Helping to Prevent Child Abuse -- and Future Criminal Consequences: Hawai'i Healthy Start.



Series: NIJ Program Focus

Published: October 1995

22 pages

48,518 bytes




About This Study


Ralph B. Earle, Ph.D., is an independent evaluator

living in Hawai`i. The author reviewed the training

materials, assessment instruments, and

developmental materials for Hawai`i Healthy Start;

interviewed Gail Breakey, Director of the Hawai`i

Family Stress Center; and met with Healthy Start

supervisors and staff. Julie Esselman, a research

analyst at Abt Associates Inc., in Massachusetts,

assisted the author. For further information,

contact Gladys Wong, Program Head for Healthy

Start, at (808) 946-4771.




The violence committed by youths too often is

traced to the abuse and neglect they suffered in

their early years. The link between child

maltreatment and later criminal behavior by its

victims has made the criminal justice, health, and

social service systems partners in prevention. As

part of its research initiative on family violence,

the National Institute of Justice (NIJ) is

investigating interdisciplinary approaches

involving children, their families, and their

communities. This Program Focus describes the

Hawai`i Healthy Start program, which uses home

visitors from the community to provide services to

at-risk families. Its goals are to reduce family

stress and improve family functioning, improve

parenting skills, enhance child health and

development, and prevent abuse and neglect.


Of Special Interest:


o Unlike other similar programs, Hawai`i Healthy

Start follows the child from birth (or before) to

age 5 with a range of services, and it assists and

supports other family members.


o To ensure systematic enrollment, Healthy Start

signs up most families right after delivery of the

child, although approximately 10 percent of

families are enrolled prenatally.


o Healthy Start has formal agreements with all

hospitals in Hawai`i to enable it to perform

postpartum screening through a review of the

mother's medical record or a brief inperson

interview. Fewer than 1 percent of mothers refuse

to be interviewed, 4 to 8 percent later refuse

offers of services, and about 7 percent cannot be

located after release from the hospital.


o Paraprofessional home visitors call on families

weekly for the first 6 to 12 months. Early in the

relationship, the home visitor helps parents

develop an Individual Support Plan, specifying the

kinds of services they want and need and the means

by which to receive them.


o As part of its oversight, the Maternal Child

Health Branch requires completion of a series of

Infant/Child Monitoring Questionnaires to identify

problems in child development at 4, 12, 20, and 30

months. If these show developmental delays, further

assessments are performed and appropriate services

are offered.


o In 1994 a confirmed child care abuse and neglect

case cost the Hawai`i family welfare system $25,000

for investigation, related services, and foster

care. In contrast, Hawai`i Healthy Start officials

estimate an annual average cost of $2,800 per home

visitor case.


o Preliminary evaluation findings indicate that

Healthy Start families have lower abuse/neglect

rates and their children are developing

appropriately for their ages.




Traditionally, the prevention of child abuse and

neglect has fallen under the purview of health and

social service agencies.


Increasingly, however, violence against children is

a critical priority for criminal justice officials

as well. Not only are child abuse and neglect

crimes against society's most vulnerable

members, they also may lead to crime perpetrated

later in life by the victims themselves. Reducing

the twofold effect of child abuse and neglect on

the safety and well-being of American communities

presents a formidable challenge for all segments of



A growing amount of data appears to support the

concept of a "cycle of violence" that begins with

child abuse and neglect. One recent national study

showed that being the victim of abuse and neglect

as a child increases the chances of later juvenile

delinquency and adult criminality by 40 percent.

Even among children who are neglected but not

abused, one in eight will later be arrested for a

violent offense.1 Children who experience severe

violence in the home are approximately three times

as likely as other children to use drugs and

alcohol, get into fights, and deliberately damage

property. Abused and neglected children are four

times as likely to steal and to be arrested.2


Long before some victims of child abuse and neglect

inflict pain and loss on others, they are caught up

in a child welfare system that is costly and

overburdened. For example, from 1994 to 1995 in

Hawai`i, each confirmed case of child abuse or

neglect cost nearly $15,000 per year for

investigation and services. Foster care added

another $10,000 per year. Home care for a

drug-exposed child cost $18,000 per year, and

foster care for that child, $46,000.3 For both

social and financial reasons, the criminal justice

and family welfare systems have a strong incentive

to reduce child abuse and neglect.


Although both intuition and existing scientific

data indicate a predisposition to crime and

violence among many abused and neglected children,

more research is needed to determine the exact

nature of the link, as well as the relationship of

associated factors, such as socioeconomic status.4

Nonetheless, preliminary findings underscore the

need for the criminal justice system to support and

work in partnership with child abuse and neglect

prevention efforts and the communities they serve

as a means of reducing crime in both the short term

and the long run.


