DOCUMENT RESUME

ED 394 651 PS 024 001

AUTHOR Earle, Ralph B.TITLE Helping To Prevent Child Abuse--and Future Criminal

Consequences: Hawaiti Healthy Start. ProgramFocus.

INSTITUTION Department of Justice, Washington, D.C. NationalInst. of Justice.

REPORT NO NCJ-156216PUB DATE Oct 95

NOTE 13p.

PUB TYPE Reports Descriptive (141)

EDRS PRICE MF01/PC01 Plus Postage.DESCRIPTORS At Risk Persons; *Child Abuse; Child Development

Centers; *Delinquency; Early Childhood Education;*Early Intervention; Home Visits; Parent Education;*Prevention; Screening Tests; Social SupportGroups

IDENTIF:ERS *Hawaii; *Long Term Effects

ABSTRACTThis document describes Hawai'i's Healthy Start

Program, a statewide, multisite home visitation program designed toscreen, identify, and work with at-risk families of newborns. Goalsof the program include: (1) reducing family stress; (2) improving

family functioning; (3) enhancing child health and development; and(4) preventing abuse and neglect. The Hawai'i Health Start modelincludes early intervention, following a child from (or before) birththrough age 5; home visitations; and ongoing evaluation. Familiesenrolled in the program are most often young (parents under 24 yearsold), with one or both parents unemployed (or underemployed) andundereducated. In 1994, about 65 percent of the women participatingin the program were single mothers. The program seeks to meet needsin a variety of ways, including: (1) interagency coordination andreferrals; (2) a toy-lending library; (3) parent support groups; (4)

a male home visitor who works with fathers; and (5) parent-child playsessions. Between July 1987 and June 1991, the program served over2,254 families. Ninety percent of the two-year-olds enrolled in theprogram were immunized. Eight-five percent of the enrolled childrenwere at an appropriate stage of development. Additionally, noinstance of domestic homicide had been reported in this time frame.Contains 20 notes. (JW)

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Reproductions supplied by EDRS are the best that can be madefrom the original document.

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U.S. Department of Justice

Office of Justice Programs

National Institute of Justice

U S DEPARTMENT OF EDUCATION 'CrifOrrice at Educationai Meow* and ImpecNamod

EDUCATIONAL RESOURCES INFORMATIONCENTER (ERIC)

1Crfhci: document has been reproduced asived from the person of organization

originating it.

El Minor changes have been made toimprove reproduction quality.

° Points of view or ...mons stated in thisdocument do not necessarily representofficial OERI position or policy.

National Institute of Justice

Helping To PreventChild Abuse--

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Helping To Prevent Child Abuse--and Future Criminal Consequences:Hawai`i Healthy StartBy Ralph B. Earle, Ph.D.

Traditionally, the prevention of child abuse andneglect has fallen under the purview of health andsocial service agencies. Increasingly, however, vio-lence against children is a critical priority for criminaljustice officials as well. Not only are child abuse andneglect crimes against society's most vulnerable

HighlightsThe violence committed by youths toooften is traced to the abuse and neglectthey suffered in their eirly years. Thelink between child maltreatment andlater criminal behavior by itc ,:ctimshas made the criminal justice, health,and social service systehis partners inprevention. As part of its research ini-tiative on family violence, the NationalInstitute of Justice (NIJ) is investigatinginterdisciplinary approaches involvingchildren, their families, and their com-munities. This Program Focus describesthe Hawail Healthy Start program,which`uses home visitors from the Com-munity:to provide services to at-riskfamilies. Its goals are to reduce familystress and improve family functioning,improve parenting skills, enhance childhealth and development, and preventabuse and neglect.

Of Special Interest:Unlike other similar programs,

Hawail Healthy Start follows the childfrom birth (or before) to age 5 with a

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range of services, and it assists and sup-ports other family members.

To ensure systematic enrollment,Healthy Start signs up most familiesright after delivery of the child, al-though approximately 10 percent offamilies are enrolled prenatally.

