Preventing child abuse and neglect with a program of nurse home visitation: the limiting effects of domestic violence

Interventions that prevent or respond to intimate partner violence against women and violence against children: a systematic review

Efforts to prevent or respond to intimate partner violence (IPV) and violence against children (VAC) are still disparate worldwide, despite increasing evidence of intersections across these forms of violence. We conducted a systematic review to explore interventions that prevent or respond to IPV and VAC by parents or caregivers, aiming to identify common intervention components and mechanisms that lead to a reduction in IPV and VAC. 30 unique interventions from 16 countries were identified, with 20 targeting both IPV and VAC. Key mechanisms for reducing IPV and VAC in primary prevention interventions included improved communication, conflict resolution, reflection on harmful gender norms, and awareness of the adverse consequences of IPV and VAC on children. Therapeutic programmes for women and children who were exposed to IPV facilitated engagement with IPV-related trauma, increased awareness of the effects of IPV, and promoted avoidance of unhealthy relationships. Evidence gaps in low-income and middle-income countries involved adolescent interventions, post-abuse interventions for women and children, and interventions addressing both prevention and response to IPV and VAC. Our findings strengthen evidence in support of efforts to address IPV and VAC through coordinated prevention and response programmes. However, response interventions for both IPV and VAC are rare and predominantly implemented in high-income countries. Although therapeutic programmes for parents, caregivers, and children in high-income countries are promising, their feasibility in low-income and middle-income countries remains uncertain. Despite this uncertainty, there is potential to improve the use of health services to address IPV and VAC together.

Primary Care Interventions to Prevent Child Maltreatment: Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance

Child maltreatment is associated with serious negative physical, psychological, and behavioral consequences.

Objective

To review the evidence on primary care-feasible or referable interventions to prevent child maltreatment to inform the US Preventive Services Task Force.

Data Sources

PubMed, Cochrane Library, and trial registries through February 2, 2023; references, experts, and surveillance through December 6, 2023.

Study Selection

English-language, randomized clinical trials of youth through age 18 years (or their caregivers) with no known exposure or signs or symptoms of current or past maltreatment.

Data Extraction and Synthesis

Two reviewers assessed titles/abstracts, full-text articles, and study quality, and extracted data; when at least 3 similar studies were available, meta-analyses were conducted.

Main Outcomes and Measures

Directly measured reports of child abuse or neglect (reports to Child Protective Services or removal of the child from the home); proxy measures of abuse or neglect (injury, visits to the emergency department, hospitalization); behavioral, developmental, emotional, mental, or physical health and well-being; mortality; harms.

Results

Twenty-five trials (N = 14 355 participants) were included; 23 included home visits. Evidence from 11 studies (5311 participants) indicated no differences in likelihood of reports to Child Protective Services within 1 year of intervention completion (pooled odds ratio, 1.03 [95% CI, 0.84-1.27]). Five studies (3336 participants) found no differences in removal of the child from the home within 1 to 3 years of follow-up (pooled risk ratio, 1.06 [95% CI, 0.37-2.99]). The evidence suggested no benefit for emergency department visits in the short term (<2 years) and hospitalizations. The evidence was inconclusive for all other outcomes because of the limited number of trials on each outcome and imprecise results. Among 2 trials reporting harms, neither reported statistically significant differences. Contextual evidence indicated (1) widely varying practices when screening, identifying, and reporting child maltreatment to Child Protective Services, including variations by race or ethnicity; (2) widely varying accuracy of screening instruments; and (3) evidence that child maltreatment interventions may be associated with improvements in some social determinants of health.

Conclusion and Relevance

The evidence base on interventions feasible in or referable from primary care settings to prevent child maltreatment suggested no benefit or insufficient evidence for direct or proxy measures of child maltreatment. Little information was available about possible harms. Contextual evidence pointed to the potential for bias or inaccuracy in screening, identification, and reporting of child maltreatment but also highlighted the importance of addressing social determinants when intervening to prevent child maltreatment.

Knowledge and Attitude of Pediatric Nurses in Saudi Arabia Regarding Child Abuse

Background

Child abuse, especially when caused by the child's parents or caregivers, can be either physical, psychological, and/or sexual. Pediatric nurses should be able to identify cases of child abuse, provide appropriate care, and address the issue. Nurses' knowledge, attitudes in child abuse are essential in safeguarding the well-being and safety of those children. This study aimed to investigate pediatric nurses' knowledge and attitude about child abuse and actions taken to address such abuse.

Methods

Seventy pediatric nurses working in one educational hospital in Riyadh City, Saudi Arabia participated in the study. This study followed a quantitative design. A self-administrative questionnaire was distributed to pediatric nurses. A convenience sampling was followed to include the nurses who met the criteria. An adopted validated questionnaire was used for collecting data about nurses' knowledge and attitudes regarding child abuse. The data was analyzed by SPSS with a descriptive analysis, independent t-tests or ANOVA test, and regression analysis.

Results

The descriptive results indicate that participants had adequate knowledge for identifying a child as a probable victim of child abuse. All participants agreed that an important role for nurses in managing and preventing child abuse is present. The study also indicated a favorable attitude of pediatric nurses toward child abuse. Linear regression analysis showed that nurses age between 31 and 40 years were positively associated with nurses' knowledge of child abuse, nurses with fewer years of experience and nurses with experience in dealing with a victim of child abuse had a more favorable attitude.

Conclusion

The study concludes that pediatric nurses have adequate knowledge and a positive attitude toward child abuse. Middle age was positively associated with nurses' knowledge of child abuse, while years of experience and experience in dealing with child abuse was inversely associated with nurses' attitude.

Engaging fathers to strengthen the impact of early home visitation on physical child abuse risk: Findings from the dads matter-HV randomized controlled trial

BACKGROUND

Despite growing recognition of the importance of fathers in child abuse risk, the field of perinatal home visitation has only begun to consider fathers' roles in the implementation of such services.

OBJECTIVES

This study examines the effectiveness of Dads Matter-HV ("DM-HV"), a father-inclusion enhancement to home visitation, and hypothesized mediators of impact.

METHODS

A multisite cluster randomized controlled trial was conducted with 17 home visiting program teams serving 204 families across study conditions. Program supervisors and their teams were randomized to deliver home visiting services plus DM-HV enhanced services (intervention) or home visiting services alone (control). Data were collected at three time points: baseline, 4 months post-baseline immediately following the intervention, and 12 months post-baseline. We employed structural equation modeling to estimate the effect of the intervention on physical child abuse risk and to trace hypothesized mediators, including the quality of the father-worker relationship, parents' partner support and abuse, and the timing of service initiation.

RESULTS

Results indicated that the DM-HV enhancement improved home visitor relationships with fathers, but only for families receiving services initiated postnatally. For these families, the improved quality of the father-worker relationship predicted improved parents' support of one another and reduced bidirectional mother-father partner abuse at 4-month follow-up, which in turn lowered maternal physical child abuse risk and paternal physical child abuse risk at 12-month follow-up.

CONCLUSIONS

DM-HV can strengthen the impact of home visitation services on physical child abuse risk for families when services are initiated postnatally.

Exposure to household dysfunction at childhood and later number of teeth among older Japanese adults: A life course study from the Japan Gerontological Evaluation Study

OBJECTIVES

The aim of this retrospective cohort study was to investigate the life course association between exposure to two household dysfunctions (father violence against mother and parental divorce) at childhood (≤18 years) with later number of remaining teeth (≥65 years) in functionally independent older Japanese population. This was the first study to investigate this research question in the Asian context.

METHODS

The Japan Gerontological Evaluation study (JAGES) self-reported retrospective data gathered in 2013 was used (n = 21,604). Each household dysfunction was binary variable (Yes/No), while the five categories of the number of remaining teeth were ≥20, 10-19, 5-9, 1-4, and no teeth. Sex-stratified ordered logistic regression models were used to calculate the odds ratios (OR) of having fewer teeth. The models were adjusted for age, economic adversity in childhood, educational attainment, comorbidities, and smoking status.

RESULTS

Overall, 46.4% were men and a total of 1149 participants (5.3%) experienced household dysfunction at childhood [men = 642 (6.4%), women = 507 (4.4%)]. The regression models showed higher OR of having fewer teeth among men who experienced a household dysfunction [OR = 1.16; 95% Confidence interval (CI) = 1.00-1.36] than men who did not. This association was not observed among women [OR = 0.94; 95% CI = 0.79-1.13]. Similar magnitude and direction of the association was observed among men but not among women when the two components of household dysfunction were used separately and aggregately as exposure variables.

CONCLUSION

An exposure to a household dysfunction at childhood was associated with having fewer teeth in later life among men but not among women.

Changes in Household Challenges and Subsequent Child Welfare Report

INTRODUCTION

Preventing child maltreatment and reducing adverse childhood experiences is critical for improving adult health. To inform prevention efforts, it is necessary to move beyond static risk models and instead model the dynamic changes in household challenges during the prebirth and early childhood periods. This study examined the effect of changes in the number of household challenges from prebirth (12 months before birth of a child) to early childhood (3 years after birth) period on the risk of a child maltreatment report by age 3 years.