The Hawai`i Healthy Start Model


As part of its research initiative on family

violence, the National Institute of Justice (NIJ)

is interested in interdisciplinary approaches

involving children, their families, and their

communities.5 The U.S. Advisory Board on Child Abuse

and Neglect identified home visiting in 1991 as the

most promising means for preventing the

maltreatment of children. One example of this

approach is Hawai`i Healthy Start, a statewide,

multisite home visitation program designed to

screen, identify, and work with at-risk families of

newborns to prevent abuse and promote child



Home visitation programs have become increasingly

popular in recent years as a means to address a

number of social problems and individual needs.

Programs designed primarily for families with

newborns have diverse goals and services. The goals

of Hawai`i Healthy Start are to:


o Reduce family stress and improve family


o Improve parenting skills.

o Enhance child health and development.

o Prevent abuse and neglect.


Although it shares the same name as 15 infant

mortality prevention programs on the mainland,

Healthy Start's services are not limited to the

months before and after a child's birth. Instead,

Hawai`i Healthy Start serves the child until age 5.

The program includes early identification of

families at risk for child abuse and neglect,

community-based home visiting support and

intervention services, linkage to a "medical home"

and other health care services, and coordination of

a wide range of community services, primarily for

the parents and their newborn, but also for other

family members.6 To avoid confusion with similarly

named and focused programs (see "Federal `Healthy

Start' Program" and "Healthy Families America"),

the program featured in this Program Focus is

referred to throughout as Hawai`i Healthy Start.


Program History


The development of Hawai`i Healthy Start was

strongly influenced by the late Dr. Henry Kempe, a

researcher at the University of Colorado Health

Sciences Center and Director of the National Center

for Prevention and Treatment of Child Abuse and

Neglect in Denver. Kempe operated residential

treatment and prevention programs and developed a

checklist to identify families at risk of abusing

or neglecting their children.


In the early 1970's, Kempe screened 500 families in

the Denver area and identified 100 as being at risk

for child abuse and neglect. He randomly assigned

these 100 families to two groups. One group

received home visiting services; the other received

only the usual medical services. In each group of

50, he followed 25 families for 3 years. Among the

families provided services, there were no

hospitalizations for abuse, although three families

gave a child up for adoption. Among the 25

nonserviced families, however, five children were

hospitalized variously for head injuries,

scaldings, and fractures.


In 1973 Dr. Calvin Sia, a prominent pediatrician in

Hawai`i, and members of Hawai`i's Child Protective

Service (CPS) Advisory Committee invited Kempe to

help them put together a plan for the prevention

and treatment of child abuse and neglect among

families in Hawai`i. One year later, Gail Breakey,

current Director of the Hawai`i Family Stress

Center, and Sia obtained a 3-year grant from the

National Center for Prevention and Treatment of

Child Abuse and Neglect to implement the home

visiting program developed by Kempe and the CPS

Advisory Committee. They began a small prevention

program on O`ahu, which yielded results similar to

Kempe's work. Three home visitors provided

emotional support and taught child development to

70 families for 12 to 18 months. Breakey's and

Sia's developmental work continued with a community

service grant from 1978 to 1981 to extend services

to five additional sites on neighboring islands.


Healthy Start was an outgrowth of these early

programs. It was designed at the request of the

Hawai`i Senate Ways and Means Chairman, Mamoru

Yamasaki, who was concerned with the State's

increasing costs of corrections and social

services. Originally intending to fund a

delinquency prevention project in a high school,

Yamasaki recognized the relationship between early

abuse and delinquency and decided instead to begin

with infants of families at risk for child abuse

and neglect.


Healthy Start began in Hawai`i in July 1985 as a

State-funded demonstration child abuse and neglect

prevention program at a single site on O`ahu, the

most populous island, with an annual budget of

$200,000. The original prevention program concept

was expanded to include broader implementation and

more comprehensive objectives. Hawai`i Healthy

Start was designed to serve all families of

newborns at risk within the catchment area, follow

the children to age 5, link all infants to a

medical home that would serve them through

childhood, and intensify the focus on parent-child

attachment and interaction, child health, and child



After 3 years, Healthy Start had served 241

high-risk families, 176 of which were served for at

least 1 year. No cases of child abuse and only four

cases of child neglect were reported among the 241

families. Based on these results, between 1988 and

1990 the program was expanded through general funds

appropriated by the State legislature to 13 sites

across the State, with an annual budget of over $8

million for fiscal year 1995.


Administration, Budget, and Management


The Maternal Child Health Branch of the Hawai`i

Department of Health administers the State

appropriations, monitors the program, and evaluates

the seven not-for-profit private agencies that

deliver Healthy Start services. The programs

conducted by the seven agencies vary in terms of

budget and caseload. The smallest has an annual

budget of $290,000 and serves 150 families; the

largest spends over $1 million to serve 350 to 400

families each year. In 1990 actual screening,

assessment, and case management services cost

$2,500 per case. Where available, respite care

services cost $476 per child per year.