Healthy Start has formal agreementswith all hospitals in Hawail to enable itto perform postpartum screeningthrough a review of the mother's medi-cal record or a brief inperson interview.Fewer than 1 percent of mothers refuseto be interviewed, 4 to 8 percent laterrefuse offers of services, and about 7percent cannot be located after releasefrom the hospital.

Paraprofessional home visitors call onfamilies weekly for the first 6 to 12months. Early in the relationship, thehome visitor helps parents develop anIndividual Support Plan, specifying thekinds of services they want and needand the means by which to receive them.

members. [hes also may lead to crimeperpetrated later in life by the victimsthemselves. Reducing the twofold effectof child abuse and neglect on the safetyand well-being of American communitiespresents a formidable challenge for allsegments of society.

As part of its oversight, the MaternalChild Health Branch requires comple-tion of a series of Infant/Child Monitor-ing Questionnaires to identify problemsin child development at 4, 12, 20, and 30

months. If these show developmentaldelays, further assessments are per-formed and appropriate services areoffered.

11111 In 1994 a confirmed child care abuseand neglect case cost the Hawail familywelfare system $25,000 for investiga-tion, related services, and foster care. Incontrast, Hawail Healthy Start officialsestimate an annual average cost of$2,800 per home visitor case.

III Preliminary evaluation findings indi-cate that Healthy Start families havelower abuse/neglect rates and their chil-dren are developing appropriately fortheir ages.

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A growing amount of data appears to sup-port the concept of a "cycle of violence"that begins with child abuse and neglect.One recent national study showed that be-ing the victim of abuse and neglect as achild increases the chances of later juve-nile delinquency and adult criminality by40 percent. Even among children who areneglected but not abused, one in eight willlater be arrested for a violent offense.'Children who experience severe violencein the home are approximately three timesas likely as other children to use drugsand alcohol, get into fights, and deliber-ately damage property. Abused and ne-glected children are four times as likely tosteal and to be arrested.=

Long before some victims of child abuseand neglect inflict pain and loss on others,they are caught up in a child welfare sys-tem that is costly and overburdened. Forexample. from 1994 to 1995 in Hawaii,each confirmed case of child abuse or ne-glect cost nearly S15,000 per year for in-vestigation and services. Foster careadded another $10.000 per year. Homecare for a drug-exposed child costS18.000 per year. and foster care for thatchild. $46.000.3 For both social and fi-nancial reasons, the criminal justice andfamily welfare systems have a strong in-centive to reduce child abuse and neglect.

Although both intuition and existingscientific data indicate a predispositionto crime and violence among manyabused and neglected children, more re-search is needed to determine the exactnature of the link, as well as the rela-tionship of associated factors, such associoeconomic status.' Nonetheless.preliminary findings underscore theneed for the criminal justice system tosupport and work in partnership withchild abuse and neglect prevention

efforts and the communities the, serveas a means of reducing crime in both theshort term and the long run.

The Hawai`i HealthyStart ModelAs part of its research initiative on familyviolence, the National Institute of Justice(NI1) is interested in interdisciplinary ap-proaches involving children, their fami-lies. and their communities. The U.S.Advisory Board on Child Abuse and Ne-glect identified home visiting in 1991 asthe most promising means for preventingthe maltreatment of children. One ex-ample of this approach is Hawaii HealthyStart, a statewide, multisite home visita-tion program designed to screen, identify.and work with at-risk families of new-borns to prevent abuse and promote childdevelopment.

Home visitation programs have becomeincreasingly popular in recent years as ameans to address a number of social prob-lems and individual needs. Programs de-signed primarily for families with

newborns have diverse goals and services.The goals of Hawai'i Healthy Start are to:

Reduce family stress and improvefamily functioning.

Improve parenting skills.

Enhance child health and development.

Prevent abuse and neglect.

Although it shares the same name as 15infant mortality prevention programs onthe mainland. Healthy Start's services arenot limited to the months before and aftera child's birth. Instead, Hawai'i HealthyStart serves the child until age 5. The pro-gram includes early identification of fami-lies at risk for child abuse and neglect,community-based home visiting supportand intervention services, linkage to a"medical home" and other health care ser-vices, and coordination of a wide range ofcommunity services, primarily for the par-ents and their newborn, but also for otherfamily members.6 To avoid confusionwith similarly named and focused pro-grams (see "Federal 'Healthy Start' Pro-gram" and "Healthy Families America").