METHODS

This retrospective cohort study linked data from the Alaska 2009-2011 Pregnancy Risk Assessment Monitoring System, its 3-year follow-up survey, and administrative records through 2019. Participants were 1,699 birthing parents. Latent class analyses identified prebirth and early childhood low- and high-challenge respondent groups on the basis of the level of reported household challenges. The authors then modeled the relationships between group transition membership and the risk of maltreatment using latent transition analysis. Analyses were conducted in 2021.

RESULTS

Households transitioning from a high-challenge-prebirth status to a low-challenge-early-childhood status had a lower predicted risk for child services report than households remaining in the high-challenges group. Transitioning from low- to high-challenges status predicted the highest risk for child services report than that of all other groups.

CONCLUSIONS

To reduce the risk of child maltreatment and subsequent adverse childhood experiences, healthcare providers should screen parents for the presence of household challenges during both pregnancy and early childhood and connect patients to resources targeted at reducing those challenges and providing continuous familial support.

Supporting Fathers to Prevent Child Maltreatment: How Paid Family Leave and Child Care Subsidies are Part of a Public Health Approach

There are multiple components of a public health approach for preventing child maltreatment. One of these components is the question of who to intervene with. Fathers are an under-targeted and under-studied group for child maltreatment prevention. In this conceptual article, we describe a public health approach for intervening with fathers. Acknowledging financial stress as a key risk factor for child maltreatment among fathers, we explore two policy interventions that aim to increase economic support for families during the early years of a child's life: paid family leave and child care subsidies. During the weeks following the child's birth, paid family leave can promote child-father bonding and enable fathers to engage in more caregiving during a critical family transition. After paid family leave ends, child care subsidies can make child care affordable for families with low income, thereby promoting parents' employment and earnings. We conclude by highlighting ways in which fathers can take an active role in preventing child maltreatment.

Preventing intimate partner violence among foreign-born Latinx mothers through relationship education during nurse home visiting

AIMS

This study aimed to examine the effectiveness of an augmented home visiting programme in preventing intimate partner violence among Latinx mothers by nativity.

BACKGROUND

Intimate partner violence diminishes home visit programmes' effectiveness. Immigrant Latinx mothers are especially vulnerable and need culturally tailored prevention.

METHODS

We performed secondary analyses of 33 US-born and 86 foreign-born Latinx mothers at baseline and 1- and 2-year follow-up in a longitudinal randomized controlled trial of the Nurse-Family Partnership programme augmented with nurse-delivered Within My Reach relationship education curriculum and violence screening and referrals in Oregon. We estimated proportional odds models via generalized estimating equations on total physical and sexual victimization and/or perpetration forms (an ordinal variable), adjusting for intervention, wave, age and education.

RESULTS

The intervention-nativity interaction was not significant (p = .953). Foreign-born status was associated with lower reported violence at baseline (adjusted odds ratio: 0.29, 95% confidence interval: 0.13-0.67, p = .004). This association was marginally significant at 1-year follow-up (0.43, 0.17-1.08, p = .072) and not significant at 2-year follow-up (0.75, 0.33-1.67, p = .475).

CONCLUSIONS

This augmented programme was not effective for Latinx mothers by nativity. Their nativity gap diminished over time.

IMPLICATIONS FOR NURSING MANAGEMENT

Nursing leaders should support culturally tailored home visiting programmes to detect and prevent intimate partner violence affecting Latinx immigrants.

CLINICAL TRIAL REGISTRATION

This study is registered at www.

CLINICALTRIALS

gov NCT01811719. The full trial protocol can be accessed at https://clinicaltrials.gov/ct2/show/NCT01811719.

Factors influencing the implementation of an intimate partner violence intervention in nurse home visiting: A qualitative descriptive study

AIMS

To identify factors that influenced: (1) integration of an intimate partner violence intervention into the Nurse-Family Partnership programme and (2) utilization of the intervention with fidelity to the clinical pathway by nurses in their home visits.

DESIGN

A qualitative descriptive study embedded in the intervention arm (n = 7 sites) of a 15-site cluster randomized clinical trial to evaluate the intimate partner violence intervention.

METHODS

Semi-structured interviews (n = 13) were conducted with supervisors. Nurses at the seven sites shared their experiences in focus groups conducted at two time points (n = 14 focus groups, 12 months after baseline and following collection of client trial data). Qualitative data were generated between May 2012 and September 2016, with this post hoc analysis completed in 2021. Focus group data were analysed using a rapid qualitative analysis technique. Conventional content analysis was used to categorize data from the supervisor interviews.

RESULTS

Integration was negatively impacted by: (1) a lack of centralized programme support and (2) competing programme demands. At the practice level, multiple factors related to supervisor capacity, preservation of the nurse-client relationship and nurse, client and intervention attributes influenced nurses' capacity to address intimate partner violence with fidelity to the clinical pathway. A lack of privacy in home visits was the most common barrier to addressing clients' experiences of violence. The need for increased time for nurses to develop clinical expertise prior to the evaluation of the intervention was also identified.

CONCLUSION

Before implementing an intimate partner violence intervention, home visitation programmes need to attend to site readiness, provide support to supervisors to facilitate implementation, and provide nurses with time to develop the expertise and clinical judgement required to use a complex intervention whilst also respecting clients' agency to determine when and how they will respond to the violence in their relationships.ImpactWhat problem did the study address? Given the positive impacts that participating in the Nurse-Family Partnership intimate partner violence education had on nurse home visitors' attitudes and confidence to address this type of violence experienced by first-time mothers, it was important to understand what factors contributed to the low fidelity of intervention implementation in practice, a factor that may help to explain the lack of client-level impacts on maternal outcomes. What were the main findings? Implementation of an intimate partner violence intervention in a nurse home visiting programme was influenced by contextual factors at both programme and practice levels. At the practice level, a lack of privacy in the home limited nurses' capacity to use the intervention. Supervisors were identified as having an important role to support nurses develop the expertise to use the intervention. Nurses also consistently balanced the intervention requirements to address intimate partner violence with an understanding of the complexity of this type of violence in young women's lives and respect for clients' agency to determine when and how they will respond to the violence in their relationships. Where and on whom will the research have an impact? These findings will be of interest to: (1) researchers developing and evaluating complex nursing interventions to address intimate partner violence in home visitation programmes and (2) stakeholders leading the implementation of novel innovations in the Nurse-Family Partnership programme.

Intimate Partner Violence During Pregnancy: Effects of Maternal Depression Symptoms and Parenting on Teen Depression Symptoms

Past studies have indicated that mothers who are victims of intimate partner violence (IPV) have a greater risk of developing depression symptoms. Furthermore, existing literature provides evidence that children's mental health can be affected by their mother's mental health well past infancy and early childhood. Given this, children of IPV victims are particularly at risk of developing depression symptoms. Guided by trauma theory, the ecobiodevelopmental (EBD) framework, and social learning theory, this study investigates the long-term relationship between maternal IPV victimization during pregnancy and teen depression symptoms. This study utilizes longitudinal data from the Fragile Families and Child Wellbeing Study to examine the relationship between IPV during pregnancy and maternal depression symptoms at early childhood, as well as the mechanism by which maternal depression symptoms affect child depression symptoms in the adolescent stage of development. The findings indicate that mothers who were victims of IPV during pregnancy were more likely to have depression symptoms when children turned 3 and that maternal depression symptoms could directly predict children's depression symptoms at age 15. Meanwhile, maternal depression symptoms could indirectly increase adolescent depression symptoms via physical punishment at age 5 and bullying victimization at age 9. While extensive evidence has shown that IPV during pregnancy has detrimental effects on mothers and children, our study adds to the literature that such detriments can last as long as a decade. Given that depression symptoms can be detrimental to later development, the findings call for universal and comprehensive IPV screening tools and swift service referrals for pregnant women who are experiencing IPV. At the same time, trauma-informed parenting education for women, along with school- and community-based interventions for children, may also mitigate these harmful associations.

A realist model for home visitation program evaluation

Increased attention on home visitation as a strategy to reduce child maltreatment and increased funding to support home visitation programs has led to their rapid and widespread adoption in the United States and internationally. The rapid adoption of home visitation programs has occurred without an adequate understanding of the underlying mechanisms of influence on child maltreatment. Consequently, there is a lack of consistency in structures and processes across programs. The variability in structures and processes within and across programs has contributed to the inconsistent findings related to the effectiveness of home visitation as a strategy to constrain child maltreatment. Identifying the underlying mechanisms that are facilitating or constraining program success or failure is essential for informing policy and practice. We propose the use of realist theory to identify the underlying mechanisms of home visitation programs. While realist theory has been used broadly in the social sciences, its uptake in nursing has been slow. Despite its limited use in nursing, realism's primary function, seeking to identify the underlying mechanisms in complex social programs, makes it suitable for investigating many complex phenomena that are of interest to nurse scientists. Here we discuss the theoretical foundations for home visitation programs, the recent evidence for program effectiveness, significant home visitation program components, and we propose a realist model for home visitation program evaluation that may aid in identifying how, for whom, and under what conditions home visitation programs work when these programs are implemented to address child maltreatment.

