Adolescents at risk for mistreating their children

Pergamon Child Abuse & Neglect 6 (2001) 753–769

Adolescents at risk for mistreating their children Part II: a home- and clinic-based prevention program Catherine Stevens–Simon*, Donna Nelligan, Lisa Kelly Division of Adolescent Medicine, University of Colorado Health Sciences Center, The Children’s Hospital, 1056 E. 19th Street, Denver, CO 80218, USA Received 2 August 2000; received in revised form 20 October 2000; accepted 31 October 2000

Abstract Objective: To determine if adding an intensive home visitation component to a comprehensive adolescent-oriented maternity program prevents child abuse and neglect. Methods: We studied 171 participants in a comprehensive, adolescent-oriented maternity program who were deemed to be at high risk for child abuse and neglect. Half were randomly assigned to receive in-home parenting instruction. Major disruptions of primary care-giving by the adolescent mother were classified hierarchically as abuse, neglect, and abandonment. Results: Compliance with home visits varied in relation to the support the teenage mothers received from their families and the fathers of their babies (p ⬍ .0001). There were no significant treatment group differences in the pattern of health care utilization, the rate of postpartum school return, repeat pregnancies, or child abuse and neglect. The incidence of maltreatment rose in tandem with the predicted risk status of the mother. Ultimately, 19% of the children were removed from their mother’s custody. Conclusions: Prediction efforts were effective in identifying at-risk infants, but this intensive homeand clinic-based intervention did not alter the incidence of child maltreatment or maternal life course development. A parenting program that was more inclusive of the support network might be more popular with teenagers and therefore more effective. Our findings also emphasize the importance of including counseling specifically designed to prevent teenagers from abandoning their children. © 2001 Elsevier Science Ltd. All rights reserved. Keywords: Child abuse; Adolescent pregnancy; Adolescent parenting

* Corresponding author. 0145-2134/01/$ – see front matter © 2001 Elsevier Science Ltd. All rights reserved. PII: S 0 1 4 5 - 2 1 3 4 ( 0 1 ) 0 0 2 3 7 - X

754

C. Stevens–Simon et al. / Child Abuse & Neglect 6 (2001) 753–769

Introduction During the four decades since the publication of Dr. C. Henry Kempe’s (1976) landmark paper “The Battered Child Syndrome,” efforts to prevent child abuse and neglect have proliferated at the primary, secondary, and tertiary level, with home visitation emerging as one of the most promising secondary prevention strategies (American Academy of Pediatrics, 1998; US Advisory Board on Child Abuse and Neglect, 1991; Wissow, 1995). Home visiting is hypothesized to reduce child abuse and neglect directly by promoting the use of nonviolent, age-appropriate childrearing techniques and environmental safety, and indirectly by enhancing parental emotional well-being and life course development. The clearest evidence of the potential for home visitation to actually prevent child abuse and neglect comes from a series of publications in which Olds and colleagues demonstrated that 2 years of exposure to an intensive home-based intervention significantly reduced substantiated cases of child abuse over the next 15 years in a semirural community in New York (Olds, Eckenrode, Henderson, Kitzman, Powers, Cole, Sidora, Morris, Pettitt, & Luckey, 1997; Olds, Henderson, Chamberlin, & Tatelbaum, 1986; Olds, Hill, Robinson, Song, & Little, 2000). Other randomized trials of home visitation programs have not produced similar overall reductions in the rates of child abuse and neglect (Olds et al., 2000). This may be because most studies lack the power to detect a statistically significant difference in a relatively rare outcome like abuse, and/or because the presence of a home visitor, who is required to report suspicions of maltreatment, creates a surveillance bias that works against the demonstration of abuse prevention (Brayden, Altemeier, Dietrich, Tucker, Christensen, McLaughlin, & Sherrod, 1993; Olds, Henderson, Kitzman, & Cole, 1995; Olds & Kitzman, 1993). Indeed, when more common, nonreportable indices of dysfunctional parental behavior are assessed as proxies for child abuse and neglect, positive findings are typically observed simultaneously in several domains, which collectively create a coherent picture of reduced care-giving dysfunction (Brayden et al., 1993; Olds et al., 1995; Olds et al., 2000; Olds & Kitzman, 1993). Specifically, studies show that home visitation improves the safety of the home environment, decreases utilization of health care services for injuries and ingestions, improves the quality of mother-child interactions, reduces maternal self-reported use of harsh disciplinary strategies and feelings of frustration related to infant crying, and promotes greater sensitivity to children’s cues, understanding of child development, and use of educationally stimulating toys in the home (Brayden et al., 1993; Olds et al., 1995; Olds et al., 2000; Olds & Kitzman, 1993). Moreover, evidence from a variety of sources indicates these programs are most effective when home visiting is integrated into an existing health care system, and when services are provided preferentially to poor, unmarried teenage mothers, who have little sense of control over their lives and/or are identified prenatally as being at increased risk for dysfunctional parenting (American Academy of Pediatrics, 1998; Olds et al., 1997; Olds et al. 1986; Olds et al., 2000; US Advisory Board on Child Abuse and Neglect, 1991). In a previous study, we demonstrated that participants in the Colorado Adolescent Maternity Program, (CAMP) who scored 25 or higher on the Family Stress Checklist (Murphy, Orkow, & Nicola, 1985) were significantly more likely to mistreat their children during the first 2 years of life (Stevens–Simon, Nelligan, & Kelly, in press). The purpose of

C. Stevens–Simon et al. / Child Abuse & Neglect 6 (2001) 753–769

755

this randomized controlled trial was to determine whether the addition of an intensive home visitation component to CAMP decreased the frequency with which dysfunctional parenting behavior resulted in a major disruption of primary care-giving by this prospectively identified high risk group of adolescent mothers.