Federal "Healthy Start" Program To ReduceInfant Mortality

In 1991 the U. S. Department of Health andHuman Services began a 5-year program,also called "Healthy Start," to reduce in-fant mortality by 50 percent in 15 mainlandcommunities. The Federal program wasdesigned to strengthen the maternal andinfant care system in these communitiesthrough six recommended activities:perinatal care, family planning and infantcare, psychosocial services, facilitating ser-vices, individual development, and com-munity development and public education,

The Federal Healthy Start program istrying to reduce deaths during thefirst year of life. It does not providethe child development and stress man-agement services offered by HawaiHealthy Start or by the Healthy Fami-lies America programs. The ChicagoHealthy Start program, however, re-cently adopted Hawail's model at

four sites as part of its strategy toprevent domestic violence.

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Healthy Families America:Home Visitation To Prevent Child Abuse andNeglect on the Mainland

In January 1992 the National Committeeto Prevent Child Abuse (NCPCA), inpartnership with Ronald McDonaldChildren's Charities (RMCC) and in col-laboration with the Hawai'i Family Stress'Center, launched the Healthy FamiliesAmerica (IVA) initiative. Building ontwo decades of research and the experi-ences of Hawai'i Healthy Start in puttingthat research into practice, HFA was de-signed to help establish horno visitationprograms, service networks,and funding

:opportunities in each State s011iat all newparents can receive nacessa4+*.ducationand support. As of axing l95, HFAprograms had been irnpleniented at 101pilot sites in 20 States on the mainland.'

NCPCA, in collaboration with theHawail Family Stress Center, providestraining and technical assistance to HFAhome visitation programs, tisink Hawai `iHealthy Start as one example Of an effec-tive program. NCPCA also *prepareda number of other individuals across thecountry to serve as trainers forState andlo:11 HFA efforts. Although each HFAsite has aimed to meet the 4ieeds andbuild on the strengths.of its Ceinmunity,-all have embraced the 12 HFA criteriafor effective programa as defined by re-search and the experience 'Of'Hawai `iHealthy Start.

HFA programs have been funded by amix of private foundations, Federal funds,block grants, and State appropriations.Arizona, Indiana, and Oregon have passedmultimillion dollar appropriations forstatewide services.

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The HFA goal is to offer all new parentsin each service area at least one or twohome visits. Thus far in practice, how-ever, most programs have provided ser-vices primarily to families with the great-est needs. The programs serve a range ofpopulations, from inner-city AfricanAmericans in Atlanta to Central Ameri-can immigrants in Fairfax, Virginia.

NCPCA is coordinating efforts to helpeach .program develop an evaluationcomponent,- including a national net-work of eQuaters". to collaborate oncommon outcorne measures. All sitestrack child abuse and neglect cases andmonitor child development and immu-nization; many sites use Nursing ChildAssessment Satellite Training (NCAST)assessments.

The first HFA program to provide out-come data from an outside evaluationwas in Arizona. Out of the 111 familiesenrolled in 1992, two families had vali-dated reports of abuse, and one familyhad a validated report of neglect fo Jow-ing the entrance of thelarget child hi theproject. The combined abuse and ne-glect rate (CAN) Wai 2.7 percent, com-pared with 2.1 percent for the Hawaifamilies. However, the Arizona familieswere at higher risk than their Hawai 'Iancounterparts: 50 percent had a previoushistory of abuse (versus 38 percent inHawail), and they had a higher percent-age of severe risk items on the KempeFamily Stress Checklist. At age 6months, only four of 57 children screenedshowed delay in one area of develop-ment; none ' ,wed delay in more thanone area.'

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the program featured in this ProgramI Focus is referred to throughout as

Hawaii Healthy Start.