To establish a new program, Hawai`i Healthy Start

officials recommend a yearly budget of $349,000 to

handle 140 cases per year, allocating about

$283,000 to personnel costs, $34,000 to operating

expenses, and $32,000 to overhead. This budget does

not include funds for evaluation, but it would fund

a program manager at $35,000, a supervisor at

$30,000, one family assessment worker and six

family support workers (who serve as the home

visitors) from $19,000 to $21,000, and a secretary

at $21,000. At this level, the supervisor would

direct five home visitors and/or family assessment

workers. The program manager would supervise up to

three additional home visitors. Hawai`i Healthy

Start maintains about a 1:5 ratio of supervisors to

staff and recommends that other programs try to do

the same--regardless of the level of staff

training--to ensure adequate supervision critical

to program success and avoid overburdening





In 1994 Healthy Start made initial contact with 65

percent of the more than 16,000 newborns of

civilian families in the State. From these 10,485

contacts, 2,800 families (27 percent) enrolled in

home visitation services. Enrolled families tend to

be young (parents under 24 years old); of Hawai`ian

(32 percent), Caucasian (23 percent), Filipino (18

percent), or Japanese (10 percent) ancestry; and

low-income (50 percent receive welfare), with the

father unemployed and the mother undereducated.

Thirty-eight percent of the families have a history

of substance abuse; 43 percent have a history of

domestic violence; and 22 percent are homeless or

living in temporary, overcrowded conditions with

other families. About 65 percent of enrolled women

are single.


Service Flow


Enrollment. Hawai`i Healthy Start enlists most

families immediately after delivery of the child,

as this is the best way of ensuring systematic

enrollment. About 10 percent of families are

enrolled prenatally through contacts with clinics,

obstetricians, and public health nurses. Private

physicians are encouraged to refer pregnant women

who may need services to the program. For those who

enter the program before a child's birth, Hawai`i

Healthy Start has developed a curriculum for home

visitors to use with women and those of their

husbands or partners who are involved with the

family. Home visitors help them understand the

physiological and emotional effects of pregnancy

and prepare them for taking care of the baby.

Hawai`i Healthy Start also stresses regular

prenatal care and assists enrolled women in

identifying and using a primary care physician for

both preventive care and later infant treatment.


Screening at birth. Throughout Hawai`i, postpartum

screening begins in the hospital with either a

review of the mother's medical records or a brief

inperson interview. The program has formal

agreements with each hospital. Using the Healthy

Start screening questionnaire, the family

assessment worker checks 15 items as true, false,

or unknown. ("See Healthy Start Screening



Three situations prompt an assessment interview:

o The mother is single, separated, or divorced;

had poor prenatal care; or sought an abortion.

o Responses for two or more items are "true."9

o Responses for seven or more items are "unknown."


This first screening determines who requires an

indepth assessment interview. One family assessment

worker can perform 550 screenings and 225

assessments per year.


Assessment. If the screening suggests the need for

assessment, the family assessment worker visits the

mother and introduces her to the Healthy Start

program. If the father is present, he is also

interviewed. All interviews are voluntary.

According to the family assessment worker

supervisor at Kapiolani Medical Center for Women

and Children (where about half of all children on

O`ahu are born), mothers of newborns are usually

quite willing to talk about any concerns having to

do with their home situations. Less than 1 percent

refuse to be interviewed.


During a casual conversation, which takes from 45

minutes to an hour, the family assessment worker

covers the ten topics on the Kempe Family Stress

Checklist. Immediately after leaving the room, the

family assessment worker scores the ten items as

normal (0), mild (5), or severe (10). This

screening assessment identifies the factors that

place the family at high risk for abuse and

neglect. Families scoring above 25 are invited and

encouraged to become enrolled in services.

Depending on the community served, about 85 to 95

percent accept, 4 to 8 percent refuse, and about 7

percent cannot be found after they leave the

hospital, usually because they move and cannot be

contacted. (Some families who score in the 10-20

point range are assessed as "clinically positive"

if the family assessment worker senses that the

mother or father is not forthcoming. These families

are offered services.) If a family scores above 40

and does not accept services, the supervisor will

consider referring the family to the Child

Protective Services.


The first home visit. Paraprofessional home

visitors call on families weekly (or more

frequently, if needed) for the first 6 to 12

months. The first 11/2 hour visit is spent

describing the program and the role of the home

visitor. The home visitor usually starts the

conversation with something like the following:


I work with the Healthy Start program. I have new

information about babies that I didn't know about

when I was raising my kids. It can make being a

mother easier, but not easy! Also, you can look at

me as your information center about this community.

I live here, too, and I didn't know about WIC

[Special Supplemental Food Program for Women,

Infants, and Children] or the well baby clinic

before I started this job.


I hope you will learn to think of me as your

"special" friend, someone here completely for you

and the baby. I am here to talk when you need to

share something that concerns you. I know that it

is hard to start with a new baby and to have so

much on your mind.


If the mother--or, if present, the father--is

reluctant, the home visitor will ask if it is all

right to come back the following week or offer a

ride to the doctor, if needed.10


During the first 3 months of weekly visits, the

primary focus is on helping the parents with basic

family support, such as learning how to mix formula

and wash the baby and understanding the baby's

early stages of development and sleep patterns, as

well as on answering the most common question, "Why

does my baby cry so much?"