Relationship Between Adverse Childhood Experiences and Resilience in College Students in China

A great body of literature has documented that adverse childhood experiences (ACEs) are related to individuals' psychological functioning and mental health. However, the majority of ACE studies focus on psychological dysfunction and less is known about how ACEs are associated with other positive psychological outcomes, including resilience. The current study assessed the relationship between ACEs and resilience, using a sample of college students in China. We hypothesized that college students who had ACEs would have lower levels of resilience. Data came from 1,871 college students from twelve colleges in China through an anonymous online survey between late September and early October 2020. Linear regression analyses were conducted. Aligned with our hypotheses, ACEs had a negative association with individuals' resilience. Despite several limitations, this study found a negative association between ACEs and college students' resilience. Preventive services and interventions are in need to protect individuals from ACEs.

A systematic review and qualitative meta-synthesis of the roles of home-visiting nurses working with women experiencing family violence

AIMS

To systematically review and synthesize qualitative research exploring home-visiting nurses' roles and identify the challenges for nurses working with women experiencing family violence.

DESIGN

We undertook a thematic synthesis of qualitative studies, focusing on the family violence work of nurse home visitors.

DATA SOURCES

A systematic search of four scientific databases (ProQuest Central, CINAHL, MEDLINE, EMBASE) was undertaken in August 2021. Grey literature was searched, including government and non-government research documents, theses, clinical guidelines, policy documents and practice frameworks.

REVIEW METHODS

Inclusion criteria included research from high-income countries, peer-reviewed qualitative studies in English published from 1985 to 2021, and included research on home-visiting nurse family violence practice. The first author conducted the data search and the initial screening. The first and second authors independently reviewed the full text of 115 papers, identifying 26 for inclusion in the thematic synthesis (Figure 1-PRISMA flowchart).

RESULTS

The thematic synthesis identified two themes: (1) relationship building-with the client, with services and with colleagues/self; and (2) family violence practice-ask/screen, validate/name, assess risk/safety plan and safeguard children.

CONCLUSION

The thematic synthesis confirmed the multiple roles fulfilled by home-visiting nurses and enabled insight into the challenges they face as they undertake complex and demanding work. The roles of the home-visiting nurse have evolved, with the initial focus on safeguarding children leading to broader family violence nursing practice roles, including the identification of family violence and safety planning discussions with women.

IMPACT

Our meta-synthesis has confirmed the high-level communication and rapport-building skills required by nurses undertaking complex and conflicting roles. Nurses need support and supervision to undertake emotionally demanding work. Integrated health systems, clinical practice guidelines and tools, and training programmes need to encompass the breadth and complexity of the roles of these specialist practitioners.

Maximizing the return on investment in Early Childhood Home Visiting through enhanced eligibility screening

BACKGROUND

The MIECHV (Maternal, Infant, and Early Childhood Home Visiting) program invests substantial federal resources to prevent child maltreatment and emergency medical costs. Eligibility is based on screening of demographic or clinical risk factors, but because screening accuracy in predicting poor outcomes is unknown, assignment to home-visiting might miss high-risk families or waste resources on low-risk families.

OBJECTIVES

To guide eligibility decisions, this study tested accuracy of demographic and clinical screening in predicting child maltreatment and emergency medical care.

PARTICIPANTS AND SETTING

A population-representative sample of 201 birthing mothers (39.8% Black, 33.8% Latina) in Durham, NC, was enrolled between July 2009, and December 2010, and followed through December 2015.

METHODS

Participants were screened demographically (i.e., Medicaid, first-born, teenage, no high school diploma) and clinically (i.e., health/health care, parenting readiness, home safety, and parent mental health) at birth and followed through age 60 months, when Child Protective Services and hospital records were reviewed. Cox hazard models tested accuracy of prediction from screening variables.

RESULTS

Demographic factors did not significantly predict outcomes, except having Medicaid/uninsured predicted more emergency medical care and being first-born was a (surprising) protective factor against a child maltreatment investigation. In contrast, clinical factors strongly predicted both maltreatment investigations (Hazard Ratio = 4.01 [95% CI = 1.97, 8.15], sensitivity = 0.70, specificity = 0.64, accuracy = 0.65) and emergency medical care (Hazard Ratio = 2.14 [95% CI = 1.03, 2.14], sensitivity = 0.50, specificity = 0.69, accuracy = 0.58).

CONCLUSIONS

Even with added costs for clinical screening, selecting families for home visiting based on assessed clinical risk will improve accuracy and may yield a higher return on investment. The authors recommend a universal system of screening and care to support birthing families.

Effectiveness of a health promotion intervention to address determinants of child neglect in a disadvantaged community in Sri Lanka

BACKGROUND

Child neglect is a form of child maltreatment and it is a neglected area of research. As similar to other forms of maltreatment, neglect also results in negative health outcomes for children. Child neglect is concentrated in disadvantaged communities. The community-centered health promotion approach empowers communities to identify and address determinants of perceived health issues. This study aimed to implement a health promotion intervention to enable a disadvantaged community to address determinants of child neglect and evaluate the effectiveness of the intervention.

METHODS

A quasi-experimental study design was used. Two disadvantaged communities in Anuradhapura District, Sri Lanka with similar socio-demographic characteristics were purposively selected as the experimental and control study settings. The mothers who have at least one child in the age range 5-18 years were included in the sample. The sample included 42 mothers from the experimental group and 44 mothers from the control group. The elder children of mothers in the experimental group were selected to be the agents of change. A health promotion intervention was implemented only with the experimental setting. The steps of the intervention included; (1) identifying prevention of child neglect as a goal, (2) understanding the determinants, (3) analyzing determinants and identifying actions and (4) implementing and modifying the actions. The total study duration was 1 year, with the intervention taking an average of 6 months. Data were collected at both pre and post-intervention phases from mothers and children through interviewer-administered questionnaires.

RESULTS

Mothers of the experimental group improved their knowledge on child neglect significantly in comparison to the control group (p < 0.05). In the post-intervention phase, there were significant differences in attitudes related to child neglect between experimental and control groups (p < 0.05). Following the health promotion intervention, mothers of the experimental group had significantly improved their practices related to the safety, education, nutrition of children, relationships with the child and social support for child caring (p < 0.05) when compared with the control group.

CONCLUSIONS

The health promotion intervention was effective in addressing the selected determinants of child neglect in a disadvantaged community. Children could act as active agents of change to deliver the interventions to their mothers (perpetrators).

Adverse childhood experiences, mindfulness and happiness in Chinese college students during the COVID-19 pandemic

The rise of literature on adverse childhood experiences (ACEs) has indicated a strong relationship between ACEs and negative life outcomes, leading to important implications for services to the population. However, less is known about the effects of ACEs on happiness and the role of mindfulness in this relation. This study examined the relationships between ACEs and happiness and whether mindfulness mediated the effects of ACEs on happiness in a sample of Chinese college students. The data were collected from 1871 college students from 12 colleges across China in September 2020. The findings of this study show that ACEs had significant negative effects on students' happiness and that mindfulness helped to substantially reduce the negative effects of ACEs on happiness. Students who experienced emotional neglect and abuse in childhood were affected the most. By contrast, this group is not the primary focus of mindfulness-based interventions in existing literature; thus, this study calls for specific mindfulness-based interventions for this vulnerable population.

Nurse-Family Partnership nurses' attitudes and confidence in identifying and responding to intimate partner violence: An explanatory sequential mixed methods evaluation

AIMS

To evaluate the effect of an intimate partner violence intervention education component on nurses' attitudes in addressing intimate partner violence; complementary aims included understanding nurses' perceptions of the education and how it influenced their attitudes and confidence to address intimate partner violence in practice.

DESIGN

An explanatory sequential mixed methods design embedded within a 15-site cluster randomized clinical trial that evaluated an intimate partner violence intervention within the Nurse-Family Partnership programme.

METHODS

Data were collected between February 2011 and September 2016. Quantitative assessment of nurses' attitudes about addressing intimate partner violence was completed by nurses in the intervention (n = 77) and control groups (n = 101) at baseline, 12 months and at study closure using the Public Health Nurses' Responses to Women Who Are Abused Scale. Qualitative data were collected from nurses in the intervention group at two timepoints (n = 14 focus groups) and focused on their perceptions of the education component. Data were analysed using content analysis.

RESULTS

Nurses in the intervention group reported large improvements in their thoughts, feelings and perceived behaviours related to addressing intimate partner violence; a strong effect of the education was found from baseline to 12 months and baseline to study closure timepoints. Nurses reported that the education component was acceptable and increased their confidence to address intimate partner violence.

CONCLUSION

Nurses reported improved attitudes about and confidence in addressing intimate partner violence after receiving the education component. However, these findings need to be considered together with trial results showing no main effects for clients, and a low level of intervention fidelity.

IMPACT

These evaluation findings underscore that improvement in nurses' self-reported educational outcomes about addressing intimate partner violence cannot be assumed to result in adherence to intervention implementation or improvement in client outcomes. These are important considerations for developing nurse education on intimate partner violence.