Program HistoryThe des elopment of Hawaii HealthyStart was strongly influenced by the lateDr Henry Kempe, a researcher at theUniversity of Colorado Health SciencesCenter and Director of the National Cen-ter for Prevention and Treatment of ChildAbuse and Neglect in Denver. Kempeoperated residential treatment and presen-lion proerams and developed a checklistto identify families at risk of abusing orneglecting their children.

In the early 1970's Kempe screened 500families in the Denver area and identified100 as being at risk for child abuse andneglect. He randomly assigned these WOfamilies to two groups. One group re-ceived home visiting services: the otherreceived only the usual medical services.In each eroup of 50. he followed 25 fami-lies for 3 years..Among the families pro-vided services, there were no hospitahra-lions for abuse, although three familiesgave a child up for adoption. Among the25 nonserviced families, however, nyechildren were hospitalized variously forhead injuries. scaldings, and fractures

In 1973 Dr. Calvin Sia, a prominent pe-diatrician in Hawai'i. and members ofHawai'i's Child Protective Service (CPS)Advisory Committee invited Kempe tohelp them put together a plan for the pre-vention and treatment of child abuse andneglect among families in Hawaii. Oneyear later, Gail Breakev. current Directorof the Hawai'i Family Stress Center. andSia obtained a 3-year grant from theNational Center for Prevention and Treat-ment of Child Abuse and Neglect toimplement the home visiting program de-

veloped by Kempe and the CPS AdvisoryCommittee. They began a smag preven-tion program on 0`ahu, which yielded re-sults similar to Kempe's work. Threehome visitors provided emotional supportand taught child development to 70 fami-lies for 12 to 18 months. Breakey's andSia's developmental work continued witha community service grant from 1978 to1981 to extend services to five additionalsites on neighboring islands.

Healthy Start was an outgrowth of theseearly programs. It was designed at the re-quest of the Hawai'i Senate Ways andMeans Chairman, Mamoru Yamasaki,who was concerned with the State's in-creasing costs of corrections and socialservices. Originally intending to fund adelinquency prevention project in a highschool, Yamasaki recognized the relation-ship between early abuse and delinquencyand decided instead to begin with infantsof families at risk for child abuse and neglect.

Healthy Start began in Hawaii in July1985 as a State-funded demonstrationchild abuse and neglect prevention pro-gram at a single site on 0`ahu, the mostpopulous island, with an annual budget of$200,000. The original prevention pro-gram concept was expanded to includebroader implementation and more com-prehensive objectives. Hawaii HealthyStart was designed to serve all families ofnewborns at risk within the catchmentarea, follow the children to age 5, link allinfants to a medical home that wouldserve them through childhood, and inten-sify the focus on parent-child attachmentand interaction, child health, and childdevelopment.

After 3 years, Healthy Start had served241 high-risk families, 176 of which wereserved for at least 1 year. No cases ofchild abuse and only four cases of child

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neglect were reported among the 241families. Based on these results, between1988 and 1990 the program %VW expandedthrough general funds appropriated by theState legislature to 13 sites across theState, with an annual budget of over $8million for fiscal year 1995.

Administration, Budget,and ManagementThe Maternal Child Health Branch of theHawaii Department of Health adminis-ters the State appropriations, monitors theprogram, and evaluates the seven not-for-profit private agencies that deliverHealthy Start services. The programs con-ducted by the seven agencies vary interms of budget and caseload. The small-est has an annual budget of $290,000 andserves 150 families; the largest spendsover $1 million to serve 350 to 400 fami-lies each year. In 1990 actual screening,assessment, and case management ser-vices cost $2,500 per case. Where avail-able, respite care services cost $476 perchild per year.

To establish a new program, HawaiiHealthy Start officials recommend ayearly budget of $349,000 to handle 140cases per year, allocating about $283,000to personnel costs, $34,000 to operatingexpenses, and $32,000 to overhead. Thisbudget does not include funds for evalua-tion, but it would fund a program managerat $35,000, a supervisor at $30,000, onefamily assessment worker and six familysupport workers (who serve as the homevisitors) from $19,000 to $21,000, and asecretary at $21,000. At this level, the su-pervisor would direct five home visitorsand/or family assessment workers. Theprogram manager would supervise up tothree additional home visitors. HawaiiHealthy Start maintains about a 1:5 ratio

of supervisors to staff and recommendsthat other programs try to do the sameregardless of the level of staff trainingto ensure adequate supervision critical toprogram success and avoid overburdeningsupervisors.