Family support plan. A great deal of the home

visitor's time is spent listening to parents and

providing emotional support; helping them obtain

food, formula, and baby supplies; assisting them

with housing and job applications; getting them to

appointments; and providing informal counseling on

a wide range of issues, including domestic violence

and drug abuse. As one home visitor put it, "It's

hard to teach the mother about child development

when her eyes are only on her own crises."

Therefore, early in their relationship, the home

visitor and the family develop an Individual Family

Support Plan, which lists the services that Healthy

Start provides, plus assistance available from

other social service agencies. The family checks

the services they want to receive during the next 6

months. The plan spells out "What we want," "Ways

to get it," "Who can help," "Target date," and

"What happened." The parent(s), the home visitor,

and the supervisor complete and sign the plan,

which also records the other service providers

involved with the family.


Assessing development. During the first few weeks,

the home visitor watches for signs that the mother

is bonding to the infant. If she is not, the

visitor models the attachment behavior (e.g.,

showing the mother how to hold and talk to the baby

while making eye contact).


Healthy Start mothers complete a series of

Infant/Child Monitoring Questionnaires, designed to

identify problems in child development at 4, 8, 12,

16, 20, 24, 30, 36, and 48 months. If necessary,

the home visitor reads the questions to the mother.

Separate forms are used for girls and boys. Each

form has five sections, covering communication,

gross motor skills, fine motor skills, adaptive

skills, andpersonal-social skills. Some questions

asked at 4 months are:


o "Does your baby chuckle softly?"

o "While on her back, does your baby move her head

from side to side?"

o "Does your baby generally hold her hands open or

partly open?"

o "When you put a toy in her hand, does your baby

look at it?"

o "When in front of a large mirror, does your baby

smile or coo at herself?"


As part of its oversight, the Maternal Child Health

Branch requires assessments at 4, 12, 20, and 30

months. If these reveal any developmental delays in

the infant, assessments at 8, 16, and 24 months are

performed. Periodic assessments are also used to

determine when the family is stable enough for

biweekly visits. The assessment is then repeated

every 6 months to determine if visits can be safely

reduced to every month, and then to every 3 months.

Each family stays in the program until the child is

5 years old.


Meeting multiple needs. In addition to using the

family support plan and the Infant/Child Monitoring

Questionnaire, the program attempts to meet the

families' multiple needs through the following:

o Parent skill building, individually and in

groups, to provide parents with information about

the needs of their children (primarily the newborn,

but also older children) at each stage of

development and what activities may be used to cope

with these needs.


o Nursing Child Assessment Satellite Training

(NCAST) assessment of feeding, the home, and

teaching, in order to plan interventions.


o Interagency coordination and referrals.


o A toy-lending library.


o Parent support groups to increase self-esteem and

reduce social isolation.

Some Healthy Start agencies in Hawai`i also provide

these services:


o Respite care, to enable parents to participate in

socialization groups, recreational activities, or

parenting classes, or to attend to personal needs.


o A male home visitor who works with the father to

reduce high-risk behavior.


o Parent-child play mornings to increase bonding

and interaction.


o A child development specialist who monitors and

tracks the child's development and coordinates

referrals for developmental testing and services,

as needed.


Focusing on child development. A major clinical

challenge to Hawai`i Healthy Start has been how to

strengthen the focus on child development. Most of

the families served are described as "chaotic";

they are poor, live in substandard housing, are

unemployed, and have emotional and frequently

substance abuse problems. Home visitors are often

caught up in the multiple and recurring crises of

the parents and in helping the family deal with

these immediate problems. This makes it difficult

for the home visitor to turn the parents' attention

to the child's emotional and social needs and to

engage them in active intervention with the child.


Hawai`i Healthy Start has responded to this

challenge in some of its agencies by adding child

development specialists to the team. If the home

visitor cannot fully address a child's

developmental needs, a specialist goes to the home

to teach the parents how to interact more

constructively with their child. The crux of

healthy development, in the view of Hawai`i Healthy

Start, is to encourage parents to see their

children as enjoyable and to play with them



Staff Qualifications, Training, and Supervision


Both home visitors and family assessment workers

are required, at minimum, to have a high school

degree or General Equivalency Degree. Several staff

have completed some college work, while others have

a bachelor's or associate's degree. Recruited

through newspaper advertisements, they are

interviewed first in groups of three or four and

then individually. Each structured interview

includes at least one sample vignette that asks the

applicant to react to a specific situation.

Ideally, applicants have been well-nurtured

themselves, have strong social support systems, and

have effective parenting skills. The presence of

these attributes is established through extensive

interviews about their childhood and the discipline

they experienced.