Examining the Effectiveness of the Fathers and Babies Intervention: A Pilot Study

There is increasing recognition of the importance of addressing the mental health of fathers, including during the perinatal period. Fathers exhibiting mental health concerns during the perinatal period are at heightened risk for future negative mental health outcomes and are less likely to engage in nurturing relationships with their children, leading to a sequalae of negative child outcomes during infancy and into adolescence. Although interventions have been developed for perinatal fathers, they typically do not focus directly on addressing paternal mental health. To fill this gap, we developed the Fathers and Babies intervention to be delivered to perinatal fathers whose partners (mothers) were enrolled in home visiting programs. A pre-post longitudinal study was conducted in which 30 father-mother dyads were recruited from home visiting programs. Fathers received the 12-session Fathers and Babies intervention while the mother concurrently received the Mothers and Babies intervention delivered to her by a home visitor. Baseline, 3- and 6-month self-report surveys were conducted with both fathers and mothers. Fathers and mothers had statistically significant decreases in perceived stress between baseline and both follow-up time points, with moderate effect sizes generated for both sexes. No statistically significant differences were found for depressive symptoms, anxiety symptoms, or perceived partner support, although we found small effects for reductions in depressive symptoms among fathers, as well as increases in the percentage of fathers and mothers who reported high levels of emotional and instrumental support post-intervention. While preliminary, these findings suggest the potential for Fathers and Babies to positively impact the mental health of fathers in the perinatal period, and also signal the viability of home visiting as a setting for delivering this intervention. Future research should employ a comparison group to generate stronger evidence of intervention effectiveness and include measurement of dyadic relationships and paternal parenting practices.

Building Healthy Children: A preventive intervention for high-risk young families

The Building Healthy Children (BHC) home-visiting preventive intervention was designed to provide concrete support and evidence-based intervention to young mothers and their infants who were at heightened risk for child maltreatment and poor developmental outcomes. This paper presents two studies examining the short- and long-term effectiveness of this program at promoting positive parenting and maternal mental health, while preventing child maltreatment and harsh parenting. It also examines the intervention's sustained effect on child symptomatology and self-regulation. At baseline, young mothers and their infants were randomly assigned to receive BHC or Enhanced Community Standard. Families were assessed longitudinally across four time points. Data were also collected from the child's teacher at follow-up. Mothers who received BHC evidenced significant reductions in depressive symptoms at mid-intervention, which was associated with improvements in parenting self-efficacy and stress as well as decreased child internalizing and externalizing symptoms at postintervention. The follow-up study found that BHC mothers exhibited less harsh and inconsistent parenting, and marginally less psychological aggression. BHC children also exhibited less externalizing behavior and self-regulatory difficulties across parent and teacher report. Following the impactful legacy of Dr. Edward Zigler, these findings underline the importance of early, evidence-based prevention to promote well-being in high-risk children and families.

The Role of Social Support on Depression Among Vulnerable Caregivers Reporting Bidirectional Physical Violence

Intimate partner violence (IPV) is a public health concern found across genders, socioeconomic strata, cultures, and ethnicities. While IPV is traditionally examined from either the victim or initiator role, it is also important to consider relationships in which both partners experience and demonstrate violence. The current study examined the relation between IPV chronicity and depression among 403 female caregivers with young children. Specifically, the current study examined the association between bidirectional IPV and depression. Furthermore, the impact of social support on depression levels among those caregivers was assessed. Results suggest that of those couples who experienced violence, bidirectional IPV was reported significantly more frequently than unidirectional IPV only. No significant differences in depression were found between those reporting bidirectional versus unidirectional IPV. Among those involved in bidirectional IPV, having greater social support was associated with significantly lower depression levels. Findings suggest that both initiation and experiences of IPV should be assessed among caregivers of vulnerable children. The potential impact of social support was also identified in this study. Clinicians may consider assessing family violence broadly, including bidirectional IPV, particularly among parents of young children with other adverse life conditions. Development and sustainment of healthy relationships through social support may facilitate adjustment for the caregivers.

The Family Nurse Partnership to reduce maltreatment and improve child health and development in young children: the BB:2–6 routine data-linkage follow-up to earlier RCT

Background

The short-term effectiveness (to 24 months post partum) of a preventative home-visiting intervention, the Family Nurse Partnership, was previously assessed in the Building Blocks trial (BB:0–2).

Objectives

The objectives were to establish the medium-term effectiveness of the Family Nurse Partnership in reducing maltreatment and improving maternal health (second pregnancies) and child health, developmental and educational outcomes (e.g. early educational attendance, school readiness); to explore effect moderators and mediators; and to describe the costs of enhancing usually provided health and social care with the Family Nurse Partnership.

Design

Children and their mothers from an existing trial cohort were followed up using routine data until the child was 7 years of age.

Setting

This study was set in 18 partnerships between local authorities and health-care organisations in England.

Participants

The participants were mothers [and their firstborn child(ren)] recruited as pregnant women aged ≤ 19 years, in local authority Family Nurse Partnership catchment areas, at < 25 weeks’ gestation, able to provide consent and able to converse in English. Participants mandatorily withdrawn (e.g. owing to miscarriage) from the BB:0–2 trial were excluded.

Interventions

The intervention comprised up to a maximum of 64 home visits by specially trained family nurses from early pregnancy until the firstborn child was 2 years of age, plus usually provided health and social care support. The comparator was usual care alone.

Main outcome measures

The primary outcome measure was child-in-need status recorded at any time during follow-up. The secondary outcomes were as follows: (1) referral to social services, child protection registration (plan), child-in-need categorisation, looked-after status, recorded injuries and ingestions at any time during follow-up; (2) early child care and educational attendance, school readiness (Early Years Foundation Stage Profile score) and attainment at Key Stage 1; and (3) health-care costs.

Data sources

The following data sources were used: maternally reported baseline and follow-up data (BB:0–2), Hospital Episode Statistics data (NHS Digital), social care and educational data (National Pupil Database) and abortions data (Department of Health and Social Care).

Results

There were no differences between study arms in the rates of referral to social services, being registered as a child in need, receiving child protection plans, entering care or timing of first referral for children subsequently assessed as in need. There were no differences between study arms in rates of hospital emergency attendance, admission for injuries or ingestions, or in duration of stay for admitted children. Children in the Family Nurse Partnership arm were more likely to achieve a good level of development at reception age (school readiness), an effect strengthened when adjusting for birth month. Differences at Key Stage 1 were not statistically different, but, after adjusting for birth month, children in the Family Nurse Partnership arm were more likely to reach the expected standard in reading. Programme effects were greater for boys (Key Stage 1: writing); children of younger mothers (Key Stage 1: writing, Key Stage 1: mathematics); and children of mothers not in employment, education or training at study baseline (Key Stage 1: writing). There were no differences between families who were part of the Family Nurse Partnership and those who were not for any other outcome. The differences between study arms in resource use and costs were negligible.

Limitations

The outcomes are constrained to those available from routine sources.

Conclusions

There is no observable benefit of the programme for maltreatment or maternal outcomes, but it does generate advantages in school readiness and attainment at Key Stage 1.

Future work

The trajectory of longer-term programme benefits should be mapped using routine and participant-reported measures.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 2. See the NIHR Journals Library website for further project information.

Assessment and Response to Intimate Partner Violence in Home Visitation: A Qualitative Needs Assessment With Home Visitors in a Statewide Program

There is growing recognition that home visitation programs serving at-risk families may be an appropriate mechanism for detecting and reducing intimate partner violence (IPV). More research is needed about how home visitors assess and respond to IPV, especially in rural and underserved areas with unique social and geographic challenges. This study describes the qualitative, needs assessment phase of a larger mixed-methods evaluation of IPV assessment, referral processes, and safety planning with clients within a statewide home visitation program. Three focus groups were conducted with home visitors (n = 16) in West Virginia's Home Visitation Program in May 2015. Home visitors represented four separate home visitation models and provided services across 12 of West Virginia's 55 counties. Guiding questions focused on home visitors' current protocol, experiences, barriers, and facilitators to (a) screening and assessment for IPV, (b) making referrals after disclosures of IPV, and (c) developing safety plans with IPV-exposed clients. Barriers identified by home visitors included the nature of assessment tools, issues with service availability and access in rural areas, and lack of education and training surrounding safety planning. Facilitators included building relationships and trust with clients, providing anticipatory guidance when making referrals, and tailoring safety plans to clients' unique situations. Participants also expressed a critical need to develop procedures for assuring home visitor safety when supporting IPV-exposed clients. These qualitative data highlight issues surrounding the management of IPV in home visitation and have the potential to inform future enhancements to programs that are specifically tailored to the needs of rural, disadvantaged communities.

Adverse Childhood Experiences and Mindfulness in Chinese College Students During the COVID-19 Pandemic

Mindfulness has been found to have many positive effects on life outcomes, including mental health and educational achievement. However, less is known about the antecedents of mindfulness, particularly in Chinese college students. This study examines the effect of adverse childhood experiences (ACEs) on mindfulness among Chinese college students in September 2020, during the COVID-19 pandemic. We hypothesized that ACEs negatively affected students' mindfulness. The data were collected from 1,871 college students from 12 colleges across China. The results aligned with our hypothesis that ACEs was negatively associated with mindfulness. In particular, emotional abuse and neglect in childhood appear to have the most negative effects on mindfulness compared to other dimensions of ACEs such as physical abuse and household challenges.