ClienteleIn 1994 Healthy Start made initial contactwith 65 percent of the more than 16,000newborns of civilian families in the State.From these 10,485 contacts, 2,800 fami-lies (27 percent) enrolled in home visita-tion services. Enrolled families tend to beyoung (parents under 24 years old); ofHawaiian (32 percent), Caucasian (23percent), Filipino (18 percent), or Japa-nese (10 percent) ancestry; and low-in-come (50 percent receive welfare), withthe father unemployed and the motherundereducated. Thirty-eight percent of thefamilies have a history of substanceabuse; 43 percent have a history of do-mestic violence; and 22 percent are home-less or living in temporary, overcrowdedconditions with other families. About 65percent of enrolled women are single.

Service FlowEnrollment. Hawaii Healthy Start enlistsmost families immediately after deliveryof the child, as this is the best way of en-suring systematic enrollment. About 10percent of families are enrolled prenatallythrough contacts with clinics, obstetri-cians, and public health nurses. Privatephysicians are encouraged to refer preg-nant women who may need services to theprogram. For those who enter the programbefore a child's birth, Hawaii HealthyStart has developed a curriculum forhome visitors to use with women andthose of their husbands or partners whoare involved with the family. Home visi-

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tors help them understand the physiologi-cal and emotional effects of pregnancyand prepare them for taking care of thebaby. Hawai'i Healthy Start also stressesregular prenatal care and assists enrolledwomen in identifying and using a primarycare physician for both preventive careand later infant treatment.

Screening at birth. Throughout Hawai'i,postpartum screening begins in the hospi-tal with either a review of the mother'smedical records or a brief inperson inter-view. The program has formal agree-ments with each hospital. Using theHealthy Start screening questionnaire, thefamily assessment worker checks 15items as true, false, or unknown. ("SeeHealthy Start Screening Instrument.")

Three situations prompt an assessmentinterview:

The mother is single, separated. or di-vorced: had poor prenatal care: orsought an abortion.

Responses for two or more items are"true."'

Responses for seven or mote items are"unknown.-

This first screening determines who re-quires an indepth assessment interview.One family assessment worker can [xi--form 550 screenings and 225 assessmentsper year.

Assessment. if the screening suggests theneed for assessment, the family assess-ment worker visits the mother and intro-duces her to the Healthy Start program. Ifthe father is present, he is also inter-viewed. All interviews are voluntary. Ac-cording to the family assessment worketsupervisor at Kapiolani Medical Centerfor Women and Children (where alunit

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Healthy Start Screening InstrumentI. 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

half of all children on O'ahu are born).mothers of newborns arc usually quitewilling to talk about any concerns havingto do with their home situations. Lessthan 1 percent refuse to be interviewed.

During a casual conversation, which takesfrom 45 minutes to an hour, the family as-sessment worker covers the ten topics onthe Kempe Family Stress Checklist. Im-mediately after leaving the room, the fam-ily assessment worker scores the ten itemsas normal (0). mild (5), or severe (10)This screening assessment identifies thefactors that place the family at high riskfor abuse and neglect. Families scoringabove 25 are invited and encouraged tobecome enrolled in services. Dependingon the community served, about 85 to 95percent accept. 4 to 8 percent refuse, andabout 7 percent cannot be found after theyleave the hospital. usually because theymove and cannot be contacted. (Somefamilies who score in the 10-20 pointrange are assessed as "clinically positive"if the family assessment worker sensesthat the mother or father is not forthcom-ing. These families are offered services.)If a family scores above 40 and does notaccept services, the supervisor will con-sider referring the family to the Child Pro-tective Services.