Methods Subjects The population eligible for study was a racially and ethnically diverse (49% White, 28% Black, 20% Hispanic, and 3% other) group of 171 poor (94% Medicaid recipients), predominantly unmarried (95%), primiparous (96%), 13 through 19-year-old mothers (mean ⫹ SD ⫽ 17.5 ⫹ 1.4 years) who scored 25 or higher on The Family Stress Checklist (mean ⫹ SD ⫽ 33 ⫹ 9; range:25 to 65), and identified CAMP as their and their infant’s primary health care provider at delivery. The latter restriction was added because the home visitation component of the intervention was designed to augment the care provided in the CAMP clinic (American Academy of Pediatrics, 1998). Specifically, the home visitor was to serve as the link between the CAMP clinic staff, the adolescent and her family, and an array of community-based social and mental health service providers. All CAMP prenatal patients have the opportunity to join the postpartum program (Stevens–Simon et al., 2000). However, participation is voluntary, and during the study period only 151 (72%) of the 209 teenagers who scored 25 or higher on the Family Stress Checklist elected to do so. Lack of transportation and the desire to utilize their own former pediatric health care provider were the most frequent reasons the teenagers gave for leaving CAMP at delivery. As a group, those who left did not differ significantly from those who remained with regard to age, race, parity, adequacy of the prenatal care, Family Stress Checklist score, or the other widely recognized risk factors for child abuse and neglect we studied. However, there may have been other, less tangible differences between the two groups of teenagers. The remaining 20 (11.6%) of the 171 potential study participants received prenatal care in traditional, adult-oriented obstetric settings, and joined CAMP consecutively during the first two postpartum months. They did not differ from the 151 former CAMP prenatal patients except they were less apt to be primiparas (75% compared to 98.7%; p ⫽ .03), and the fathers of their babies were less apt to be teenagers (26.3% compared to 52.3%; p ⫽ .03). All 171 of these mother-infant dyads agreed to be randomly assigned to the intervention (N ⫽ 84) and control (N ⫽ 87) groups during their first postpartum visit to the CAMP clinic (mean ⫹ SD ⫽ 2.2 ⫹ 1.9 weeks postpartum). However, 17 (20%) of the 84 teenagers who were randomized to the intervention group subsequently declined or simply failed to participate in the first home visit. By contrast, none of those randomized to the control group declined to participate in the study. An additional 9 (10.7%) of the 84 teenagers randomized to the intervention group were lost to the study because of miscommunication between the CAMP clinic and research staffs. These 26 teenagers did not differ from their 58 peers who participated in the intervention with regard to age, race, parity, or educational or marital

756

C. Stevens–Simon et al. / Child Abuse & Neglect 6 (2001) 753–769

status. They were, however, significantly less apt to have been CAMP prenatal patients (69.2% compared to 93.0%; p ⫽ .02), scored lower on the Family Stress Checklist (mean ⫹ SD ⫽ 30.4 ⫹ 5.8 compared to 34.7⫹9.3; p ⫽ .01), and were significantly less apt to live with at least one biological parent, to rate the support they received from their family as inadequate, and to be stressed and depressed at delivery. Taken together, these data suggest that the teenagers who decided not to participate in the in-home intervention were at lower psychosocial risk for abuse and neglect than those who participated. However, because we cannot exclude the possibility that there were other, less tangible differences between the two groups of teenagers, it is difficult to know how the loss of 26 (31%) of the 84 intervention group members affected our results. The remaining 145 teenagers (58 intervention and 87 control) are the focus of this report. The study was approved by the Institutional Review Board at the University of Colorado Health Sciences Center. The intervention CAMP is a comprehensive, multidisciplinary prenatal, delivery, and postnatal care program, located in a large, urban, teaching hospital. Detailed descriptions of the CAMP intervention have been published previously (Stevens–Simon et al., 2000; Stevens–Simon et al., 2001). Briefly, the program integrates the professional services of health care providers trained in obstetrics, pediatrics, and adolescent medicine, a social worker, and a dietician. The goal is to reduce the incidence of adverse pregnancy outcomes and repeat teen pregnancies, and to increase the number of young people who graduate from high school and become productive members of their communities and nurturing, nonabusive parents. As part of the enrollment procedure, all CAMP patients meet with the program social worker, who assesses their potential for dysfunctional parenting by interspersing questions designed to elicit information bearing on the 10-item Family Stress Checklist in her initial intake interview. Those who score 25 or higher on the Family Stress Checklist are considered to be at risk for dysfunctional parenting (Stevens–Simon et al., 2001), and were therefore eligible for participation in this study. To promote staff-patient interaction and facilitate the implementation of individual care plans, parents and children are seen together after delivery. Clinic appointments are scheduled monthly for the first 6 months, every other month for the next 6 months, and then at 3 month intervals until the child is 2 years old. As described previously (Stevens–Simon et al., 2000), the components of the postpartum program were selected with the expectation that the intervention would prevent adverse maternal and child outcomes directly by simplifying access to preventative health care and social services, and indirectly by discouraging school drop-out, encouraging the pursuit of careers that foster competency and are incompatible with closely spaced childbearing, enhancing family support, and promoting linkages to community service agencies. The CAMP clinic was the primary health care provided for all study participants. In addition, the mother-infant dyads randomized to the intervention group received home visits. These visits were planned to start immediately after randomization, and were to be scheduled weekly for the first 16 postpartum weeks, and then at diminishing frequency to meet individual needs and promote compliance with CAMP health and contraceptive maintenance

