips, and nonprescription drugs) items during their pregnancy. These summary scores are called Eat Right and Eat Bad, respectively. Prenatal indicated how often a client visited her doctor in the second and third trimesters of pregnancy. Birth outcomes. Birth outcome data was self-reported and assessed which of the following, if any, events took place during delivery: drug treatment, use of forceps, episiotomy, cesarean section, induced labor, breech delivery, or any other. The occurrence of any event was given an equal weighting of one and a summary score was calculated as Pregnancy Problems. Hospital Stay indicated total days mother and newborn were in the hospital around the time of the delivery. The baby’s birthweight was also calculated in grams (Birthweight). Discomfort was a summary score that indicated the discrepancy between how much discomfort the client expected to experience during pregnancy and delivery and how much she did experience. Worries comprised 12 items, with 4 points each, that assessed the degree to which a client worried about issues related to having a newborn including feeding, paying bills, and taking care of a sick baby. Child temperament. Because of a demonstrated relationship to the Denver Developmental Screening Test and the Bayley Scales of Infant Development, the Infant Temperament Questionnaires (ITQ, Carey, 1970), a self-report instrument, was used to assess children. The instrument has subscales indicating levels of activity, mood, and distractibility. Child welfare. Four self-report measures indicated problems in caregiving for a child. Need Care indicates whether the client’s child has been removed from her care by a police officer or social worker or if a neighbor has cared for the child because the mother did not get around to it. Health indicates the ratings from minor to very serious of eight common illnesses or medical conditions (e.g., virus, rash, diarrhea) that the child might have experienced. Emergency Care indicates how many times a client has taken her newborn to the emergency medical service. Baby Care indicates the combined number of times that a baby has had check-ups, DPT shots, and polio shots.

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369

Child Abuse Reports and Removals To determine how many families in the study later became involved with formal child welfare services, county department of social services’ intake and case records were reviewed for (1) intake calls that were closed on contact (the least serious kind of report); (2) investigated but unsubstantiated reports; and (3) investigated and substantiated reports. Data were collected by social workers blind to condition. Of all the families, 33% were reported for child abuse during or since the service period. If families were listed under any of these categories, they were identified as in the Total Reports group. County records were reviewed for reports before and after entrance into the study: Prior and Since data were collected. If study members had moved out of the county, they may have been reported but this was not known to this study. Otherwise, most reports would be known.

RESULTS Screening and referral procedures effectively identified women who were socially isolated and had high child abuse risk scores. Less than half of participants in either group reported involvement in a supportive relationship with at least one adult figure or the baby’s father. For a substantial group of participants, no family member, friend, relative, or the baby’s father would be with them during labor (8%) or after delivery (18%). About one-quarter of the participants reported that they would not have any family or other adult to help them during their first week home after delivery, that they did not feel well prepared to care for the baby, or that they would not have help from an experienced mother in taking care of the baby. The average preservice, abridged CAP1 score for project participants indicated high child abuse risk (Milner, 1980; Milner & Wimberly, 1979, 1980). Participants’ mean score of 108 on the 35-item short version of the CAP1 was well above the average score for a normative parenting group on the longer 77-item version (M = 87). If prorated to match the full instrument, 89% of participants’ scores were above the CAPI’s mean of 115, and 38% of participants’ scores were in the highest risk range (i.e., greater than 123) as identified by Ayoub, Jacewitz, Gold, and Milner (1983). Such proportional calculations must, of course, be carefully interpreted. The mean score for the services group (M = 108) was somewhat, but not statistically, higher than for the control group (M = 103). To minimize chance findings, multivariate tests of significance were used to compare CPEP and control group posttest scores for conceptually related groups of dependent variables. The six groups used for the multivariate analyses of covariance (MANCOVAs) and the instruments comprising them were (1) well-being (CES-D, STAI, PEARLIN, and CAPI); (2) support (CRUS, SSP, ISSB, and SSI); (3) prenatal care (Eat Bad, Eat Right, and Prenatal Visits); (4) birth outcomes (Pregnancy Problems, Hospital Stay, Birthweight, and Discomfort); (5) baby temperament (Activity, Mood, and Distractibility); (6) child welfare (Need Care, Emergency Medical Care, Baby Care, and Health). When pretest data was available, tests controlled for differences between groups at pretest. (Variables for which high scores indicated less risk were multiplied by - 1 before entry into the MANCOVA.) No MANOVAs or ANOVAs indicated significant differences between groups at posttest (see Table 2). Given the sample size, the evaluation has only a one-in-three chance of detecting a small effect size (i.e., d = .lO), but has a power of .80 for an effect size of .20 and a greater than 95% chance of detecting a medium effect size of .30 (Borenstein & Cohen, 1988). The chances are good that with alpha set at .05, important differences between the groups did not go unnoticed because of the sample size. Consumer satisfaction scores show that clients evaluated the service favorably. Most (92%)