The first home visit. Paraprofessionalhome visitors call on families weekly (ormore frequently. if needed) for the first 0to 12 months. The first IV: hour visit is

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

spent describing the program and the toleof the home visitor. The home visitor usu-ally starts the conversation with some-thing like the following:

I work with the Healthy Start pro-gram. I have new information aboutbabies that I didn't know about whenI was raising my kids. It can makebeing a mother easier, but not easy!Also, you can look at me as your in-formation center about this commu-nity. I live here, too, and I didn'tknow about WIC [Special Supple-mental Food Program for Women. In-fants, and Children] or the well babclinic before I started this joh.

hope you will learn to think of meas your "special" friend, someonehere completely for you and the bah).I am here to talk when you need toshare something that concerns you. Iknov, that it is hard to start with anew baby and to have so much onyour mind.

If the motheror. if present, the fatheris reluctant, the hotne visitor will ask if itis all right to come back the follow ingweek or offer a ride to the doctor, ifneeded.'

During the first 3 months of weekly visits.the primary focus is on helping the par-ents %kith basic family support. such aslearning how to mix formula and wash thebaby and understanding the baby's early

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stages of development and sleep patterns,as well as on answering the most commonquestion, "Why does my baby cry somuch?"

Family support plan. A great deal of thehome visitor's time is spent listening toparents and providing emotional support;helping them obtain food, formula, andbaby supplies; assisting them with hous-ing and job applications; getting them toappointments; and providing informalcounseling on a wide range of issues, in-cluding domestic violence and drugabuse. As one home visitor put it, "It'shard to teach the mother about child de-velopment when her eyes are only on herown crises." Therefore, early in their rela-tionship, the home visitor and the familydevelop an Individual Family SupportPlan, which lists the services that HealthyStart provides, plus assistance availablefrom other social service agencies. Thefamily checks the services they want toreceive during the next 6 months. Theplan spells out "What we want," "Ways toget it," "Who can help," "Target date,"and "What happened." The parent(s), thehome visitor, and the supervisor completeand sign the plan, which also records theother service providers involved with thefamily.

Assessing development. During the firstfew weeks, the home visitor watches forsigns that the mother is bonding to the in-fant. If she is not, the visitor models theattachment behavior (e.g., showing themother how to hold and talk to the babywhile making eye contact).

Healthy Start mothers complete a series ofInfant/Child Monitoring Questionnaires,designed to identify problems in childdevelopment at 4, 8, 12, 16, 20, 24, 30,36, and 48 months. If necessary, the homevisitor reads the questions to the mother.

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Bonding and attachment in infancy are crucial for the child to trust others as an adult.

Separate forms are used for girls andboys. Each form has five sections, cover-ing communication, gross motor skills,fine motor skills, adaptive skills, andpersonal-social skills. Some questionsasked at 4 months are:

"Does your baby chuckle softly?"

"While on her back, does your babymove her head from side to side?"

"Does your baby generally hold herhands open or partly open?"

"When you put a toy in her hand, doesyour baby look at it?"

"When in front of a large mirror, doesyour baby smile or coo at herself?"

As part of its oversight, the MaternalChild Health Branch requires assessmentsat 4, 12, 20, and 30 months. If these re-veal any developmental delays in the in-fant, assessments at 8, 16, and 24 monthsare performed. Periodic assessments arealso used to determine when the family isstable enough for biweekly visits. The as-sessment is then repeated every 6 monthsto determine if visits can be safely re-duced to every month, and then to every 3months. Each family stays in the programuntil the child is 5 years old.

Meeting multiple needs. In addition tousing the family support plan and the In-fant/Child Monitoring Questionnaire, theprogram attempts to meet the families'multiple needs through the following:

Parent skill building, individually and ingroups, to provide parents with informa-tion about the needs of their children (pri-marily the newborn, but also olderchildren) at each stage of developmentand what activities may be used to copewith these needs.

Nursing Child Assessment SateiliteTraining (NCAST) assessment of feeding,the home, and teaching, in order to planinterventions.

Interagency coordination and referrals.

A toy-lending library.

Parent support groups to increase self-esteem and reduce social isolation.

Some Healthy Start agencies in Hawaiialso provide these services:

Respite care, to enable parents to partici-pate in socialization groups, recreationalactivities, or parenting classes, or to at-tend to personal needs.