All home visitors, family assessment workers, and

supervisors attend a 6-week orientation, covering

topics such as team building, child abuse and

neglect, cultural sensitivity, child development,

stress management, early identification of risk

factors, supporting family growth, and promoting

parent-child interaction and child development. Ten

to 14 weeks later, staff receive an additional 2

weeks of training. Home visitors and family

assessment workers receive at least 1 day of

inservice training per quarter, plus informal

training during case management sessions and weekly

team meetings.


Family assessment workers. In addition to the

training described above, family assesssment

workers receive intensive training in interview

techniques, the entire assessment process, and

community referral sources. Every day, the

supervisor reviews all screenings and assessment

interviews for completeness and appropriate

disposition. Because the family assessment workers

work only 6 days a week and maternity stays are

shrinking to 24 hours, some families are missed at

the hospital and instead reached at home by

telephone. A monthly log compares the number of

births with the number of families screened and

documents action taken for those not seen at birth.

Also monthly, each supervisor shadows two family

assessment workers and documents observations as

they conduct an assessment. And, once a month, the

supervisor calls two families who refused an

interview or services to discuss the reasons why.

Finally, once a year, 20 intake files are chosen at

random for quality assurance review by management.


Home visitors. In addition to training received

with other staff, home visitors are taught how to

enter the home, work nonjudgmentally, and empower

families. They also are trained in cultural

competence regarding parenting and ways to promote

mother/child bonding and child development.


Home visitors are sometimes matched ethnically to

the family, but overall compatibility is the most

important criterion in assignment. Some of the

Hawai`i Healthy Start programs use male home

visitors to work with families in which the father

is involved with the child. Supervisors review the

caseloads with each home visitor for 2 hours each

week; the supervisory ratio is one to five or six.

Home visitors' caseloads vary from 15 to 25

families, depending on the families' level of risk

and the home visitor's experience. All home

visitors work 40 hours per week, with a daily

average of three 11/2 hour visits; the remaining

time is spent on case management.


Links to the Criminal Justice System


While Healthy Start does not have formal working

agreements with the criminal justice system in

Hawai`i, it does collaborate with Family Court and

related agencies, particularly in cases of domestic

violence. A home visitor may accompany the mother

or father to Family Court for support. The Court

also may ask the home visitor for a report on the

family to help decide a case's disposition. When

warranted, the home visitor encourages the mother

to develop a safety plan, including having

telephone numbers for and transportation to the

spouse abuse shelter and a bag packed with

necessities for herself and her child(ren). The

home visitor also encourages the batterer to attend

anger management classes staffed and run by other

community agencies. Where corresponding classes are

available for partners, mothers are encouraged also

to attend.


In addition, Healthy Start staff work closely with

Hawai`i's victim assistance program. Healthy Start

staff make presentations to victim advocates on the

program's services and its clients' needs. In turn,

victim advocates train program staff on court

procedures and accept referrals, usually battered

women who need assistance through the court system.

On occasion, judges have referred pregnant women or

new mothers involved in the criminal justice system

to the program, but their participation is on a

voluntary basis. When a mother is incarcerated at

the time of birth, program staff try to work with

her both before and after she is released. If the

father is incarcerated, staff encourage family

visits, if appropriate. Also, if the family has a

probation or parole officer, staff try to

coordinate services.


Hawai`i Healthy Start is linked directly to the

criminal justice system through its aims to prevent

child abuse and neglect. Another significant but

more indirect link lies in Hawai`i Healthy Start's

long-term potential to reduce later criminal

behavior documented as characteristic of many child

abuse and neglect victims. At the very least, a

decreased rate of child mistreatment would

represent a strong and positive step toward

long-term crime prevention.




Internal outcome evaluation of Hawai`i Healthy

Start has been conducted primarily in terms of

confirmed cases of abuse and neglect. Between July

1987 and June 1991, 13,477 families were screened

and/or assessed, 9,870 of which were determined to

be at low risk. Of the 3,607 families at high risk,

1,353 were enrolled in Healthy Start, 901 were

enrolled in less intensive home-visiting programs,

and another 1,353 went unserved, due to limited

program capacity.


Among the 1,353 Healthy Start families, the

confirmed rates for abuse and neglect were 0.7

percent and 1.2 percent, respectively. The combined

abuse/neglect (CAN) rate was 1.9 percent. The CAN

rate for at-risk families not served was 5.0

percent, quite low, compared with results from

studies using control groups denied services.11

However, the percentage may actually be higher

because the at-risk families not served in Hawai`i

were not monitored for abuse and neglect, nor were

their medical records reviewed. The 3.1 percent

difference in CAN rates between Healthy Start and

unserved at-risk families is a conservative

estimate and represents about 42 cases prevented

during the 4-year period. (The CAN rate for the

9,870 low-risk families was 0.3 percent.)12


At $15,000/case/year, the 42 fewer abuse and

neglect cases attributable to Healthy Start between

1987 and 1991 represent a savings of over $1.26

million in child protection services (CPS) costs

alone. (The average CPS case lasts 2 years.)