C. Stevens–Simon et al. / Child Abuse & Neglect 6 (2001) 753–769

757

visits. Home visits were never scheduled more than 6 weeks apart, and were supplemented with telephone calls to ensure a minimum of two contacts between the home visitor and the teenager each month. The home visitor was a middle-aged, college-educated, Hispanic woman who also served as a paraprofessional health educator in the CAMP prenatal clinic. In this capacity, she was always present in the waiting room when the prenatal clinic was in session. There she met with the patients individually and in small groups, to provide anticipatory parenting instruction and support. These prenatal contacts enabled the home visitor to introduce concepts and information she planned to cover in detail after delivery, at a time when prevention rather than problem detection could be emphasized, and when the teens were apt to be most open to new information about childrearing (Larson, 1980; Olds et al., 2000; Siegel, Bauman, & Schaefer, 1980). Thus, by delivery the visitor had established a close, friendly, working relationship with most families. The goal of the home visitation component of the program was to promote maternal competency and nurturant parenting behavior, thereby stopping the transmission of negative self-efficacy attitudes and dysfunctional parenting styles to the next generation. To this end, the visitor worked with the teenagers and their families to develop individualized programs for eliminating the specific behaviors and attitudes that put them at increased risk for maltreating their children. The necessity of love, trust, honesty, patience, and consistency in childrearing, and the detrimental effects of observed violence on child development were stressed at every visit. Parents were encouraged to cuddle their infants, to identify and respond promptly to their cues, to talk gently to and praise the achievements of their toddlers, and to interact in a quiet, nonviolent manner with other adults in the home. Each visit took 1 to 2 hours and included extensive counseling and anticipatory guidance, as well as medical, educational, and social service referrals to meet individual needs. Methods of instruction included didactic presentations, role playing, and hands-on opportunities. Moreover, each lesson plan was accompanied by instructional handouts, developmentally appropriate games, and an information sheet about career opportunities that the visitor left in the home. Most of the counseling was directed; typically, the teenager raised an issue that was of immediate personal concern and the visitor responded, first with practical solutions to the specific problem the teenager posed, and then generalized to a more global discussion of the problem as it related to dysfunctional parenting or negative life-course development. To this end, she drew on her own experience as a mother, and a parenting curriculum created by the CAMP staff as a guide to ensure that all of the teenagers received the information they needed to develop adequate parenting and child care skills. Specifically, these loosely structured visit protocols included: (1) assessing individual and environmental strengths and weaknesses, and identifying attitudes and behaviors that antedate child abuse and neglect, repeat conception, and school dropout; (2) helping the teenagers develop a sense of competency and self-efficacy by identifying small achievable objectives, the accomplishment of which would build their confidence and motivation to actively manage other aspects of their lives; particular emphasis was placed on actually carrying out specific activities, since performance accomplishments have been shown to have the most impact on efficacy expectations (Olds et al., 2000); (3) presenting didactic material about age-appropriate ways of enhancing child development and disciplining children, well and sick child care, and peaceful, adaptive techniques for managing stress; (4) helping the teenagers appreciate and manage individual

758

C. Stevens–Simon et al. / Child Abuse & Neglect 6 (2001) 753–769

differences in infant temperament (e.g., teenagers often misinterpret their infants’ crying as a care-giving failure on their part or as an indication that the infants are intentionally trying to disrupt their lives); (5) enhancing informal support from family and friends; family involvement was strongly encouraged so that the prevention message was as constant and long lasting as possible, and the messages the teenagers received from the home visitor and the CAMP clinic staff did not conflict with the messages they received at home; particular emphasis was placed on helping the teenagers identify and resolve sources of interpersonal conflict with their mothers and the fathers of their babies, since these two people have the most impact on the psychological well-being of teenage mothers (Barnet, Joffe, Duggan, Wilson, & Repke, 1996); (6) coordinating referrals to social service agencies, and educational and vocational training programs; and (7) monitoring and promoting appropriate utilization of medical services, and clarifying and re-enforcing health care providers’ instructions and recommendations, with emphasis on the importance of keeping health and contraception maintenance appointments in the CAMP clinic, and calling the clinic rather than dropping in or using the emergency department. To this end, the visitor worked in close collaboration with other members of the CAMP staff, meeting weekly with them to develop strategies for addressing identified problems. This multidisciplinary approach ensured that the young mothers had a number of supportive adults in their social support networks, and the home visitor had access to the resources and services the teenagers needed to achieve their goals (American Academy of Pediatrics, 1998). Data collection and definition of variables Information about the pattern of health care service utilization (e.g., the number of CAMP clinic visits for sick and well infant and teen care, emergency department visits, and hospitalizations) and potentially confounding personal and environmental characteristics was elicited prospectively, with a precoded, self-administered, multiple choice questionnaire, supplemented with information obtained during a structured enrollment interview, and a review of the mother’s and child’s medical records. The intake questionnaire was written at a fourth grade reading level, and was designed to collect information about the social context into which the child was born, with emphasis on commonly cited demographic, psychosocial, and behavioral risk factors for dysfunctional parenting and repeat pregnancy during adolescence (Stevens–Simon et al., 2000). The variables examined as potential confounders of the relationship between treatment group assignment and subsequent child maltreatment were identified a priori from a review of the adolescent parenting and child maltreatment literatures; they included: (1) sociodemographic factors such as age, race, and type of health insurance; (2) psychosocial factors such as living arrangements, school enrollment, involvement in socially problematic behaviors (fighting, delinquency, and illicit substance abuse, assessed by history and periodic urine toxicology screening), past or present physical or sexual abuse, suicide attempts, depression/stress [defined by the Center for Epidemiologic Studies Depression scale and a checklist of 20 negative life events (Newton, Webster, Binu, Maskrey, & Phillips, 1979; Radloff, 1977; Stevens–Simon & McAnarney, 1995)]; lack of support from prime people [for example, their own mother or the baby’s father (Barnet et al., 1996), or a related adult (Flanagan, Coll, Andreozzi, & Riggs, 1995)]; and inadequate family

C. Stevens–Simon et al. / Child Abuse & Neglect 6 (2001) 753–769

759

support [defined by the Family Apgar Scale (Smilkstein, Ashworth, & Montano, 1982)]; and (3) pregnancy-related factors such as the wantedness of the pregnancy, the birth weight and gestational age of the infant, and neonatal intensive care unit admissions. Outcome variables The negative care-giving practices that have deleterious effects on the physical and psychological growth and development of children are not mutually exclusive, and many infants suffer more than one type of maltreatment (Wissow, 1995). Nevertheless, we classified the dysfunctional parenting behaviors that resulted in a major disruption of primary care-giving by the adolescent mother, hierarchically, according to the following criteria: (1) abuse, including physical (inflicting bodily harm through excessive force or forcing a child to engage in physically harmful activities), sexual (contact or interaction between a child and an adult, when the child is being used for the sexual stimulation of that adult or another person), and emotional (coercive, demeaning, or overly distant behavior by a caretaker that interferes with a child’s normal social or psychological development); (2) neglect (failure to provide basic shelter, supervision, medical care, or support for a child); and (3) abandonment (the mother left the home, putting a friend or relative in charge of the child’s care). In addition to these traditional forms of child maltreatment, we recorded the timing of the teenager’s next pregnancy. Although repeat conception is not usually an endpoint in studies of child maltreatment, the stress associated with a rapid repeat conception has been identified as a particularly important mediator of child abuse and neglect at this age (Zuravin, 1988). We also recorded the timing of immunizations, since failure to comply with the recommended schedule for childhood immunizations is a type of medical neglect. Moreover, because studies suggest that the frequency of parent-initiated pediatric acute care visits identifies mothers and infants who are experiencing a strain in their relationship (Hardy & Street, 1989; Harris, Weston, & Lieberman, 1989; Leventhal, Pew, Berg, & Garber, 1996; Stevens–Simon et al., 2000), and because such visits represent an expensive, potentially preventable, health care expenditure, information about the pattern of health care utilization (e.g., the number of CAMP clinic visits for sick and well infant and teen care, Emergency Department visits, and hospitalizations) was abstracted from the medical records. Finally a trained research assistant, who was blinded to treatment group assignment, tested the children at 12 and 24 months of age, using the Bayley Scales for Mental and Motor Development (Bayley, 1992). The children were tested in their homes, in the presence of their mother or another primary care-giver, who was also asked to complete the Home Screening Questionnaire (Coons, Gay, Fandal, Ker, & Frankenburg, 1981). This multiple choice questionnaire and toy checklist is written at a third grade reading level. It was developed from the lengthier Caldwell Home Inventory (Caldwell & Bradley, 1978), to enable health care and social service providers, with no specific training in child development, to screen toddlers during office visits for qualities of the home environment and parental care-giving that could be detrimental to the child’s development. The maximum score is 43 (11 for the toy checklist); validation studies indicate that a score of 32 or less is suspect and highly predictive of a low Caldwell Home Inventory score (Coons et al., 1981). We did not formally assess maternal attitudes and beliefs about harsh disciplinary tactics,