A male home visitor who works with thefather to reduce high-risk behavior.

Parent-child play mornings to increasebonding and interaction.

A child development specialist whomonitors and tracks the child's develop-ment and coordinates referrals for devel-opmental testing and services, as needed.

Focusing on child development. A majorclinical challenge to Hawaii Healthy

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Start has been how to strengthen the focuson child development. Most of the fami-lies served are described as "chaotic";they are poor, live in substandard hous-ing, are unemployed, and have emotionaland frequently substance abuse problems.Home visitors are often caught up in themultiple and recurring crises of the par-ents and in helping the family deal withthese immediate problems. This makes itdifficult for the home visitor to turn theparents' attention to the child's emotionaland social needs and to engage them inactive intervention with the child.

Hawail Healthy Start has responded tothis challenge in some of its agencies byadding child development specialists tothe team. If the home visitor cannot fullyaddress a child's developmental needs, aspecialist goes to the home to teach theparents how to interact more construc-tively with their child. The crux ofhealthy development, in the view ofHawail Healthy Start, is to encourageparents to see their children as enjoyableand to play with them spontaneously.

Staff Qualifications,Training, andSupervisionBoth home visitors and family assessmentworkers are required, at minimum, tohave a high school degree or GeneralEquivalency Degree. Several staff havecompleted some college work, while oth-ers have a bachelor's or associate's de-gree. Recruited through newspaperadvertisements, they are interviewed firstin groups of three or four and then indi-vidually. Each structured interview in-cludes at least one sample vignette thatasks the applicant to react to a specificsituation. Ideally, applicants have beenwell-nurtured themselves, have strong so-

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A key component of Hawai'i's Healthy Start Program

cial support systems, and have effectiveparenting skills. The presence of these at-tributes is established through extensiveinterviews about their childhood and thediscipline they experienced.

All home visitors, family assessmentworkers, and supervisors attend a 6-weekorientation, covering topics such as teambuilding, child abuse and neglect, culturalsensitivity, child development, stressmanagement, early identification of riskfactors, supporting family growth, andpromoting parent-child interaction andchild development. Ten to 14 weeks later,staff receive an additional 2 weeks oftraining. Home visitors and family assess-ment workers receive at least 1 day ofinservice training per quarter, plus infor-mal training during case management ses-sions and weekly team meetings.

Family assessment workers. In additionto the training described above, familyassesssment workers receive intensive

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Photo by Dannette Lyman

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is to monitor infants' development.

training in interview techniques, the entireassessment process, and community refer-ral sources. Every day, the supervisor re-views all screenings and assessmentinterviews for completeness and appropri-ate disposition. Because the family as-sessment workers work only 6 days aweek and maternity stays are shrinking to24 hours, some families are missed at thehospital and instead reached at home bytelephone. A monthly log compares thenumber of births with the number of fami-lies screened and documents action takenfor those not seen at birth. Also monthly,each supervisor shadows two family as-sessment workers and documents obser-vations as they conduct an assessment.And, once a month, the supervisor callstwo families who refused an interview orservices to discuss the reasons why. Fi-nally, once a year, 20 intake files are cho-sen at random for quality assurancereview by management.

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Home visitors. In addition to training re-ceived with other staff, home visitors aretaught how to enter the home, worknonjudgmentally, and empower families.They also are trained in cultural compe-tence regarding parenting and ways topromote mother/child bonding and childdevelopment.

Home visitors are sometimes matchedethnically to the family, but overall com-patibility is the most important criterionin assignment. Some of the Hawai'iHealthy Start programs use male homevisitors to work with families in which thefather is involved with the child. Supervi-sors review the caseloads with each homevisitor for 2 hours each week; the supervi-sory ratio is one to five or six. Home visi-tors' caseloads vary from 15 io 25families, depending on the families' levelof risk and the home visitor's experience.All home visitors work 40 hours perweek, with a daily average of three P/zhour visits; the remaining time is spent oncase management.

