Elsevier

The Lancet

Volume 365, Issue 9473, 21–27 May 2005, Pages 1786-1793
The Lancet

Articles
Effectiveness of home visitation by public-health nurses in prevention of the recurrence of child physical abuse and neglect: a randomised controlled trial

https://doi.org/10.1016/S0140-6736(05)66388-XGet rights and content

Summary

Background

Recurrence of child maltreatment is a major problem, yet little is known about approaches to reduce this risk in families referred to child protection agencies. Since home visitation by nurses for disadvantaged first-time mothers has proven effective in prevention of child abuse and neglect, we aimed to investigate whether this approach might reduce recidivism.

Methods

We enrolled in a randomised controlled trial 163 families with a history of one index child being exposed to physical abuse or neglect to compare standard treatment with a programme of home visitation by nurses in addition to standard treatment. The main outcome was recurrence of child physical abuse and neglect based on a standardised review of child protection records. Analysis was by intention to treat.

Findings

At 3-years' follow-up, records were available for 160 of 163 (98%) families randomised. 139 (85%) completed follow-up. Recurrence of child physical abuse (31 [43%] in the control group vs 29 [33%] in the intervention group) and neglect (37 [51%] vs 41 [47%]) did not differ between groups. However, hospital records showed significantly higher recurrence of either physical abuse or neglect in the intervention group than in the control group (21 [24%] vs 8 [11%]). There were no differences between groups for the other secondary outcome measures.

Interpretation

Despite the positive results of home visitation by nurses as an early prevention strategy, this visit-based strategy does not seem to be effective in prevention of recidivism of physical abuse and neglect in families associated with the child protection system. Much more effort needs to be directed towards prevention before a pattern of abuse or neglect is established in a family.

Introduction

During the past two decades, interventions to prevent child abuse and neglect have been assessed increasingly in high-risk community samples in randomised controlled trials.1, 2, 3 Although recurrence of child abuse and neglect is common4, 5, 6 and is associated with negative health outcomes for children, most programmes aimed at preventing recidivism in families have not undergone such rigorous investigation.7 Wolfe and Wekerle7 have reviewed studies of interventions provided to families in which child maltreatment has occurred, but they draw attention to the “relative paucity of carefully designed studies”. They emphasise that the measure of success in home-based interventions is usually avoidance of alternative placement. Although important, this outcome is distinct from recurrence of maltreatment. Services provided to families associated with the child protection system are sometimes implemented without determining whether they prevent child abuse and neglect from happening again.8

Rates of recurrence in child protection system populations vary because of differences in methods and definitions.5 Some studies examined rates of reabuse by the perpetrator,4 whereas others examined revictimisation of children6, 9 or recurrence within families.5 In a review, DePanfilis and Zuravin10 concluded that there is no standard method for assessing recidivism of child maltreatment. Reported recurrence rates of child abuse and neglect in published work range from 9% to 67%.4, 5, 6, 8, 9, 11, 12 Clearly there is a need to develop interventions that prevent recurrence of child abuse and neglect. Since the best evidence for prevention of physical abuse and neglect in high-risk groups before it occurs comes from the nurse home visitation programme developed by Olds and colleagues,13, 14 we investigated whether a programme of home visiting by nurses would be effective in preventing recurrence of physical abuse or neglect in families in which it had already occurred.

Section snippets

Setting and participants

The study was done in Hamilton, Canada, a city in the south-central region of Ontario with a population of about 300 000 at the time of the study. We invited consecutive eligible families who were referred to the two local child protection agencies (CPAs) between Mar 24, 1995, and Oct 30, 1996, to participate in the study. Families were eligible if they met the following criteria: (1) the index child was younger than 13 years, (2) the reported episode of physical abuse or neglect occurred

Results

Figure 1 shows the trial profile. Table 2 summarises the characteristics of the 163 families randomised. CPA records were available for 72 of 74 (97%) control families and 88 of 89 (99%) intervention families. For other measures, figure 1 shows the proportion of families who completed follow-up. Losses were small and similar between the two groups. Parent non-completers were similar to completers for age, marital status, work status, education, spouse's work status and education, but not for

Discussion

On the basis of CPA records, the intensive 2-year programme of home visitation by nurses was not more effective than standard services in preventing recurrence. The incident severity findings and the proxy measures are consistent with this finding. We were surprised by the hospital data that showed a higher rate of physical abuse or neglect in the intervention group. This finding could have been the result of nurses identifying the need for medical care in children in the visited families,

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