760

C. Stevens–Simon et al. / Child Abuse & Neglect 6 (2001) 753–769

Table 1 Background characteristics at randomization by treatment group Characteristics

Sociodemographic: N(%) Conceived prior to age 16 years Minority race/ethnicity Medicaid recipient Multipara CAMP prenatal patient Psychosocial: N(%) Not living with a parent Not living with a related adult Was abused School dropout Problem behaviors* Depressed/stressed⫹ No prime support Poor family support⫹ Positive urine toxicology**⫹⫹

Treatment group Intervention

Control

(N ⫽ 58) 15 (26) 28 (48) 55 (95) 1 (2) 55 (95)

(N ⫽ 87) 30 (35) 40 (47) 79 (91) 3 (4) 78 (90)

34 (59) 22 (38) 42 (72) 28 (48) 50 (86) 40 (74) 16 (28) 20 (36) 5 (11)

53 (61) 27 (31) 68 (78) 53 (61) 75 (86) 54 (65) 23 (27) 33 (38) 19 (26)

* Substance abuse, legal problems, rape, suicide, runaway. ** All positive screens contained metabolites of marijuana; p ⫽ .03. Missing data for intervention and control groups: ⫹ N ⫽ 54 and 85; ⫹⫹ N ⫽ 47 and 72, respectively.

because the clinical significance of changes in self-reported beliefs about parenting is not clear. Data analysis Summary statistics were used to describe the study population. Comparisons between the two treatment groups were conducted with Student’s t tests when the outcome variable was continuous, and ␹2 analyses when the outcome variable was categorical. All statistical analyses were performed with SPSS/PC⫹ (Nie, Hull, & Jenkins, 1989). Results The data presented in Tables 1 and 2 show that, at enrollment, members of the two study groups were at similar sociodemographic risk for child abuse and neglect. Moreover, they had similar scores on the Family Stress Checklist (mean ⫹ SD ⫽ 33 ⫹ 8), and had had an equivalent amount of contact with the home visitor before delivery. On average, prenatal contact with the home visitor began at 20 weeks gestation, and over the subsequent 18 weeks of the pregnancy the home visitor typically met with the teenagers six times in the prenatal clinic (range 0 –21), and 1 time at their homes (range 0 –3). However, 23 (16%) of the study participants had no prenatal contact with the home visitor, 12 had not been CAMP prenatal patients, and 11 were missed because of scheduling errors. On average, the teenagers gave birth at 38.7 ⫾ 1.7 weeks gestation to infants weighing 3097 ⫾ 500 g.

C. Stevens–Simon et al. / Child Abuse & Neglect 6 (2001) 753–769

761

Table 2 Infant characteristics at randomization by treatment group Treatment group

Characteristics N(%) Wanted⫹ Low birth weight Preterm NICU⫹⫹ Male sex ⫹

Intervention

Control

(N ⫽ 58) 15 (36) 6 (10) 5 (9) 3 (5) 23 (40)

(N ⫽ 87) 29 (42) 8 (9) 8 (9) 8 (9) 45 (52)

Missing data for intervention and control groups: N ⫽ 42 and 69, respectively. Admitted to the neonatal intensive care unit.

⫹⫹

The first postpartum home visit usually took place within 2 weeks of randomization, and, on average, the home visitor made 8 (50%) of the 16 visits planned for the first 16 postpartum weeks (range 1–13), 16 (73%) of the 22 visits planned for the first postpartum year (range 6 –22), and 5 (55%) of the 9 visits planned for the second postpartum year (range: 0 –12). Compliance with the planned visit schedule varied in relation to the support the teenagers received from their mother, the fathers of their babies, and other family members. On average, the home visitor made 18 ⫾ 3 visits during the first postpartum year when a relative or friend participated with the teenager, compared to only 13 ⫾ 4 visits when the teenager was the sole participant (p ⬍ .0001). Moreover, the 33 teenagers who represented the upper half of the home visit distribution during the first postpartum year (e.g., those who received at least 16 (73%) of the 22 home visits planned for the first postpartum year) were also significantly more apt than their peers who received fewer visits to have mother, family members, and babies’ fathers who supported them by actively participating in the home visits during the first (93.9% compared to 44.0%; p ⬍ .0001) and second (69.7% compared to 12%; p ⬍ .0001) postpartum years. Attrition also undermined the fidelity of the intervention. During the first six postpartum months, 55 (95%) of the 58 teenagers participated actively in the intervention, but by 12 months only 49 (85%) were doing so, and by the end of the study only 31 (53.4%) of the original 58 teenagers were still being visited. Moreover, because of the mobility of the study population, only 45 (77.6%) of the 58 teenagers in the experimental group and 62 (71.3%) of the 87 teenagers assigned to the control group were still attending the CAMP clinic at the end of the first postpartum year (p ⫽ ns). By the end of the study, CAMP clinic participation had fallen to 51.7% (N ⫽ 30) and 50.6% (n ⫽ 44), respectively, in the two groups (p ⫽ ns). Those who left CAMP did not differ significantly from those who remained in the program with regard to the characteristics listed in Tables 1 and 2, or Family Stress Checklist score. Despite the high rate of attrition from the CAMP clinic, all of the study participants except one control subject were located for the 6 month evaluation (n ⫽ 144), and all but four control subjects were located for the 12 month evaluation (N ⫽ 141). By the end of the study, 127 (87.6%) of the participants were located (95% of the experimental group and 83.5% of the control group; p ⫽ .006). Because selective loss tested with Student’s t tests again