370

Richard

P. Barth

Table 2. Mean Scores for CPEP and Control Grouos Pretest CPEP (n = 97)

Parent Well-Being CES-D STAI PEARLIN CAPI Goal Level support CRUS SSP ISSB SSI Prenatal Care Eat Bad Eat Right Prenatal Care Birth Outcomes Pregnancy Problems Hospital Stay Birthweight (grams) Discomfort Worries Child Temperament Activity Mood Distractibility Child Welfare Health Need Care Emergency Baby Care

Posttest Control (n = 94)

CPEP (n = 97)

Control (n = 94)

Mean

SD

Mean

SD

41.17 39.63 19.94 107.55 1.63

11.01

10.85 4.09 49.94 0.68

42.86 39.31 20.36 102.83 1.82

12.83 12.63 3.73 45.44 0.80

39.54 39.25 19.98 99.76 2.29

12.30 12.98 3.73 45.82

2.45 2.84 45.33 8.61

2.12 I .92 13.34 2.93

2.42 2.87 48.88 7.65

2.09 1.74 14.66 2.64

2.00 2.50 45.78 12.11

Note. High scores are negative except for the ISSB, SSI, Birthweight, No between group differences in post-tests are significant.

Mean

SD

Mean

SD

41.40 40.4 1 20.28 93.37 2.98

12.38 13.23 3.52 46.6 1 I .02

1.86 I .64 13.29 2.52

1.94 2.44 44.62 12.02

2.17 I .99 15.32 2.56

8.12 6.21 9.90

2.38 2.81 3.17

8.28 6.10 9.73

2.88 2.83 3.48

1.49 8.41 3396 1.31 25.04

1.06 3.88 683 .19 7.55

1.36 9.80 3255 1.36 24.19

1.09 4.57 625 .45 6.48

48.05 22.05 24.1 I

9.35 4.54 6.50

50.18 23.91 24.59

8.75 4.93 6.44

5.62 2.08 1.44 7.43

2.92 0.31 .50 3.55

5.43 2.06 1.44 7.09

2.96 0.29 .50 3.89

1.03

and Baby Care.

clients who received full services mailed completed consumer satisfaction inventories to the project evaluator. On 7-point scales, with 7 indicating most agreement, clients reported a high overall level of satisfaction with the program (A4 = 4.7). On the most important question asked by the project-that is, did the project prevent child abuse-the evidence is equivocal (see Table 3). Data were only obtainable on the number of families reported in the CPEP and control groups prior to and since receiving services and the total number of reports per family. That is, reports about the abuse of children born subsequent to CPEP services would not be included. The average time between the end of CPEP services and the follow-up review of case records was about three years with a range from roughly two to five years. The groups did not differ significantly on the total number of months that they were followed. Number of months since the end of services was marginally related to total substantiated reports @ = .068). The analyses were repeated to test for differences between groups for study participants for whom there had been more than 3.5 years since entering the study. No differences between groups or significant group by time interactions were found. Prior to participation in the study, the CPEP group contained disproportionately more families than the control group (16 vs. 10) that had ever been reported for child abuse and

371

Prevention services Table 3. Number of Child Abuse Reports and Actions for CPEP and Control Families Increase in #

Since

Prior ~

CPEP

F

Information Contact or Intake Investigated Unsubstantiated Total Total Contacts In-Home Out-of-Home Total Actions**

Reports*

T

of New Reports or Court Actions

CPEP

Control ~

~

F

F

T

T

CPEP

Control ____

~

F

F

T

Control ~ T

F

T

at

5 13 16 2 1

3

2

25

7 1 8 10

1 2 39

13

7 21 3 17 25 2 1

11 :: ::

12 4 64

14 31 38 12 4

104

11

4

55 18 73

13 27

14 4 102

40

19 39 47 15 3

5

3

10 13 23

41 59

10 3 41

74

F = Number offamilies reported. T = Total number of reports or court actions to assume dependency per group.