Although there are many other signs of the

program's success (see "Indicators of Success for

Hawai`i Healthy Start"), formal evaluation results

are pending. Currently, two randomized control

evaluations are being conducted, one by Deborah

Daro and Karen McCurdy of the National Committee to

Prevent Child Abuse (NCPCA), the other by Ann

Duggan and Sharon Buchbinder of the Johns Hopkins

University School of Medicine, Loretta Fuddy of

Hawai`i Maternal and Child Care, and Calvin Sia.


In its second year, the NCPCA study is observing

newborn to 18-month-old children served by the

Hawai`i Family Stress Center at two locations on

O`ahu. The study is looking at multiple outcomes--

potential for child abuse, parenting skills, the

mother's social support, the child's mental

development, and the physical environment in the

home. Results are expected in 1996.


The Johns Hopkins study is just starting. A

prospective study, it will follow children

throughout the State for 5 years. This study will

cover child abuse and neglect, service delivery,

adequacy of medical care, use of community

resources, home environment, child health, child

development, and school readiness. It will also

include a cost/benefit analysis. Some data will be

available in 3 years, but the entire study will not

be completed until 1999.


Current Issues in Home Visitation


Heading into the late 1990's, home visitation

programs like Hawai`i Healthy Start face

significant questions regarding program structure

and service delivery. Although much research

remains to be conducted, several indepth studies

provide evidence of the effectiveness of some home

visiting programs and indicate what factors may

lead to their success.


Breadth of services. Among the many program issues

being discussed and researched are the breadth of

services offered and the qualifications of staff

who deliver the services. Although there appears

to be a general consensus among researchers that

home visitation programs should attempt to address

a wide range of clients' needs, this view is

tempered by the opinion that programs should have

realistic expectations of what they can

accomplish.14 One review of randomized trials of

home visitation programs designed to prevent child

abuse and neglect found that programs with the most

positive effects used comprehensive approaches to

address a number of family needs.15 Moreover, the

successful programs provided both prenatal and

postnatal services. (Recognizing the shortcoming of

delaying outreach until birth, Hawai`i Healthy

Start is currently planning a statewide program to

provide prenatal care to all who need it.) Home

visitation programs that, for instance, concentrate

primarily on teaching mothers how to stimulate

their infants' educational development or on

providing only basic emotional support have shown

little success.16 It has been suggested that home

visitation programs collaborate extensively with

other community resources and service providers to

address families' needs.17


Staff qualifications. Perhaps one of the more

widely discussed questions regarding home

visitation programs is whether professionals

(particularly nurses) or paraprofessionals (usually

individuals from the community with little advanced

education) should be the primary service

deliverers. Researchers and practitioners point to

a number of advantages and disadvantages to using

either professionals or paraprofessionals. It

should be noted, however, that no systematic study

comparing the two types of home visitors has been

completed yet.


In general, professionals' expertise--and the

confidence this inspires among clients and in

themselves--seems to promote effective service

delivery and more easily forestall job stress. One

review indicated that programs with the most

positive effects employed nurses as home visitors.

However, it remains unclear whether the greater

success stemmed from nurses' qualifications and

training, clients' perceptions of nurses'

qualifications, the comprehensiveness of services

that programs with nurses tend to provide, or some

other factor or combination of these.18 The main

disadvantages of nurses and other professionals are

that they are expensive and scarce.


The majority of new home visiting programs,

including Hawai`i Healthy Start, employ primarily

paraprofessionals as service providers.

Disadvantages of using paraprofessionals as home

visitors include their relative lack of expertise

and credibility, increased staff turnover due to

job burnout, and need for extensive training and

supervision. Also, although paraprofessionals may

command smaller salaries than professionals, the

level of training and supervision required may

cancel out any potential financial savings to a

program.19 However, paraprofessionals from within

the community being served may be better able to

recruit families and communicate with them--because

of shared beliefs, language or dialect, and

experiences--than professionals outside that

community. Paraprofessionals also may better serve

as role models for clients.20


For example, Hawai`i Healthy Start staff say that

the program's paraprofessionals establish rapport

with families easily and are not threatening (as,

staff say, professionals can be). Staff recruitment

interviews specifically screen for people who are

warm, caring, and nonjudgmental. Paraprofessionals

are taught to accept the family "as it is" and to

be patient with slow progress. In general, service

deliverers from the community are considered

necessary to obtain participants' trust.




As the criminal justice system increasingly focuses

its attention on crime and violence reduction, the

prevention of child abuse and neglect has become a

critical priority. This approach takes on added

urgency in light of research documenting the cycle

of violence that begins with child mistreatment and

can lead to later delinquency and criminal

behavior. By providing comprehensive home

visitation services to families at risk for child

abuse and neglect, Hawai`i Healthy Start is taking

an important step toward reducing both child abuse

and later crime by many of its victims. As such,

Hawai`i Healthy Start and similar home visitation

programs may warrant the support of the criminal

justice system and society.