762

C. Stevens–Simon et al. / Child Abuse & Neglect 6 (2001) 753–769

Table 3 Incidence of maltreatment during the first two years among intervention and control group infants Type of maltreatment⫹

N(%) Abuse Neglect* Abandonment Any maltreatment

Incidence Treatment Group⫹⫹ Intervention

Control

(N ⫽ 55) 2 (3.6) 2 (3.6) 6 (10.9) 10 (18.2)

(N ⫽ 72) 0 11 (15.3) 3 (4.6) 14 (19.4)

⫹

Dysfunctional parenting behaviors that resulted in a major disruption of primary caregiving by the adolescent mother, were classified hierarchically. ⫹⫹ By the end of the study, 127 (87.6%) of the participants were located: 55 members (95%) of the intervention group and 72 members (83.5%) of the control group; p ⫽ .006. * p ⫽ .02.

revealed no statistically significant differences between those who were lost and those who were not, it seems unlikely that attrition biased our findings. No significant treatment group difference in the pattern of health care utilization, hospitalizations, immunizations, postpartum school returned, or scores on the Bayley Scales or the Home Screening Questionnaire emerged during the study period. On average, 16% of the 12-month-olds and 4% of the 2-year-olds were underimmunized by the standards of the American Academy of Pediatrics (US Department of Health and Human Services, Public Health Service, 1992). Members of the intervention group were more likely than the controls to begin using a reliable form of hormonal contraception during the puerperium (96.5% compared to 87.4%; p ⫽ .04). However, there were no significant treatment group differences in the repeat pregnancy rate during the study period. Ultimately, 11% of the adolescent mothers became pregnant again during the first postpartum year, and by the end of the study 32% had done so. During the first six postpartum months, 5 (3.5%) of the 144 located infants were removed from their mothers, all for neglect. Although there were no statistically significant treatment group differences in the incidence of maltreatment, 4 of the 5 removed infants were in the control group. During the second half of the first postpartum year, six more infants were removed from their mothers, bringing the total number of removed infants to 11 (or 7.8% of the 141 located infants; 1 was abused, 8 were neglected, and 2 were abandoned). Again, no significant treatment group differences in the prevalence of maltreatment emerged. By the end of the study, 24 (18.9%) of the 127 located children had been removed from their mothers. The data presented in Table 3 show that home visited infants were less apt to have been removed for neglect, but more apt to have been removed for serious abuse and to be abandoned. Even when we limited the analysis to the 33 intervention group participants who received at least 16 (73%) of the 22 home visits planned for the first postpartum year (e.g., the upper half of the completed home visit distribution) and the 87 controls, home visitation had no demonstrable effect on the incidence of maltreatment and postpartum school return, or the

C. Stevens–Simon et al. / Child Abuse & Neglect 6 (2001) 753–769

763

prevalence of contraceptive use. Although the 33 teenagers who were visited most frequently were significantly less apt than their 87 nonvisited peers to become pregnant again during the first postpartum year (3% compared to 13.3%; p ⫽ .04), this difference did not endure. During the second postpartum year, when home visits became less frequent and family involvement in them began to wane, the repeat pregnancy rate rose to 26.7% and 33.8%, respectively, in the intervention and control groups. Moreover, because these frequently visited teenagers also received significantly more support from their family members and boyfriends than their less frequently visited peers did, it is difficult to evaluate the role of home visitation in their more favorable outcome during the first postpartum year. Because treatment groups assignment did not affect outcome, we combined the two study groups. Subsequent analyses revealed that the mothers of children who were mistreated during the first year of life had significantly higher Checklist scores than did the mothers of nonabused children (42.3 ⫹ 10.3 compared to 32.5 ⫹ 8.4; p ⬍ .0001). This was also true of children who were abused during the second year of life (39.0 ⫹ 2.1 compared to 32.3 ⫹ 8.3; p ⫽ .001).

Discussion The enormous human and financial costs associated with child abuse and neglect makes the prevention of this heinous crime a highly sought after public health objective (Kempe, 1976; US Advisory Board on Child Abuse & Neglect, 1991; Wissow, 1995). The results of this study confirm the clinical usefulness of the Family Stress Checklist for systematically identifying a subgroup of adolescent mothers who are at increased risk for mistreating their children. Like Murphy and colleagues (Murphy et al., 1985), we found that the incidence of abuse rose in tandem with the mother’s score on the Family Stress Checklist. Although no single scale item or group of items is more predictive of abuse than the total scale score (Murphy et al., 1985), we found that the individual items could be used to tailor the in-home intervention to address specific, modifiable, maternal characteristics, and environmental factors that predisposed individual teenagers and their families to abusive childrearing practices. Thus, for example, the home visitor provided guidance about alternative ways of coping with stress to teenagers who became violent when frustrated, and helped those who had grown up in chaotic, unpredictable environments to set small, achievable goals—the accomplishment of which would enable them to develop the sense of self-efficacy and competency needed to parent successfully. Olds and colleagues demonstrated that 2 years of exposure to an intensive, home-based intervention significantly reduced substantiated cases of child abuse (Olds et al., 1997; Olds et al., 1986; Olds et al., 2000). However, the results of this and most other randomized controlled trials of home visitation programs have not produced similarly favorable results (Brayden et al., 1993; Olds et al., 1995; Olds et al., 2000; Olds & Kitzman, 1993). A small sample size, rare outcome measures, and the combined scourges of intervention attenuation and program attrition conspired to prevent us from demonstrating the effectiveness of this intervention, as they have others (Brayden et al., 1993; Olds et al., 1995; Olds et al., 2000; Olds & Kitzman, 1993). High attrition rates are a deplorable but common problem, partic-