* Total Contacts & Reports is the sum of Information Contact/Closed at Intake + Total. ** Total Actions is the sum of Total Contacts & Reports + Dependency.

significantly more unsubstantiated reports (25 vs. 14). Also, participants in the CPEP groups had received more total reports and actions (CPEP families had received 39 prior reports and actions as compared to the 28 for non-CPEP families). Thus, CPEP clients appeared to have been at greater jeopardy; however, the mean number of families reported and the mean number of total reports and actions did not substantially differ. Child abuse reports during the service period slightly favored the control group-they had 9 total actions and the CPEP group had 11. Of those 11, 7 were a direct result of CPEP’s involvement with the family. Following the program, CPEP and control groups were equal in the increase in the number of families reported. Given some between group differences in prior reports, an analysis of covariance on reports during or since entry into the project was run with prior reports as the covariate. No significant differences emerged, hinting that influence of prior reports on the outcomes is not overwhelming. A separate analysis was conducted to see if the prevention effects were any more evident for families that had not been reported for child abuse prior to participation in the study. There were no significant differences in the increases in information referrals or closed on contact calls since the program, or substantiated reports since the program. The control group had a significantly greater (_D< .05) increase in unsubstantiated reports than the treatment group. There was a tendency (p < .082) for the CPEP group that had not been previously referred to have lower total actions since the program than the control group. Since these are the only findings that distinguish the two groups, they may be an artifact of multiple tests of outcome or could indicate that CPEP is more effective as a primary prevention program than an intervention program. A subsequent analysis tested for the differences between the 24 persons- 15 in the CPEP group (16%) and 9 in the control group ( 12%)-with more than one report prior to participation in the study. The CPEP group had a somewhat (p = .093) higher likelihood of another report subsequent to beginning participation in the study. This may well be a surveillance effect (in that these very troubled families were more closely observed if they were receiving home-based services) but could not be argued to show a strong prevention effect. Thus there is some evidence to suggest a true primary prevention capacity for less troubled CPEP families even though the evidence falls short of indicating primary and secondary prevention of child abuse.

372

Richard P. Barth

Data was also collected on families that received court-ordered in-home or out-of-home services prior and since participation in the study (see Table 3). Since participation in the study, child welfare services assumed in-home dependency of children in 12 of the families in the CPEP group and 12 of families in the control group; 4% of the CPEP and control families received out-of-home dependency services, respectively.

DISCUSSION Paraprofessional services like CPEP appear not to be designed for unilateral intervention on behalf of highly distressed families. Paraprofessionals may be overmatched by the multiple problems of families. As public social services increasingly limits the time and scope of its service to the most serious families, other very troubled families are often referred to altemative community-based services. To be successful, paraprofessionals would then need skills for helping clients with a range of problems (e.g., mental illness and substance abuse), for which clients may not be receiving professional services. Professionals and paraprofessionals can certainly collaborate better than they do now; several exemplary projects give proof (e.g., Miller, et al., 1984), but the efficacy of paraprofessional services with highly troubled clients continues to be suspect. One should understand, however, that the program was of short duration and lacked a tight curriculum to promote qualities of parenting. According to a recent review (Olds & Kitzman, 1990), these features (along with paraprofessional service providers) characterize less effective home visitation programs. These final results fundamentally agree with a preliminary report on this project (Barth, Hacking, & Ash, 1988). At that time, the research had followed only 50 families for one to six months after the close of services. Whereas no differences between groups on child abuse reports were noted then, the findings were more sanguine regarding a range of self-report indicators; 8 of the 24 measures shown in Table 2 of this report were significant at that time. The declining effectiveness may be partly attributable to the increasingly difficult clients that CPEP received over time (i.e., more families that child welfare services had evaluated but decided not to make court dependents). Also the positive influence of the initial and intensive staff training (which was not fully replicated when new staff were hired as original staff left) probably waned. Olds (1988a) and others (Anisfeld & Lipper, 1983; Peoples & Siegel, 1983) have argued that “positive effects of intervention are likely to be concentrated on families at greatest risk” (p. 25 1). This concept may not extend to families that have already been the object of child abuse reports (whether or not they were investigated or substantiated). This is an imperfect evaluation of a program that is popular and well received by clients. A case study suggests the value of CPEP to clients like Maria who was 28, indigent, non-English speaking, unemployed, illegal, living with another family, and pregnant when referred to CPEP by a medical social worker. CPEP helped her obtain an apartment one week before the baby’s birth, to gain entry into a community college, meet other women through a Lamaze class which they paid for, and to find work. CPEP may not have prevented anything except more hardship and temporary homelessness. Maria’s family, like millions of other struggling families would probably have made their own path to stability, but could and did benefit from assistance. This is a worthwhile service, but not a child abuse prevention service. Other home-visitation programs have also fallen short of making measurable differences (Barkaukas, 1983; Siegel, et al., 1980; Van Doornick, Dawson, Butterfield, & Alexander, 1980). The best outcomes seem to arise with professional staff, longer services, and a service population that is at enough risk to need services but not at such risk that home-visitor approaches, whether staffed by professionals or paraprofessionals, have no chance to succeed (e.g., Gray et al., 1979; Olds & Kitzman, 1990).