Adverse Childhood Experiences and Psychological Well-Being in Chinese College Students: Moderated Mediation by Gender and Resilience

Adverse childhood experiences (ACEs), including child abuse/neglect and household challenges, are a prevalent social issue that impacts individuals' well-being worldwide. Relatively few ACEs studies orient to the presence of psychological wellness, especially in ethnically Chinese populations. Furthermore, less is known about resilience as a mechanism between ACEs and psychological well-being, in addition to the moderating effect of gender. This study examined the relationship between ACEs and psychological well-being among Chinese college students and the potential mediating and moderating effects of resilience and gender, respectively. A total of 1,871 college students studying social science from 12 Chinese colleges completed an anonymous online survey between late September and early October 2020. Multiple-group path analyses were conducted to examine whether the relationships among ACEs, resilience, and psychological well-being differed as a function of gender. Results suggested that gender moderated the relationships studied. For female students, resilience mediated the association between abuse/neglect and psychological well-being, where abuse/neglect was negatively associated with resilience, which in turn had a negative relationship with psychological well-being. For male students, household challenges were negatively related to psychological well-being through reduced resilience. Based on the findings, various ACE-informed initiatives may be essential to prevent and protect individuals from ACEs. We also call for resilience-based interventions to enhance individuals' resilience and thus strengthen their psychological well-being.

The Intergenerational Effects of Intimate Partner Violence in Pregnancy: Mediating Pathways and Implications for Prevention

Prenatal intimate partner violence (P-IPV) can have significant adverse impacts on both mother and fetus. Existing P-IPV interventions focus on the safety of the mother and on reducing revictimization; yet expanding these to address the adverse impact on the fetus has considerable potential for preventing long-term negative developmental outcomes. In this review, we draw together evidence on major pathways linking exposure to P-IPV and child outcomes, arguing that these pathways represent potential targets to improve P-IPV intervention efforts. Using a narrative review of 112 articles, we discuss candidate pathways linking P-IPV to child outcomes, as well as their implications for intervention. Articles were identified via key word searches of social science and medical databases and by inspection of reference lists of the most relevant articles, including recent reviews and meta-analyses. Articles were included if they addressed issues relevant to understanding the effects of P-IPV on child outcomes via six core pathways: maternal stress and mental illness, maternal-fetal attachment, maternal substance use, maternal nutritional intake, maternal antenatal health-care utilization, and infection. We also included articles relevant for linking these pathways to P-IPV interventions. We conclude that developing comprehensive P-IPV interventions that target immediate risk to the mother as well as long-term child outcomes via the candidate mediating pathways identified have significant potential to help reduce the global burden of P-IPV.

Moderators of treatment effects in a child maltreatment prevention programme in South Africa

BACKGROUND

Previous research has found mixed results on whether the most disadvantaged families benefit as much as less disadvantaged families from parenting interventions designed to reduce child maltreatment, and little in known in low-income settings.

OBJECTIVE

In this study, we test the effects of child, caregiver, household, and community characteristics as treatment moderators of intervention outcomes - child maltreatment and parenting practices. We test characteristics previously examined elsewhere as well as factors relevant to the South African context.

PARTICIPANTS AND SETTING

This analysis includes adolescents (ages 10-18) and their caregivers (N = 552 pairs) who participated in a randomised trial of a parenting programme in the Eastern Cape Province of South Africa.

METHODS

Data from the caregiver and adolescent standardised questionnaires collected at baseline, post-test (1-month post-intervention), and follow-up (5-9 months) were analysed using longitudinal multilevel analyses. We tested seven hypothesised moderators for each of the primary outcomes through interactions of treatment effect with baseline moderators.

RESULTS

No moderator effects were statistically significant after correcting for multiple comparisons testing. Hence, in line with several recent studies examining moderation effects in parenting programmes, our study suggests that parenting interventions aiming to reduce child maltreatment and promote parenting skills in low- and middle-income countries may be similarly effective for families facing various levels of economic, social, and health risk factors.

CONCLUSIONS

It may be useful to explicitly power trials for testing moderator effects, study different types of moderators and use person-centred analyses to further understand variations in treatment effects.

Seeing the Forest in Family Violence Research: Moving to a Family-Centered Approach

Victims of family violence are sorted into fragmented systems that fail to address the family as an integrated unit. Each system provides specialized care to each type of victim (child, older adult, adult, animal) and centers on the expertise of the medical and service providers involved. Similarly, researchers commonly study abuse from the frame of the victim, rather than looking at a broader frame-the family. We propose the following 5 steps to create a research paradigm to holistically address the response, recognition, and prevention of family violence.By developing an integrated research model to address family violence, and by using that model to support integrated systems of care, we propose a fundamental paradigm shift to improve the lives of families living with and suffering from violence.

Reflective parenting home visiting program: A longitudinal study on the effects upon depression, anxiety and parenting stress in first-time mothers

Objective

Our study aimed to investigate the effects of a reflective parenting home visiting program in first time-mothers at risk for depression, anxiety, and parenting stress, from three to 12 months after their child's birth.

Study design

The sample was composed by 77 first-time mothers and their healthy babies (53% boys and 47% girls). Mothers filled out the Edinburgh Postnatal Depression Scale, the State-Trait Anxiety Inventory, and the Parenting Stress Index-SF at 3, 6 and 12 months of the child. Thirty-six mothers were assigned to the experimental group and received the reflective parenting home-visiting program, the other 36 constituted the control group.

Results

Analyses showed a significant higher reduction in the level of depression, anxiety and parenting stress among mothers belonging to the experimental group, compared to the control group.

Conclusion

Our findings confirm the benefits of reflective parenting home visiting programs and underline the need to constantly evaluate the levels of depression, anxiety and parenting stress throughout the perinatal period to target effective prevention programs to foster early mother-child attachment bond.

Development of an academic practice partnership to improve maternal child health

This manuscript describes one nursing school's innovative community-based partnership with community organizations and Nurse-Family Partnership (NFP), an established nurse home visiting program for first-time, low income mothers and infants. The aim of this academic nursing endeavor with the community and NFP is to improve the health and well-being of low-income, first time mothers and their children while also providing comprehensive, population-based nursing experiences for students and service leadership and scholarship opportunities for faculty. The academic-practice community partnership described here makes a case for utilizing the expertise and capacity of a nursing school to implement and administer an NFP program and serves as an exemplar for the recommendations described in the New Era for Academic Nursing report (AACN, 2016). The value of forming partnerships between a public health department, the philanthropic community and an academic nursing institution is highlighted. In this case, the three organizations partnering together around a common purpose of improving birth outcomes enabled the partnership to accomplish more than any individual organization could have accomplished alone.

Training maternal and child health nurses in early relational trauma: An evaluation of the MERTIL workforce training

BACKGROUND

Parents who experience relational trauma may inadvertently create contexts of care that undermine secure beginnings to life for their young children. Universal health services such as Maternal and Child Health (MCH) services offer a unique whole-of-population platform for prevention through early detection and intervention. To date however, relevant workforce training has been minimal.

OBJECTIVES

We report on an evaluation of state-wide workforce training to support MCH nurses to identify and respond to early relational trauma within parent-child dyads.

DESIGN

Process and learning evaluation data were obtained at baseline (N = 1450), exit (n = 734) and follow-up (n = 651).

SETTINGS AND PARTICIPANTS

Specialist training was developed and delivered to 1513 MCH staff in Victoria, Australia, via a 20-hour program of online learning and clinical skills workshops.

RESULTS

At baseline, across eight measures of confidence in recognizing and responding to relational trauma, 30-49% of nurses rated their confidence as low. Significant increases in all areas of self-rated learning were found post-training. Three months post-training, gains in confidence and capability were sustained, with no significant variations by participant role or setting. Overall program satisfaction was >90%. Continuing concerns at follow-up focused on pragmatic concerns about inadequacy of referral networks and appropriate intervention pathways.

CONCLUSIONS

In this evaluation of a state-wide training program for nurses working with early relational trauma, we found excellent uptake and program satisfaction, and results support learning impact and retention. Findings are discussed with regard to translation potential across early childhood settings.

Evaluating the real-world implementation of the Family Nurse Partnership in England: protocol for a data linkage study

INTRODUCTION

Almost 20 000 babies are born to teenage mothers each year in England, with poorer outcomes for mothers and babies than among older mothers. A nurse home visitation programme in the USA was found to improve a wide range of outcomes for young mothers and their children. However, a randomised controlled trial in England found no effect on short-term primary outcomes, although cognitive development up to age 2 showed improvement. Our study will use linked routinely collected health, education and social care data to evaluate the real-world effects of the Family Nurse Partnership (FNP) on child outcomes up to age 7, with a focus on identifying whether the FNP works better for particular groups of families, thereby informing programme targeting and resource allocation.