764

C. Stevens–Simon et al. / Child Abuse & Neglect 6 (2001) 753–769

ularly for programs that utilize paraprofessional home visitors to treat impoverished teenagers (Karoly, Greenwood, & Everingham, 1998; Korfmacher, O’Brien, Hiatt, & Olds, 1999; Olds et al., 2000). A recent report that mothers who receive home visits from paraprofessionals are more likely to withdraw prematurely from parenting programs than mothers who are visited by nurses raises concerns about the use of paraprofessional home visitors (Korfmacher et al., 1999). In theory, the CAMP home visitor followed the COACH relationship building model described by Hanks and colleagues (Hanks, Kitzman, & Milligan, 1995), focusing first on developing a therapeutic relationship with the adolescent mother, and then on providing her with information and referrals (Barnard, Magyary, Sumner, Booth, Mitchell, & Spieker, 1988; O’Brien & Baca, 1997). However, her caseload may have been too large to enable her to accomplish this task, especially with teenagers who did not exhibit an intrinsic ability to establish supportive, interpersonal relationships (e.g., those whose family members and boyfriends chose not to participate in the home visits) (Barnard et al., 1988). Moreover, because nurses appear to be more capable of forging strong, therapeutic alliances with families than paraprofessionals (Korfmacheret al., 1999), employing a highly trained nurse home visitor might have improved the fidelity of our intervention. However, many of the teenagers who participated in this study were lost to follow-up for reasons that were beyond the visitor’s control (e.g., moves). Thus, to some extent, our high attrition rate may have been an inevitable consequence of the instability of the study population, rather than evidence of poor program design (Karoly et al., 1998). Other investigators have also been unable to deliver more than attenuated versions of their interventions (Karoly et al., 1998; Korfmacher et al., 1999; Olds et al., 2000). Indeed, this experience is so ubiquitous that it has been suggested that at-risk mothers may simply be unwilling to accept as much in-home intervention as program designers feel they need to become productive community members and nurturing, nonabusive parents (Karoly et al., 1998). Within this context, it is important that, in this study, compliance with the planned home visit schedule varied in relation to the support the teenagers received for program participation from their mother, the fathers of their babies, and other family members. Because causality cannot be inferred from these correlational data, we are unable to determine whether this reflects some unmeasured, intrinsic quality of the adolescent mother that made it easier for her to establish supportive relationships with friends, family members, and the CAMP home visitor (Barnard et al., 1988), or the importance of the ecological intervention model (O’Brien & Baca, 1997). To the extent that the latter is true, our observation suggests that it might be possible to increase the amount of parenting instruction teenage mothers will accept by designing interventions that are more inclusive of their support networks. Moreover, because it is unreasonable to expect any intervention to change attitudes and behaviors in directions that are opposite to the rest of the world as modeled by family members and peers, eliciting this type of support is apt to have benefits that go far beyond the immediate goal of improving compliance with the intervention. Indeed, the data presented in Table 3 suggest that the CAMP home visitation intervention may have encouraged some teenagers to solve their parenting problems by voluntarily turning their child-care responsibilities over to friends or relatives, rather than simply neglecting them until their children were removed.

C. Stevens–Simon et al. / Child Abuse & Neglect 6 (2001) 753–769

765

Despite these problems related to the mechanics of program implementation, the adolescent mothers who participated in this intervention received as many home visits during the first 2 postpartum years as the women who participated in the more successful trials of the Nurse Home Visitation Program in Elmira, NY, Memphis, TN, and Denver, CO (Korfmacher et al., 1999; Olds et al., 2000). Moreover, even when we limited the analysis to the 33 members of the intervention group who received at least three-quarters of the home visits planned for the first postpartum year (e.g., 16 or more visits), the CAMP intervention had no demonstrable effect on the overall incidence of maltreatment. The small size of the study population clearly limited our ability to demonstrate the efficacy of the intervention for preventing child abuse and neglect. If we had used more common indices of dysfunctional parental behavior (e.g., attitudes about discipline or feelings of frustration related to infant crying) as proxies for child abuse and neglect, evidence of reduced care-giving dysfunction might have emerged (Larson, 1980; Olds et al., 2000). However, we did not do so because the clinical significance of changes in self-reported beliefs about parenting is not clear. Similarly, had we not included abandonment as an outcome measure, the overall incidence of maltreatment would have been lower and treatment group differences more impressive. However, like Leventhal and colleagues (Leventhal et al., 1996), we included abandonment in our definition of dysfunctional parenting behaviors because it clearly represents a major disruption of primary care-giving by the adolescent mother, the consequences of which are not apt to be entirely benign. Although voluntarily abdicating one’s child-care responsibilities to friends or relatives is arguably preferable to neglecting them, the frequency with which teenagers in the intervention group abandoned their children suggests that it may be important to include counseling specifically designed to help these young women define acceptable parenting roles for themselves (Flanagan et al., 1995). The intervention also failed to improve maternal life course development. Despite her best efforts, our paraprofessional home visitor had no effect on postpartum school return. Moreover, even though members of the intervention group were more likely to begin using a reliable form of hormonal contraception during the puerperium, they were not less apt to become pregnant again. This finding is consistent with the results of most other studies in showing that, in absence of changes in life course development that make the costs of conception greater than those of contraceptive use (e.g., postpartum school return), the efficacy of even the most promising pregnancy prevention intervention decays over time, as women tend to use birth control less consistently and to become pregnant, essentially by default (Kitzman, Olds, Sidora, Henderson, Hanks, Cole, Luckey, Bondy, Cole, & Glazner, 2000; Stevens–Simon, Dolgan, Kelly, & Singer, 1997; Stevens–Simon & Kelly, 1999; Stevens–Simon, Kelly, & Kulick, 2000). The significance of our finding that the 33 teenagers who were visited most frequently were the least apt to become pregnant again during the first postpartum year is difficult to interpret, since they were not a random sample of the intervention group, and received significantly more support from their boyfriends and families than did the other 25 home-visited teenagers. Thus we cannot decide from these data if frequent home visits prevented rapid repeat conception, or if compliance with the home visit schedule and contraception was jointly determined by the receipt of adequate social support or some undetected factor.