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CPEP assumed an ecological approach. That is not the same as successfully making an ecological intervention. That is, service providers’ attempts to address issues of housing, drug treatment, and linguistic and social isolation are constrained by the unavailability of such services. Also, an ecological model assumes that the client can participate in and maintain efforts to improve the social ecology. This is also not the case when the client is ove~helmed by drugs or mental illness. The research design certainly has imperfections. The appropriate length of follow-up for child abuse prevention studies has no consensus. The usual complaint is that the follow-up is too short. In this case, the follow-up may have been too long for some families. That is, should prevention programs that last six months be expected to influence the next five years of that family’s functioning? Indeed, in this study, children who were not yet born during the service period may have been the subject of future reports to children’s protective services. Although the idea that services will protect subsequent children is very appealing, that is too much to expect. Certainly, in-home child abuse prevention services do not exist independent of other agencies. This program was primarily intended to help mothers manage during the perinatal period, and other programs must be able to take over later. Another shortcoming of the research is that the county in which this study was based-an urban and suburban county of more than 700,000 people-increasingly became unable to investigate cases of general child neglect. As reports of child abuse skyrocketed, their efforts were redirected to sexual abuse, physical abuse, and drug-affected newborns. Since CPEP was directed at helping families in endangering environments to improve the conditions of living, such families in the CPEP and control group were not highly likely to receive investigations and even more unlikely is that these investigations would be substantiated. Reports from CPEP staff may have been more likely to be acted upon by child welfare services. Since most of the data gathered were self-report data, the likelihood that respondents would over- or underreport the difficulties they were having must be considered. The possibility exists, for example, that service group members would think that they could receive more services if they reported more difficulties or that control group members would want to impress the interviewers about their autonomy by reporting fewer di~culties. Of course, the possibility also exists that service group members would have reasons related to cognitive consistency to argue that the program they had participated in was helpful, and control group members might have thought they could get more services by explicitly reporting their troubles. There is insufficient data from this study or others to confirm any of these hunches. Suffice to say, that data collected from emergency rooms would be better than emergency room reports, and that the heavy reliance of the study on self-report data places it squarely but unfo~unately in the midst of the vast majority of child abuse research studies. Child abuse prevention research is grueling and imperfect. Yet, this study contains many desirable elements including a relatively large sample size, random assignment to groups, and long term follow up. Whereas, this is not a conclusive report, this and other reports from this project indicate that even a conceptually strong paraprofessionally delivered in-home service program that is well regarded by clients and unequivocably intended to reduce child abuse may not do so. Such a disconcerting finding cannot be denied, Nor should we overlook the obvious needs of families in grave need of assistance during periods of pregnancy and straineven if child abuse cannot always be prevented. The results support the provision of CPEP types of services for families that have not already begun destructive patterns of interaction with their children. Such programs appear insufficient, however, for families who have already been referred to children’s protective services. Intensive family preservation services are needed for the most troubled families, which will experience abuse and foster care without them. CPEP type services may assist families in less distress. Acknowledgement-The author thanks Betty Allured, Jordana Ash, Franc&a Azocar, Nancy Colvin, Susan Hacking, Clarence Jackson, Jeanne Rodriguez, Dawn MiIls, Linda Waddin~on, and two anonymous reviewers.