METHODS AND ANALYSIS

We will construct a retrospective cohort of all women aged 13-24 years giving birth in English NHS hospitals between 2010 and 2017, linking information on mothers and children from FNP programme data, Hospital Episodes Statistics and the National Pupil Database. To assess the effectiveness of FNP, we will compare outcomes for eligible mothers ever and never enrolled in FNP, and their children, using two analysis strategies to adjust for measured confounding: propensity score matching and analyses adjusting for maternal characteristics up to enrolment/28 weeks gestation. Outcomes of interest include early childhood development, childhood unplanned hospital admissions for injury or maltreatment-related diagnoses and children in care. Subgroup analyses will determine whether the effect of FNP varied according to maternal characteristics (eg, age and education).

ETHICS AND DISSEMINATION

The Nottingham Research Ethics Committee approved this study. Mothers participating in FNP were supportive of our planned research. Results will inform policy-makers for targeting home visiting programmes. Methodological findings on the accuracy and reliability of cross-sectoral data linkage will be of interest to researchers.

Prevalence of child maltreatment in the Netherlands: An update and cross-time comparison

BACKGROUND

The third Netherlands' Prevalence study of Maltreatment of children and youth (NPM-2017) continues the tradition of periodically mapping the national prevalence of child maltreatment.

OBJECTIVE

The NPM-2017 provides an update of the current prevalence rates of child maltreatment and of changes in its prevalence over the last 12 years. In addition, risk factors for child maltreatment and its co-occurrence with domestic violence were investigated.

PARTICIPANTS AND SETTING

Prevalence data were based on cases reported to 'Safe at Home' organizations (former CPS agencies) and observations of professionals working with children (sentinels).

METHODS

Sentinels (N = 785) filled out a form for each case of suspected child maltreatment that they observed within their professional sample during a three-month period.

RESULTS

An overall prevalence estimate of child maltreatment in the Netherlands in 2017 of 26-37 per 1000 children was computed. The most important risk factors for child maltreatment were low parental education (RR=4.95), parental unemployment (RR = 3.64), immigrant status (RR = 3.61), and single parenthood (RR = 2.29). Neither prevalence rates nor risk factors changed significantly between 2005, 2010, and 2017. Finally, in 46 % of the reported families child maltreatment occurred in a context of domestic violence.

CONCLUSIONS

The prevalence of co-occurring domestic violence may indicate that family violence observed within one dyad could be a marker for dysfunctional functioning of the family system. Child maltreatment remains a considerable problem in the Netherlands with a stable prevalence over the last 12 years and stability in characteristics that make families vulnerable for child maltreatment.

Why achieving gender equality is of fundamental importance to improve the health and well-being of future generations: a DOHaD perspective

Despite progress in gender equality, women continue to be disadvantaged compared with men. Worldwide, women are more often confronted with poverty, violence, and mental health problems, and they have less access to food and education. All these factors do not only affect women themselves, but also have a negative impact on the child's early environment and impair its early development, thereby reducing the health and well-being of future generations. Framing gender equality as a women's issue fails to highlight the importance of gender equality for the health and well-being of the next generation. As a scientific community investigating early human development and health, we have failed to fully recognize and underscore the importance of gender equality in achieving the best possible start for every child. If women and men had equal rights and opportunities, their children would be more likely to reach their full potential which would improve the health and well-being of future generations. Our studies and interventions have not fully taken into account the complexity of gender inequality and women's disadvantaged positions in society. We need better insight into the complex adaptive interactions between various societal and human factors contributing to gender inequality and find approaches that take this complexity into account. If we want DOHaD science to have societal impact, we should strive beyond gender equality for gender equity and help women achieve equal rights and opportunities. We need to work with public health professionals, human rights activists, and policymakers to gauge the importance of gender equality. After all, gender equality is not only a fundamental human right, but also a necessary foundation for healthier future generations.

Family functioning and involvement in home visiting: Examining program characteristics as moderators to support retention in services

Developing strategies to improve retention in home visiting programs is critical to their success. The purpose of the study is to examine how the content provided during home visits moderates the association between family risks (economic, household functioning, and conflict) and retention in services. Parents (n = 1,322) voluntarily enrolled in Healthy Families America (n = 618) and Parents as Teachers (n = 704). Family characteristics were collected using the Family Map Inventories. Multilevel analyses showed a moderating impact of the time home visitors spent supporting parent-child interaction for all family risks examined. Moderating effects demonstrated a stronger positive association between focusing on the parent-child relationship and retention at 6 and 12 months for parents demonstrating greater needs. There were no moderating effects of child development content or case management activities with retention at 6 and 12 months. Together, families were more likely to stay in services when home visitors focused on parent-child interaction and child development, but less likely retained with more case management. Parents with greater risks were more likely to remain in services with more time focused on supporting parent-child interactions. Findings suggest the need to support our home visiting workforce in their work to promote healthy parent-child relationships.

Study protocol: randomized controlled trial of manualized components in home visitation to reduce mothers' risk for child maltreatment

BACKGROUND

This study tests whether home visitation to prevent child maltreatment can be improved by adding manualized program components, targeting four key risk factors for child maltreatment: low parental self-efficacy, high levels of perceived stress, parental anger, and post-traumatic stress symptoms. Home visitation is widely implemented, but effects on child maltreatment risk tend to be modest at best. Home visitation tends to be rather flexible (i.e., professionals decide how to support each family). We will test whether adding manualized program components increases program effectiveness, by ensuring that key risk factors are addressed, while maintaining flexibility. In addition, we will test whether any component effects on reduced child maltreatment risk can be explained (i.e., is mediated) by ameliorated risk factors. Lastly, we will test whether the components are more effective for some mothers (e.g., those at highest child maltreatment risk) than for others.

METHODS

We will conduct a randomized controlled trial among 398 mothers enrolled in a Dutch home visiting program targeting families at risk for child maltreatment. Mothers in the experimental group will receive the manualized components in two consecutive home visits, while mothers in the control group will receive regular home visits (care as usual). Mothers will fill out questionnaires at four time points: before and after each of the two home visits. Outcome variables include the four targeted risk factors parental self-efficacy, perceived stress, parental anger, and (recognition of) post-traumatic stress symptoms, as well as parenting practices (e.g., rejection and affection), and risk for child maltreatment.

DISCUSSION

This study aims to determine whether adding manualized program components to a flexible home visiting program increases program effectiveness on risk for child maltreatment. In addition, our test of whether the effects of the components on risk for child maltreatment is explained (i.e., mediated) by amelioration of the targeted risk factors, may contribute to our understanding of the role of these risk factors in child maltreatment. Our tests of which mothers benefit most from adding the components may help move the field towards evidence-based personalized family support.

TRIAL REGISTRATION

This trial has been retrospectively registered in the Netherlands Trial Register (NL8005).

Characteristics of effective collaboration: A study of Nurse-Family Partnership and child welfare

BACKGROUND

In February 2018, President Trump signed into law the Family First Prevention Act, legislation in the United States aimed at providing prevention services for families at risk of entering the child welfare system. The effectiveness of these prevention efforts is dependent on the formation of collaborative relationships between prevention-programs and child welfare.

OBJECTIVE

To identify factors that influence the ability of the Nurse-Family Partnership (NFP) and Child Protective Services (CPS) to collaborate in serving high-risk mothers and their children.

PARTICIPANTS

123 NFP, CPS workers, and community partners.

SETTING

Seven sites in the U.S. state of Colorado selected to include an array of community sizes, geographies, apparent levels of collaboration, and variations in internal structures and practices.

METHODS

Using an adapted grounded theory approach, we conducted semi-structured interviews with frontline NFP and CPS workers and supervisors. Interviews were recorded, transcribed, validated, and coded in NVivo 10.

RESULTS

Alignment of core organizational mission and methods was key in determining collaboration levels between NFP and CPS. Only when workers perceived there to be alignment in organizational mission, did other factors such as program eligibility, communication channels, and risk and safety assessment practices influence the perceived benefits and efforts undertaken to enhance collaboration.

CONCLUSIONS

High-risk families frequently require services that go beyond the scope of any one organization. As programs that serve high-risk families refine their efforts to serve them effectively, collaborative efforts should focus on examining opportunities and challenges involved in creating greater mission alignment.

Cost-Benefit Analysis of Two Child Abuse and Neglect Primary Prevention Programs for US States

We assessed the US state-level budget and societal impact of implementing two child abuse and neglect (CAN) primary prevention programs. CAN cost estimates and data from two prevention programs (Child-Parent Centers and Nurse-Family Partnership) were combined with current population, cost, and CAN incidence data by US state. A cost-benefit mathematical model for each program by US state compared program costs with the future monetary value of benefits from reduced CAN. The models used a lifetime time horizon from government payer and societal perspectives. Both programs could potentially avert CAN among tens of thousands of children across the country. Lower costs from reduced CAN may substantially offset, but not always entirely eliminate, payers' program implementation cost. Results are sensitive to the rate of CAN in each US state. Given the considerable lifetime societal cost of CAN, including victims' lost work productivity, the programs were cost saving from the societal perspective in all US states using base case methods. This analysis represents an overall minimum return on payers' investment because averted CAN is just one of many positive health and educational outcomes associated with these programs and non-monetary benefits from reduced CAN were not included. Translating cost and effectiveness research on injury prevention programs for local conditions might increase decision makers' adoption of effective programs.