766

C. Stevens–Simon et al. / Child Abuse & Neglect 6 (2001) 753–769

Conclusion The results of this study do not support the efficacy of home visitation as a means of improving the life course development of adolescent mothers, or reducing the maltreatment of their children. This conclusion is consistent with those of most other studies (Brayden et al., 1993; Olds et al., 1995; Olds et al., 2000; Olds & Kitzman, 1993). Although the long-term effects of the Nurse Home Visitation Program in Elmira, NY are encouraging (Olds et al., 1997; Olds et al., 2000), other investigators have not been able to demonstrate that interventions designed to foster maternal social competency and mastery through the development of an interpersonal relationship with a home visitor produce the same enduring effects on parenting as has been associated with the natural tendency to establish these types of supportive relationships (Barnard et al., 1988). Clearly, with only 58 home visited teenagers, any conclusions must be regarded as preliminary and speculative. Nevertheless, our finding that the joint participation of relatives and friends in home visits was associated with improved compliance suggests the potential importance of employing an ecological intervention model with this population (O’Brien & Baca, 1997; Olds et al., 2000). However, because this was a post hoc observation, the therapeutic value of this approach remains hypothetical. Finally, we surmise that the fidelity and efficacy of future interventions of this type could be improved by employing a more highly trained nurse home visitor (Korfmacher et al., 1999), and by ensuring that her case load allows her the additional time required to develop a therapeutic relationship with mothers who have few intrinsic physiological resources (Barnard et al., 1988; Olds et al., 2000).

Acknowledgments The authors wish to thank Grace Cisneros, the staff and the patients of the Colorado Adolescent Maternity Program for their participation in this study and their help with data collection.

References American Academy of Pediatrics (1998). The role of home-visitation programs in improving health outcomes for children and families. Pediatrics, 101, 486 – 489. Barnard, K. E., Magyary, D., Sumner, G., Booth, C. L., Mitchell, S. K., & Spieker, S. (1988). Prevention of parenting alterations for women with low social support. Psychiatry, 51, 248 –253. Barnet, B., Joffe, A., Duggan, A., Wilson, M., & Repke, J. (1996). Depressive symptoms, stress, and social support in pregnant and postpartum adolescents. Archives of Pediatrics & Adolescent Medicine, 150, 64 – 69. Bayley, N. (1992). Manual for the Bayley scales of infant development. Berkley, CA: The Psychological Corporation. Brayden, R., Altemeier, W., Dietrich, M., Tucker, D., Christensen, M., McLaughlin, J., & Sherrod, K. (1993). A prospective study of secondary prevention of child maltreatment. Journal of Pediatrics, 122, 511–516. Caldwell, B. M., & Bradley, R. H. (1978). Home observation for measurement of the environment manual. Little Rock, AR: University of Arkansas. Coons, C. E., Gay, E. C., Fandal, A. W., Ker, C., & Frankenburg, F. (1981). The home screening questionnaire reference manual. Denver, CO: JFK Child Development Center, University of Colorado Health Sciences Center.

C. Stevens–Simon et al. / Child Abuse & Neglect 6 (2001) 753–769

767

Flanagan, P., Coll, C. G., Andreozzi, L., & Riggs, S. (1995). Predicting maltreatment of children of teenage mothers. Archives of Pediatrics and Adolescent Medicine, 149, 451– 455. Hanks, C., Kitzman, H., & Milligan, R. (1995). Implementing the COACH relationship model: health promotion for mothers and children. Advances Nursing Science, 18, 57– 66. Hardy, J., & Street, R. (1989). Family support and parenting education in the home: an effective extension of clinic-based preventive health care services for poor children. Journal of Pediatrics, 115, 927–931. Harris, E. S., Weston, D. R., & Lieberman, A. F. (1989). Quality of mother-infant attachment and pediatric health care use. Pediatrics, 84, 248 –254. Karoly, L. A., Greenwood, P. W., & Everingham, S. S. (1998). Investing in our children: what we know and don’t know about the costs and benefits of early childhood interventions. Santa Monica, CA: RAND Corporation. Kempe, C. H. (1976). Approaches to preventing child abuse. American Journal of Diseases of Children, 130, 941–947. Kitzman, H., Olds, D., Sidora, K., Henderson, C., Hanks, C., Cole, R., Luckey, D., Bondy, J., Cole, K., & Glazner, J. (2000). Enduring effect of nurse home visitation on maternal life course. Journal of the American Medical Association, 283, 1983–1989. Korfmacher, J., O’Brien, R., Hiatt, S., & Olds, D. (1999). Differences in program implementation between nurses and paraprofessionals providing home visits during pregnancy and infancy: a randomized trial. American Journal of Public Health, 89, 1847–1851. Larson, C. (1980). Efficacy of prenatal and postpartum home visits on child health and development. Pediatrics, 66, 191–197. Leventhal, J. M., Pew, C., Berg, A. T., & Garber, R. B. (1996). Use of health services by children who were identified during the postpartum period as being at high risk of child abuse and neglect. Pediatrics, 97, 331–335. Murphy, S., Orkow, B., & Nicola, R. M. (1985). Prenatal prediction of child abuse and neglect: a prospective study. Child Abuse & Neglect, 9, 225–235. Newton, R. W., Webster, P. A. C., Binu, P. S., Maskrey, N., & Phillips, A. B. (1979). Psychosocial stress in pregnancy and its relation to the onset of premature labour. British Medical Journal, 2, 411– 413. Nie, N. H., Hull, C. H., & Jenkins, J. G. (1989). Statistical package for the social sciences (3rd ed.). New York: McGraw–Hill: SPSSX. O’Brien, R. A., & Baca, R. P. (1997). Application of solution-focused interventions to nurse home visitation for pregnant women and parents of young children. Journal Community Psychology, 25, 47–57. Olds, D. L., Eckenrode, J., Henderson, C. R., Kitzman, H., Powers, J., Cole, R., Sidora, K., Morris, P., Pettitt, L. M., & Luckey, D. (1997). Long-term effects of home visitation on maternal life course and child abuse and neglect: 15–year follow-up of a randomized trial. Journal American Medical Association, 278, 637– 643. Olds, D. L., Henderson, C. R., Chamberlin, R., & Tatelbaum, R. (1986). Preventing child abuse and neglect: a randomized trial of nurse home visitation. Pediatrics, 78, 65–78. Olds, D., Henderson, C., Kitzman, H., & Cole, R. (1995). Effects of prenatal and infancy nurse home visitation on surveillance of child maltreatment. Pediatrics, 95, 365–372. Olds, D., Hill, P., Robinson, J. A., Song, N., & Little, C. (2000). Update on home visiting from pregnant women and parents of young children. Current Problems in Pediatrics, 30, 109 –147. Olds, D. L., & Kitzman, H. (1993). Review of research on home visiting for pregnant women and parents of young children. Future Child, 3, 53–92. Radloff, L. (1977). The CES-D scale: a self-report depression scale for research in the general population. Journal Applied Psychologic Measures, 1, 385– 401. Siegel, E., Bauman, K. E., & Schaefer, E. S. (1980). Hospital and home support during infancy: impact on maternal attachment, child abuse and neglect, and health care utilization. Pediatrics, 66, 183–190. Smilkstein, G., Ashworth, C., & Montano, D. (1982). Validity and reliability of the Family APGAR as a test of family function. Journal of Family Practice, 15, 309 –311. Stevens–Simon, C., Dolgan, J. L., Kelly, L. S., & Singer, D. (1997). The Dollar-A-Day Program: an incentive program for preventing second adolescent pregnancies. The Journal of the American Medical Association, 277, 977–982.