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REFERENCES Anisfeld, E., & Lipper, E. (1983). Early contact, social support, and mother-infant bonding. Pediatrics, 72, 79-83. Ayoub, C., Jacewitz, M. M., Gold, R. G., & Milner, J. S. ( 1983). Assessment of a program’s effectiveness in selecting individuals “at risk” for problems in parenting. Journal ofC~~njca~Psycho~u~~. 39, 334-339. Barkaukas, V. (1983). Effectiveness of public health nurse home visits to primiparous mothers and their infants. American Journal of Public Health, 73, 573-580. Barrera, M., Jr. f 198 1). Social support in the adjustment of pregnant adolescents: Assessment issues. In B. H. Gottlieb {Ed.). Social ~eiwur~ and social support. Beverly Hills, CA: Sage. Barth, R. P. (1986). Social and cognitive treatmenf ofchi~dren and adolescents. San Francisco, CA: Jossey-Bass. Barth. R. P. (1989). Evaluation of a task-centered child abuse prevention program. Children and Youth Services Review, 11; 117-132. Barth, R. P., & Blythe, B. J. (1983). The relationship of stress and child abuse. Social Service Review, 57, 477-489. Barth. R. P., Hacking, S. D., & Ash, J. R. (1986).Screening, referring, and recruiting high-risk parents into child abuse prevention programs. Child Abuse & Neglect, IO, 99-iO9. _ Barth. R. P.. Hackina. S. D.. & Ash. J. R. (1988). Preventing child abuse: An experimental evaluation of the Child Parent Enrichmen~‘Proje& Journal of Prima& Prevention, 8,201-2 17. _ Barth, R. P., Schinke, S. P., & Maxwell, J. S. (1985). Coping skills training for school-age mothers. Journal ofSociaJ Service Reseurch, 8, 75-94. Borenstein, M., & Cohen, J. (1988). Statisfica~power analysis: A computer program. Hillsdale, NJ: Lau. Carey, W. B. (1970). A simplified method for measuring infant temperament. The Journalaf Pediatrics, 77, l88- 194. Daro, D. (1988).Confronting child abuse. Research@ e&rive program design. New York: Free Press. Enos, R., & Hisanga, M. (1979). Goal setting with pregnant teenagers. Child We&e, 58, 541-552. Fortune, A. E. (I 985). Task-centered practice withfamilies and groups. New York: Springer. Goldberg, S. (1983).Parent-infant bonding: Another look. Child ~eve~upmenf, 54, 135% 1382. Gray, E. B. (1982). Perinatal support programs: A strategy for the primary prevention of child abuse. Juurnal qf Primary Prevention, 2, 138-l 52. Gray J. D,, Cutler, C. A., Dean, J. G., & Kempc, C. H. f 1979). Prediction and prevention of child abuse and neglect. Journal ofSociaf Issues, 35, 129-I 39. Habif. V. L., & Lahey, B. B. (1980). Asse~ment ofthe life-stress depression relationship: The use of social supportas a moderator variable. Behavioral Assessment, 2, 167-173. Helfer, R. E. (1982). A review ofthe literature on the prevention ofchild abuse and neglect. ChildAbuse& Neglect, 6, 251-261. Helfer. R. E.. Hoffmeister, J. K., & Schnieder, C. ( 1978). MSPP: A manual for use ofthe Michigan screeningprofile of parenting. Boulder, CO: Express. Klaus. M. H.. & Kennell. J. H. (1982). Parent-~n~nf bonding. St. Louis: Mosbv. Larson, C. P.‘( 1980). Efficacy ofparental and postpartum home visits on child-health and development. Pediatrics, 66.191-197. Miller, K., Fein, E., Howe, G, W,, Gaudio, C. P., & Bishop, G. B. (1984). Time-limited, goal-focused parent aid service. Social Casework, 65,472-477. Milner, J. S. (1980). The Child Abuse Potential Inventory. (Manual). Webster, NC: Psytec Corp. Milner, J. S., & Wimberley, R. C. (1979). An inventory for the identification of child abusers. Journal ofChnicu/ Psychology, 35, 95-100. Milner, J. S.. & Wimberley, R. C. (1980). Prediction and explanations of child abuse. Journal of Clinical Psychology, 36,875-884. Murphy, S., Orkow, B., & Nicola, R. M. (1985). Prenatal prediction of child abuse and neglect: A prospective study. Child Abuse & Neglect, 9, 225-235. Olds, D. L. (1982). The prenatal/early infancy project: An ecological approach to prevention of developmental disabilities. In J. Belsky (Ed.). In fhe begmning: Readings on infancy (pp. 270-285). New York: Columbia. Olds, D. L. (1988a) Common design and rneth~olo~~l problems encountered in evaluating family support services: Illustmtions from the prenatal/early infancy project. In H. B. Weiss&F. H. Jacobs (Eds.), Eva~uatingj~rn~l~~ programs (pp. 239-266). New York: Aldine de Gruyter. Olds, D. L. (1988b). The prenatal/early infancy program. In R. H. Price, E. L. Cowen, R. P. Lorion, & J. RamosMcKay (Eds.), 14 ounces of prevention: A casebook for practitioners (pp. 9-23). Washington, DC: American Psychological Association. Olds, D. L., & Kitzman, H. (1990). Can home visitation improve the health ofwomen and children at environmental risk? Pediatrics, 86, 108-l 16. Payne. C. (Ed.). (1983). Programs to strengthen families: A resource guide. Chicago, IL: Yale University and the Family Resource Center. Pea&n, I. L., & Schooler, C. (I 978). The structure of coping. Journal of Heahh and Social Behavior. 19, 2-2 1.