A scoping review of mental health prevention and intervention initiatives for infants and preschoolers at risk for socio-emotional difficulties

BACKGROUND

Infant mental health has emerged as a unique area of practice and research distinguished from child and youth sub-specialties by its advocacy for a relational practice framework with an emphasis on parents/caregivers being integral to assessment, treatment, and prevention initiatives. A diverse array of initiatives offered across a broad spectrum of delivery methods is available to clinicians. However, to date, a large-scale mapping of the research evidence regarding these interventions has yet to be completed to help inform clinician's decisions regarding the best approaches for their clients. To address this knowledge gap, this study aimed to report on the landscape of research pertaining to mental health interventions for infants and preschoolers (0-5 years), and their families at risk for socio-emotional difficulties and negative developmental outcomes.

METHOD

A scoping review methodology was used to conduct a large-scale mapping of the intervention research pertaining to infants and preschoolers (0-5) at risk for socio-emotional difficulties. We searched MEDLINE, PsycINFO, EMBASE, Web of Science, The Cochrane Library, CINAHL, LILACS, ProQuest Nursing & Allied Health Source, World Cat, and ClinicalTrials.gov , from inception to December 31, 2012. We extracted information regarding publication date, geographical location, study design, level of risk, population, key intervention mechanism, and outcome measures.

RESULTS

We identified 533 potential studies from 1233 title and abstracts after the first round of screening. Full text article review in the second round of screening resulted in a total of 162 included articles for the final analysis. Results indicated that over 50% of interventions evaluated were randomized controlled trials conducted in Westernized countries. Most studies could be subdivided by level of risk within a preventative public health framework including universal, selected, indicated, and direct treatment for children formally diagnosed with a mental disorder. Risk factors experienced by children and their families were heterogeneously defined and numerous outcome measures across included studies. The results of this study are limited to the last search date of 2012.

CONCLUSIONS

Key intervention mechanisms spanned a range of approaches including parenting groups, dyadic, in-home, cognitive-behavioral therapy, and day care-based interventions. The findings are discussed in terms of implications for broad trends and gaps in research and policy for this population.

Effect of Addition of an Intimate Partner Violence Intervention to a Nurse Home Visitation Program on Maternal Quality of Life: A Randomized Clinical Trial

IMPORTANCE

Intimate partner violence (IPV) is a public health problem with significant adverse consequences for women and children. Past evaluations of a nurse home visitation program for pregnant women and first-time mothers experiencing social and economic disadvantage have not consistently shown reductions in IPV.

OBJECTIVE

To determine the effect on maternal quality of life of a nurse home visitation program augmented by an IPV intervention, compared with the nurse home visitation program alone.

DESIGN, SETTING, AND PARTICIPANTS

Cluster-based, single-blind, randomized clinical trial at 15 sites in 8 US states (May 2011-May 2015) enrolling 492 socially disadvantaged pregnant women (≥16 years) participating in a 2.5-year nurse home visitation program.

INTERVENTIONS

In augmented program sites (n = 229 participants across 7 sites), nurses received intensive IPV education and delivered an IPV intervention that included a clinical pathway to guide assessment and tailor care focused on safety planning, violence awareness, self-efficacy, and referral to social supports. The standard program (n = 263 participants across 8 sites) included limited questions about violence exposure and information for abused women but no standardized IPV training for nurses.

MAIN OUTCOMES AND MEASURES

The primary outcome was quality of life (WHOQOL-BREF; range, 0-400; higher score indicates better quality of life) obtained through interviews at baseline and every 6 months until 24 months after delivery. From 17 prespecified secondary outcomes, 7 secondary end points are reported, including scores on the Composite Abuse Scale, SPAN (Startle, Physiological Arousal, Anger, and Numbness), Prime-MD Patient Health Questionnaire, TWEAK (Tolerance/Worry About Drinking/Eye-Opener/Amnesia/C[K]ut Down on Drinking), Drug Abuse Severity Test, and the 12-Item Short-Form Health Survey (physical and mental health), version 2.

RESULTS

Among 492 participants enrolled (mean age, 20.4 years), 421 (86%) completed the trial. Quality of life improved from baseline to 24 months in both groups (change in WHOQOL-BREF scores from 299.5 [SD, 54.4] to 308.2 [SD, 52.6] in the augmented program group vs from 293.6 [SD, 56.4] to 316.4 [SD, 57.5] in the standard program group). Based on multilevel growth curve analysis, there was no statistically significant difference between groups (modeled score difference, -4.9 [95% CI, -16.5 to 6.7]). There were no statistically significant differences between study groups in any of the secondary participant end points. There were no adverse events recorded in either group.

CONCLUSIONS AND RELEVANCE

Among pregnant women experiencing social and economic disadvantage and preparing to parent for the first time, augmentation of a nurse home visitation program with a comprehensive IPV intervention, compared with the home visitation program alone, did not significantly improve quality of life at 24 months after delivery. These findings do not support the use of this intervention.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01372098.

Implementation of the Family Nurse Partnership programme in England: experiences of key health professionals explored through trial parallel process evaluation

BACKGROUND

The Family Nurse Partnership (FNP) programme was introduced to support young first-time mothers. A randomised trial found FNP added little short-term benefit compared to usual care. The study included a comprehensive parallel process evaluation, including focus groups, conducted to aid understanding of the introduction of the programme into a new service and social context. The aim of the focus groups was to investigate views of key health professionals towards the integration and delivery of FNP programme in England.

METHODS

Focus groups were conducted separately with Family Nurses, Health Visitors and Midwives at trial sites during 2011-2012. Transcripts from audio-recordings were analysed thematically.

RESULTS

A total of 122 professionals participated in one of 19 focus groups. Family Nurses were confident in the effectiveness of FNP, although they experienced practical difficulties meeting programme fidelity targets and considered that programme goals did not sufficiently reflect client or community priorities. Health Visitors and Midwives regarded FNP as well-resourced and beneficial to clients, describing their own services as undervalued and struggling. They wished to work closely with Family Nurses, but felt excluded from doing so by practical barriers and programme protection.

CONCLUSION

FNP was described as well-resourced and delivered by highly motivated and well supported Family Nurses. FNP eligibility, content and outcomes conflicted with individual client and community priorities. These factors may have restricted the potential effectiveness of a programme developed and previously tested in a different social milieu. Building Blocks ISRCTN23019866 Registered 20/04/2009.

Assessing the social determinants of health care costs for Medicaid-enrolled adolescents in Washington State using administrative data

OBJECTIVE

The study used administrative data to identify the social determinants that have the greatest impact on Medicaid expenditures in adolescence.

DATA SOURCES

Data were compiled using the Washington State Department of Social and Health Services Integrated Client Databases, which link data from state systems including Medicaid claims and social services receipt.

STUDY DESIGN

Medical system and behavioral health service costs of over 180 000 Medicaid-enrolled adolescents aged 12-17 were measured using integrated administrative data from Washington State. Social determinants of health, including child maltreatment and parent risk factors, were also measured. Two-stage regression models were used to identify factors associated with increased health care utilization and costs.

PRINCIPAL FINDINGS

Regression models revealed that the factors most predictive of higher health care costs were child abuse, child neglect, and instability in out-of-home placements related to foster care. Other social determinants of health, such as parent risk factors, were not associated with health care costs. Child maltreatment and placement instability impacted health care costs primarily through large increases in behavioral health utilization and costs.

CONCLUSIONS

Prevention and early interventions for children and families to decrease child maltreatment and increase foster care placement stability could reduce overall health care costs.

Associations of adverse childhood experiences and suicidal behaviors in adulthood in a U.S. nationally representative sample

BACKGROUND

Suicide is a leading cause of death among adolescents and young adults. The current study extends the research linking adverse childhood experiences (ACEs) to suicidal behaviors by testing these associations using a nationally representative sample, assessing for suicide ideation and attempts in adulthood, controlling for established risk factors for suicidality, and measuring a broad array of ACEs.

METHODS

The sample included 9,421 participants from the National Longitudinal Study of Adolescent Health who participated in four waves of assessments spanning 13 years. We examined longitudinal associations between eight different ACEs (physical, sexual, and emotional abuse, neglect, parental death, incarceration, alcoholism, and family suicidality) with suicidal ideation and suicide attempts in adulthood, while controlling for depression, problem alcohol use, drug use, delinquency, impulsivity, gender, race, age, and urbanicity. We also tested for cumulative associations of ACEs with suicide ideation and attempts.

RESULTS

Logistic regression analyses indicated that physical, sexual, and emotional abuse, parental incarceration, and family history of suicidality each increased the risk by 1.4 to 2.7 times for suicidal ideation and suicide attempts in adulthood. The accumulation of ACEs increased the odds of suicide ideation and attempts. Compared with those with no ACEs, the odds of seriously considering suicide or attempting suicide in adulthood increased more than threefold among those with three or more ACEs.

CONCLUSIONS

Intervention strategies need to prevent ACEs from occurring and, if they do occur, should take into account the impact of cumulative ACEs on suicide risk. Future research should focus on identifying mediating mechanisms for the ACEs-suicidality association using longitudinal research designs and determine which ACEs are most important to include in a cumulative ACE measure.