768

C. Stevens–Simon et al. / Child Abuse & Neglect 6 (2001) 753–769

Stevens–Simon, C., & Kelly, L. S. (1999). Effect of Norplant on repeat conceptions among adolescent mother. Family Planning Perspective, 31, 88 –93. Stevens–Simon, C., Kelly, L., & Kulick, R. (2000). A village would be nice but it takes a long-acting contraceptive to prevent repeat adolescent pregnancies. Pediatric Research, 47, 13A. Stevens–Simon, C., & McAnarney, E. R. (1995). Change in depressive symptoms during pregnancy: relationship to birth outcome. Journal of Pediatrics and Adolescent Gynecology, 8, 29 –33. Stevens–Simon, C., Nelligan, D., & Kelly L. (in press). Adolescents at risk for mistreating their children. Part I: prenatal identification. Child Abuse & Neglect. US Advisory Board on Child Abuse and Neglect. (1991). Creating caring communities. Blueprint for an effective federal policy on child abuse and neglect. Washington, DC: US Department of Health and Human Services, Administration for Children and Families. US Department of Health and Human Services, Public Health Service. (1992). Standards for pediatric immunization practices. Washington DC: US Department of Health and Human Services. Wissow, L. S. (1995). Child abuse and neglect. New England Journal Medicine, 332, 1425–1431. Zuravin, S. J. (1988). Child maltreatment and teenage first births: a relationship mediated by chronic sociodemographic stress? American Journal of Orthopsychiatry, 58, 91–103.

Re´sume´ Objectif: De´terminer s’il est possible de pre´venir les mauvais traitements et la ne´gligence en enrichissant un programme complet de pre´paration a` la maternite´, destine´ aux adolescentes au moyen d’un programme intensif de visites a` domicile. Me´thodes: Les auteurs ont e´tudie´ 171 adolescentes qui participaient a` un programme e´labore´ pour les pre´parer a` la maternite´. Ces jeunes e´taient conside´re´es aptes a` maltraiter ou ne´gliger leur enfant. De fac¸on ale´atoire, la moitie´ des participantes ont rec¸u des instructions a` domicile sur leur roˆle de parent. Lorsque les me`res adolescentes ont manque´ a` leurs responsabilite´s de prodiguer des soins, ces situations ont e´te´ classe´es selon trois groupes en ordre descendant d’importance: mauvais traitements, ne´gligence et abandon. Re´sultats: La coope´ration des adolescentes a` participer au programme a` domicile variait selon l’appui qu’elles ont rec¸u de la part de leur famille et du pe`re de l’enfant (p ⬍ .0001). On a note´ aucune diffe´rence importante entre les deux groupes au niveau de l’utilisation des services de sante´, du retour a` l’e´cole apre`s la naissance, des grossesses subse´quentes ou encore des mauvais traitements et de la ne´gligence. L’incidence des mauvais traitements augmente en accord avec le statut de risque de la ` la fin, 19% des enfants ont duˆ eˆtre retire´s du foyer. me`re. A Conclusions: On a re´ussi a` pre´dire le niveau de risque pour les enfants, cependant, ce programme intensif en milieu clinique et a` domicile n’a pas modifie´ l’incidence de mauvais traitements ni le de´veloppement maternel. Il se pourrait qu’un programme qui comprend un re´seau d’appuis serait plus appre´cie´ des adolescentes, et donc, plus efficace. Les conclusions soulignent l’importance de fournir un service de counseling qui est conc¸u spe´cialement pour pre´venir l’abandon de leurs enfants par les adolescentes.

Resumen Objetivo: Determinar si el agregar el componente de una intensiva visita al hogar a un programa integral de orientacio´n adolescente a la maternidad es preventivo del abuso y la negligencia contra los nin˜os.

C. Stevens–Simon et al. / Child Abuse & Neglect 6 (2001) 753–769

769

Me´todo: Estudiamos 171 participantes en un programa integral de orientacio´n adolescente a la maternidad quienes estaban destinados a ser de alto riesgo para el abuso y la negligencia contra los nin˜os. La mitad fueron asignados al azar para recibir instruccio´n parental en la casa. Los trastornos mayores en el cuidado primario que ofrecı´an las madres adolescentes fueron clasificados en jerarquı´a como abuso, negligencia y abandono. Resultados: La aceptacio´n de las visitas al hogar variaba en relacio´n con el apoyo que las madres adolescentes recibı´an de sus familias y de los padres de sus bebes (p ⬍ .0001). No aparecieron ningunas diferencias significativas en los grupos de tratamiento en el patro´n del uso de los cuidados de salud, la tasa de vuelta a la escuela postparto, repeticio´n de embarazos, o abuso y negligencia a los nin˜os. La incidencia del maltrato aumento´ de acuerdo con el status del riesgo predicho en la madre. Finalmente el 19% de los nin˜os fueron trasladados fuera de la custodia de la madre. Conclusiones: Los esfuerzos para identificar los bebes en riesgo fueron efectivos pero e´sta intensiva intervencio´n clı´nica en el hogar no altero´ la incidencia del maltrato a los nin˜os ni el curso en el desarrollo de la vida de la madre. Un programa parental que fuera ma´s amplio en la red de apoyo podrı´a ser ma´s popular con los adolescentes y por lo tanto ma´s efectivo. Nuestros hallazgos tambie´n enfatizan la importancia de incluir consejerı´a especı´ficamente disen˜ada para prevenir que las adolescentes abandonen sus hijos.