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183-190. Spielberger, C. D., Gorsuch, R. L., & Lushene, R. E. (1970). Manualfor the state-trait anxiety inventory. Palo Alto, CA: Consulting Psychologist Press. Van Doominck, W. J., Dawson, P.. Butterfield, P. W., & Alexander, H. I. (1980). Parent-infant support through lay health visitors. Final report of Maternal and Child Health Service, Bureau of Community Health Services, PHS, National Institute of Health, Department of Health, Education, and Welfare, Grant No. MC-R-080398-030. Whitey. V., Anderson, R., & Lauderdale, M. (1980). Volunteers as mentors for abusing parents: A natural helping relationship. Child Welfare, 59, 637-644.

Resume-Des projets de prevention prenatale sont rarement tvalds. Des femmes ont &tCenvoyees au “Child Parent Enrichment Project (CPEP)” pendant ou juste apres leur grossesse, apres avoir tte identifiees a risque de maltraiter leur enfant par des professionels de la communaute. Les clients Ctaient assign&s au hasard vers les services du CPEP (n = 97) ou vers les services communautaires habituels (n = 94). Les services du CPEP sont base sur une thtorie Ccologique et comprennent des visites a domicile par des para-professionnels pour une p&iode de 6 mois ainsi qu’un lien vers d’autres resources communautaires fonnelles et informelles. Aucun avantage n’a CtC not& pour le groupe CPEP apres evaluation par des mesures basees sur l’auto-information et le suivi des cas d’enfants battus Ctait similaire dans les deux groupes. Les clients ttaient trb satisfaits de la qualitt du programme. On peut considerer un certain succts dans I’approche de families presentant des probltmes moins graves. Les r&mats sont en faveur dune grande prudence en ce qui conceme les capacites des programmes de prevention perinatale a r&element servir la clientele a risque &eve de violence, a laquelle ils sont souvent confront&s. Resumen-Los proyectos de prevenci6n perinatal de1 abuso a 10s niiios raras veces son evaluados. Se refirieron al Provecto de Enriauecimiento Padres e Hiios (Child Parent Enrichment Proiect - CPEP), durante o inmediatamente de&es de1 parto:a las clientes que fueron identificadas por profesionales de la comunidad coma de alto riesgo para abusar de sus hijos. Las clientes fueron asignadas al azar a servicios CPEP (n = 97) 6 a servicios tradicionales de la comunidad (n = 94). Los servicios CPEP estan basados en la teoria ecol6gica e in¥ seis meses de visitas al hogar por mujeres paraprofesionales asi coma contactos con otras instituciones formales e informales de la comunidad. Se concluy6, en base a las comunicaciones de las clientes del grupo CPEP durante un post-test, que el proyecto no produjo ventajas, y 10s informes de abuso a 10s nifios durante investigaciones complementarias, no mostraron diferencias significativas entre 10s dos grupos. Por otro lado, las clientes de1 grupo CPEP indicaron que estaban muy satisfechas con el programa. Se obtuvo cierto nivel mayor de Cxito en familias con problemas menos severos. Los resultados sugieren ser cautelosos respect0 a la capacidad de prevencibn de 10s programas perinatales de abuso a 10s niiios para ayudar a las poblaciones de alto riesgo.