Longitudinal Investigation of Depression, Intimate Partner Violence, and Supports Among Vulnerable Families

Intimate partner violence (IPV) affects nearly 12 million individuals and their families each year in the United States. Many negative outcomes are associated with IPV, with depression being one of the most prevalent mental health problems. Most previous studies on IPV have used cross-sectional designs to examine the potential protective effects of support on depression. The current study fills this gap by conducting a longitudinal investigation of the roles of social support and family resources on depression among caregivers of young children. The study sample consisted of 548 female caregivers. Findings suggest that among those with an IPV history, those with higher social support reported lower depressive symptoms than those with less social support. No significant interaction was found for family resources and IPV. Rather, family resources had a main effect on depressive symptoms with no differential impact based on IPV status. Findings suggest the importance of connecting vulnerable families to supports such as social support and family resources to help mitigate depressive symptoms. Future research should consider the underlying mechanisms of social support as a protective factor among IPV victims with depression.

Reducing maltreatment recurrence through home visitation: A promising intervention for child welfare involved families

Maltreatment of children is a key predictor of a range of problematic health and developmental outcomes. Not only are affected children at high risk for recurrence of maltreatment, but effective interventions with known long term impact are few and limited. While home visiting is one of the most tested secondary prevention models for improving parenting, its primary focus on young primiparous mothers underemphasizes one of the most important risk groups: child welfare involved multiparous mothers. This study's focus is a randomized controlled trial of Healthy Families New York that included a subgroup of mothers (n = 104) who had at least one substantiated child protective services (CPS) report before enrolling in the program. By the child's seventh birthday, mothers in the home visited group were as half as likely as mothers in the control group to be confirmed subjects for physical abuse or neglect (AOR = .46, p = .08). The number of substantiated reports for mothers in the control group was twice as high as for those in the home visited group (1.59 vs. 79 p = .02, ES = .44). Group differences were only observed after the child's third birthday, suggesting the possible effect of surveillance in early years. Post-hoc analyses indicate that home visited mothers had fewer subsequent births that may have contributed to less parenting stress and improved life course development for mothers. In light of our findings, we suggest considering and further testing home visiting programs as a tertiary prevention strategy for child welfare-involved mothers.

An Intimate Partner Violence Prevention Intervention in a Nurse Home Visitation Program: A Randomized Clinical Trial

BACKGROUND

Intimate partner violence (IPV) is a significant public health problem with many negative consequences, particularly for pregnant women. This randomized trial investigated the effectiveness of an IPV preventive intervention embedded within the Nurse Family Partnership (NFP) program.

MATERIALS AND METHODS

Participants enrolled over a 20-month period and were interviewed at baseline and 1- and 2-year follow-up. Eligibility criteria included first pregnancy, eligible for the nutrition program Women, Infants, and Children (WIC), English or Spanish speaking, and at least 15 years of age. All women initially referred and screened were randomized to either intervention (NFP+) or control (NFP only) condition. The final sample consisted of 238 women completing baseline assessments; retention was 81% at 2-year follow-up.

RESULTS

Analyses indicated that there were no main effects: the intervention affected participants differently depending on their baseline experience with IPV. For physical violence victimization, an interaction between baseline victimization and treatment was found; the intervention reduced victimization at 1 year (and approached significance at 2 years), but only among women who had not experienced past-year physical victimization at baseline. For sexual violence victimization, another interaction emerged; women in the intervention group were more likely to report sexual violence victimization at 2-year follow-up, but only among participants who had reported sexual victimization at baseline. The only effect on IPV perpetration was psychological perpetration at 2-year follow-up; again, the treatment effect was moderated by baseline perpetration. The intervention reduced psychological perpetration for participants who were nonperpetrators at baseline, but had no effect on those reporting perpetration.

CONCLUSIONS

Overall, findings suggest that the intervention was effective in reducing some forms of violence among those not experiencing IPV at baseline, but was ineffective or potentially harmful for those already experiencing IPV.

Primary Care Interventions to Prevent Child Maltreatment: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Child maltreatment, also referred to as child abuse and neglect, can result in lifelong negative consequences.

OBJECTIVE

To update the evidence on interventions provided in or referable from primary care to prevent child maltreatment for the US Preventive Services Task Force.

DATA SOURCES

PubMed, Cochrane Library, EMBASE, and trial registries through December 18, 2017; references; experts; literature surveillance through July 17, 2018.

STUDY SELECTION

English-language fair- and good-quality randomized clinical trials that (1) included children with no known exposure to maltreatment and no signs or symptoms of current or past maltreatment, (2) evaluated interventions feasible in a primary care setting or that could result from a referral from primary care, and (3) reported abuse or neglect outcomes or proxies for abuse or neglect (eg, injury with a specificity for abuse, visits to the emergency department, hospitalization).

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently assessed titles/abstracts, full-text articles, and study quality; a third resolved conflicts when needed. When at least 3 similar trials were available, random-effects meta-analyses were conducted.

MAIN OUTCOMES AND MEASURES

Direct measures (including reports to child protective services and removal of the child from the home) or proxy measures of abuse or neglect; behavioral, emotional, mental, or physical well-being; and harms.

RESULTS

Twenty-two trials (33 publications) were included (N = 11 132). No significant association was found between interventions and reports to child protective services within 1 year of intervention completion (10.6% vs 11.9%; pooled odds ratio [OR], 0.94 [95% CI, 0.72-1.23]; 10 trials [n = 2444]) or removal of the child from the home within 1 to 3 years of follow-up (3.5% vs 3.7%; pooled OR, 1.09 [95% CI, 0.16-7.28]; 4 trials [n = 609]). No statistically significant associations were observed between interventions and outcomes for emergency department visits in the short term (<2 years), hospitalizations, child development, school performance, and prevention of death. Nonsignificant results from single trials led to a conclusion of insufficient evidence for injuries, failure to thrive, failure to immunize, school attendance, and other measures of abuse or neglect. Inconsistent results led to a conclusion of insufficient evidence for long-term (≥2 years) outcomes for reports to child protective services (ORs range from 0.48 to 1.13; 3 trials [n = 1690]), emergency department visits (1 of 2 trials reported significant differences) and internalizing and externalizing behavior symptoms (3 of 6 trials reported reductions in behavior difficulties). No eligible trials on harms of interventions were identified.

CONCLUSIONS AND RELEVANCE

Interventions provided in or referable from primary care did not consistently prevent child maltreatment. No evidence on harms is available.

Interventions to Prevent Child Maltreatment: US Preventive Services Task Force Recommendation Statement

IMPORTANCE

In 2016, approximately 676 000 children in the United States experienced maltreatment (abuse, neglect, or both), with 75% of these children experiencing neglect, 18% experiencing physical abuse, and 8% experiencing sexual abuse. Approximately 14% of abused children experienced multiple forms of maltreatment, and more than 1700 children died as a result of maltreatment.

OBJECTIVE

To update the US Preventive Services Task Force (USPSTF) 2013 recommendation on primary care interventions to prevent child maltreatment.

EVIDENCE REVIEW

The USPSTF commissioned a review of the evidence on primary care interventions to prevent maltreatment in children and adolescents without signs or symptoms of maltreatment.

FINDINGS

The USPSTF found limited and inconsistent evidence on the benefits of primary care interventions, including home visitation programs, to prevent child maltreatment and found no evidence related to the harms of such interventions. The USPSTF concludes that the evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment. The level of certainty of the magnitude of the benefits and harms of these interventions is low.

CONCLUSIONS AND RECOMMENDATION

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment. (I statement).

A Mixed Methods Evaluation of Early Childhood Abuse Prevention Within Evidence-Based Home Visiting Programs

Objectives In this large scale, mixed methods evaluation, we determined the impact and context of early childhood home visiting on rates of child abuse-related injury. Methods Entropy-balanced and propensity score matched retrospective cohort analysis comparing children of Pennsylvania Nurse–Family Partnership (NFP), Parents As Teachers (PAT), and Early Head Start (EHS) enrollees and children of Pennsylvania Medicaid eligible women from 2008 to 2014. Abuse-related injury episodes were identified in medical assistance claims with ICD-9 codes. Weighted frequencies and logistic regression odds of injury within 24 months are presented. In-depth interviews with staff and clients (n = 150) from 11 programs were analyzed using a modified grounded theory approach. Results The odds of a healthcare encounter for early childhood abuse among clients were significantly greater than comparison children (NFP: 1.32, 95% CI [1.08, 1.62]; PAT: 4.11, 95% CI [1.60, 10.55]; EHS: 3.15, 95% CI [1.41, 7.06]). Qualitative data illustrated the circumstances of and program response to client issues related to child maltreatment, highlighting the role of non-client caregivers. All stakeholders described curricular content aimed at prevention (e.g. positive parenting) with little time dedicated to addressing current or past abuse. Clients who reported a lack of abuse-related content supposed their home visitor’s assumption of an absence of risk in their home, but were supportive of the introduction of abuse-related content. Approach, acceptance, and available resources were mediators of successfully addressing abuse. Conclusions for Practice Home visiting aims to prevent child abuse among high-risk families. Adequate home visitor capacity to proactively assess abuse risk, deliver effective preventive curriculum with fidelity to caregivers, and access appropriate resources is necessary.