1 Cathy Spatz Widom, The Cycle of Violence, National

Institute of Justice Research in Brief, Washington,

DC: U.S. Department of Justice, 1992, 3; Widom,

Victims of Childhood Sexual Abuse--Later Criminal

Consequences, National Institute of Justice

Research in Brief, Washington, DC: U.S. Department

of Justice, 1995, 4.


2 Richard J. Gelles and John W. Harrop, "The Nature

and Consequences of the Psychological Abuse of

Children: Evidence from the Second National Family

Violence Survey." Paper presented at the Eighth

National Conference on Child Abuse and Neglect,

Salt Lake City, Utah, October 24, 1989.


3 Source: John Walters, Hawai`i Department of Human



4 National Committee for Prevention of Child Abuse,

Child Abuse: Prelude to Delinquency? Research

Conference Findings, April 7-10, 1984, Washington,

DC: Office of Juvenile Justice and Delinquency

Prevention, U.S. Department of Justice, September



5 See William DeJong, Building the Peace: The

Resolving Conflict Creatively Program (RCCP),

National Institute of Justice Program Focus,

Washington, DC: U.S. Department of Justice, 1994;

DeJong, Preventing Interpersonal Violence Among

Youth: An Introduction to School, Community, and

Mass Media Strategies, National Institute of

Justice Issues and Practices in Criminal Justice,

Washington, DC: U.S. Department of Justice, 1994.


6 Healthy Start: Hawai`i's System of Family Support

Services, Honolulu: Hawai`i Department of Health,

1992, i.


7 "Healthy Families America Third Year Progress

Report," National Committee to Prevent Child Abuse,

Chicago, IL, March 1995.


8 Craig W. LeCroy and Jos‚ B. Ashford, Arizona

Healthy Families First Year Outcome Evaluation

Report, Tucson, AZ: LeCroy, Ashford & Milligan,

1994, 13-14.


9 The program hired an epidemiologist to determine

this score. Using the results of the Kempe Family

Stress Checklist as the measure of high and low

risk, a score of two or more negative factors

produces interviews of the largest percentage of

high-risk families while avoiding interviews of the

largest percentage of low-risk families (i.e., it

maximizes the sum of specificity and sensitivity).

About 4 to 5 percent of true high-risk families are

missed by this criterion and are later reported to

Child Protective Services. Even with these cases

included, however, the Confirmed Abuse and Neglect

rate of the noninterviewed families is less than

0.5 percent, which indicates that the criterion is

very efficient.


10 Vicki A. Wallach and Larry Lister, "Stages in the

Delivery of Home-Based Services to Parents at Risk

of Child Abuse: A Healthy Start Experience."

Reprinted with permission of the Journal of

Scholarly Inquiry for Nursing Practice, 9, no. 2,

1995 (in press). Published by Springer Publishing.


11 Kempe found five confirmed cases in 25 control

group families in Denver, and Olds found a 19

percent rate of confirmed abuse and neglect among a

control group of poor, unmarried teenagers in

Elmira, New York. See David Olds and Harriet

Kitzman, "Can Home Visitation Improve the Health of

Women and Children at Environmental Risk?"

Pediatrics, 86, no. 1, 1990: 112.


12 Loretta Fuddy, "Outcomes for the Hawai`i Healthy

Start Program, 1992 (revised 1/94)," Honolulu:

Hawai`i Department of Health, 1994. See also Gail

Breakey and Betsy Pratt, "Healthy Growth for

Hawai`i's Healthy Start: Toward a Systematic

Statewide Approach to the Prevention of Child Abuse

and Neglect," Zero to Three, April 1991.


13 Loretta Fuddy, "Outcomes for the Hawai`i Healthy

Start Program, 1992 (revised 1/94)."


14 Deanna S. Gomby, Carol S. Larson, Eugene M.

Lewit, and Richard E. Behrman, "Home Visiting:

Analysis and Recommendations," The Future of

Children, Center for the Future of Children, Los

Altos, CA, 3, no. 3, Winter 1993: 18; Heather B.

Weiss, "Home Visits: Necessary but Not

Sufficient," The Future of Children, Center for

the Future of Children, Los Altos, CA, 3, no. 3,

Winter 1993: 120.


15 David L. Olds and Harriet Kitzman, "Review of

Research on Home Visiting for Pregnant Women and

Parents of Young Children," The Future of Children,

Center for the Future of Children, Los Altos, CA,

3, no. 3, Winter 1993: 88.


16 Olds, "Can Home Visitation Improve the Health of

Women and Children at Environmental Risk?" 113-114;

Weiss, "Home Visits: Necessary but Not Sufficient,"

120, 122.


17 Weiss, "Home Visits: Necessary but Not

Sufficient," 122-123.


18 Olds, "Can Home Visitation Improve the Health of

Women and Children at Environmental Risk?" 115.


19 Douglas R. Powell, "Inside Home Visiting

Programs," The Future of Children, Center for the

Future of Children, Los Altos, CA, 3, no. 3, Winter

1993: 35-36.


20 Barbara Hanna Wasik, "Staffing Issues for Home

Visiting Programs," The Future of Children, Center

for the Future of Children, Los Altos, CA, 3, no.

3, Winter 1993: 144-45.


Federal "Healthy Start" Program to Reduce Infant



In 1991 the U. S. Department of Health and Human

Services began a 5-year program, also called

"Healthy Start," to reduce infant mortality by 50

percent in 15 mainland communities. The Federal

program was designed to strengthen the maternal and

infant care system in these communities through six

recommended activities: perinatal care, family

planning and infant care, psychosocial services,

facilitating services, individual development, and

community development and public education.


The Federal Healthy Start program is trying to

reduce deaths during the first year of life. It

does not provide the child development and stress

management services offered by Hawai`i Healthy

Start or by the Healthy Families America programs.

The Chicago Healthy Start program, however,

recently adopted Hawai`i's model at four sites as

part of its strategy to prevent domestic violence.


Healthy Families America: Home Visitation to

Prevent Child Abuse and Neglect on the Mainland


In January 1992 the National Committee to Prevent

Child Abuse (NCPCA), in partnership with Ronald

McDonald Children's Charities (RMCC) and in

collaboration with the Hawai`i Family Stress

Center, launched the Healthy Families America (HFA)

initiative. Building on two decades of research and

the experiences of Hawai`i Healthy Start in putting

that research into practice, HFA was designed to

help establish home visitation programs, service

networks, and funding opportunities in each State

so that all new parents can receive necessary

education and support. As of spring 1995, HFA

programs had been implemented at 101 pilot sites in

20 States on the mainland.7


NCPCA, in collaboration with the Hawai`i Family

Stress Center, provides training and technical

assistance to HFA home visitation programs, using

Hawai`i Healthy Start as one example of an

effective program. NCPCA also has prepared a number

of other individuals across the country to serve as

trainers for State and local HFA efforts. Although

each HFA site has aimed to meet the needs and build

on the strengths of its community, all have

embraced the 12 HFA criteria for effective programs

as defined by research and the experience of

Hawai`i Healthy Start.


HFA programs have been funded by a mix of private

foundations, Federal funds, block grants, and State

appropriations.Arizona, Indiana, and Oregon have

passed multimillion dollar appropriations for

statewide services.


The HFA goal is to offer all new parents in each

service area at least one or two home visits. Thus

far in practice, however, most programs have

provided services primarily to families with the

greatest needs. The programs serve a range of

populations, from inner-city African Americans in

Atlanta to Central American immigrants in Fairfax,



NCPCA is coordinating efforts to help each program

develop an evaluation component, including a

national network of evaluators to collaborate on

common outcome measures. All sites track child

abuse and neglect cases and monitor child

development and immunization; many sites use

Nursing Child Assessment Satellite Training (NCAST)



The first HFA program to provide outcome data from

an outside evaluation was in Arizona. Out of the

111 families enrolled in 1992, two families had

validated reports of abuse, and one family had a

validated report of neglect following the entrance

of the target child in the project. The combined

abuse and neglect rate (CAN) was 2.7 percent,

compared with 2.1 percent for the Hawai`i families.

However, the Arizona families were at higher risk

than their Hawai`ian counterparts: 50 percent had a

previous history of abuse (versus 38 percent in

Hawai`i), and they had a higher percentage of

severe risk items on the Kempe Family Stress

Checklist. At age 6 months, only four of 57

children screened showed delay in one area of

development; none showed delay in more than one



Healthy Start Screening Instrument

1. Marital Status: Single, Separated, Divorced

2. Partner Unemployed

3. Inadequate Income or Unknown

4. Unstable Housing

5. No Phone

6. Education Under 12 Years

7. Inadequate Emergency Contacts

8. History of Substance Abuse

9. Late or No Prenatal Care

10. History of Abortions

11. History of Psychiatric Care

12. Unsuccessful Abortion

13. Relinquishment for Adoption

14. Marital or Family Problems

15. History of Current Depression


Indicators of Success for the Hawai`i Healthy Start



Between July 1987 and June 1991, 2,254 families

were served by Healthy Start. Indicators of the

program's success over this 3-year period include:


o Ninety percent of 2-year-olds in families

receiving services were fully immunized.


o Eighty-five percent of the children in served

families had developed appropriately for their



o Of the 90 families (4 percent) known to CPS at

or prior to intake with a confirmed combined

abuse/neglect report for siblings or imminent

danger status, no further reports occurred during

these families' program enrollment. Three cases

were reported after the families left the program.


o No instances of domestic homicide have been

recorded since the program's inception.


Findings and conclusions reported here are those of

the author and do not necessarily reflect the

official position or policies of the U.S.Department

of Justice.


The National Institute of Justice is a component of

the Office of Justice Programs, which also includes

the Bureau of Justice Assistance, Bureau of Justice

Statistics, Office of Juvenile Justice and

Delinquency Prevention, and the Office for Victims

of Crime.


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