Links to the CriminalJustice SystemWhile Healthy Start does not have formalworking agreements with the criminal jus-tice system in Hawaii, it does collaboratewith Family Court and related agencies,particularly in cases of domestic violence.A home visitor may accompany themother or father to Family Court for sup-port. The Court also may ask the homevisitor for a report on the family to helpdecide a case's disposition. When war-ranted, the home visitor encourages themother to develop a safety plan, includinghaving telephone numbers for and trans-portation to the spouse abuse shelter and abag packed with necessities for herselfand her child(ren). The home visitor also

encourages the batterer to attend angermanagement classes staffed and run byother community agencies. Where corre-sponding classes are available for part-ners, mothers are encouraged also tC,attend.

In addition, Healthy Start staff workclosely with Hawaii's victim assistanceprogram. Healthy Start staff make pre-sentations to victim advocates on theprogram's services and its clients' needs.In turn, victim advocates train programstaff on court procedures and accept refer-rals, usually battered women who needassistance through the court system. Onoccasion, judges have referred pregnantwomen or new mothers involved in thecriminal justice system to the program,but their participation is on a voluntarybasis. When a mother is incarcerated atthe time of birth, program staff try towork with her both before and after she isreleased. If the father is incarcerated, staffencourage family visits, if appropriate.Also, if the family has a probation or pa-role officer, staff try to coordinate services.

Hawaii Healthy Start is linked directly tothe criminal justice system through itsaims to prevent child abuse and neglect.Another significant but more indirect linklies in Hawai Healthy Start's long-termpotential to reduce later criminal behaviordocumented as characteristic of many childabuse and neglect victims. At the very least,a decreased rate of child mistreatmentwould represent a strong and positive steptoward long-term crime prevention.

EvaluationInternal outcome evaluation of HawaiiHealthy Start has been conducted prima-rily in terms of confirmed cases of abuseand neglect. Between July 1987 and June1991, 13,477 families were screened and/

or assessed, 9,870 of which were deter-mined to be at low risk. Of the 3,607families at high risk, 1,353 were enrolledin Healthy Start, 901 were enrolled in lessintensive home-visiting programs, and an-other 1,353 went unserved, due to limitedprogram capacity.

Among the 1,353 Healthy Start families,the confirmed rates for abuse and neglectwere 0.7 percent and 1.2 percent, respec-tively. The combined abuse/neglect(CAN) rate was 1.9 percent. The CANrate for at-risk families not served was 5.0percent, quite low, compared with resultsfrom studies using control groups deniedservices." However, the percentage mayactually be higher because the at-riskfamilies not served in Hawai`i were notmonitored for abuse and neglect, nor weretheir medical records reviewed. The 3.1percent difference in CAN rates betweenHealthy Start and unserved at-risk fami-lies is a conservative estimate and repre-sents about 42 cases prevented during the4-year period. (The CAN rate for the9,870 low-risk families was 0.3 percent.)'2

At $15,000/case/year, the 42 fewer abuseand neglect cases attributable to HealthyStart between 1987 and 1991 represent asavings of over $1.26 million in child pro-tection services (CPS) costs alone. (Theaverage CPS case lasts 2 years.)

Although there are many other signs ofthe program's success (see "Indicators ofSuccess for Hawail Healthy Start"), for-mal evaluation results are pending. Cur-rently, two randomized controlevaluations are being conducted, one byDeborah Daro and Karen McCurdy of theNational Committee to Prevent ChildAbuse (NCPCA), the other by AnnDuggan and Sharon Buchbinder of theJohns Hopkins University School ofMedicine, Loretta Fuddy of Hawail Ma-

Program Focus 9

:ROGRAM FOCUS

ternal and Child Care. and Calvin Sia.

In its second year, the NCPCA study isobserving newborn to I 8-month-old chil-dren served by the Hawaii Family StressCenter at two locations on O'ahu. Thestudy is looking at multiple outcomespotential for child abuse, parenting skills.the mother's social support, the child'smental development, and the physical en-vironment in the home. Results are ex-pected in 1996.

The Johns Hopkins study is just starting.A prospective study, it will follow chil-dren throughout the State for 5 years. Thisstudy will cover child abuse and neglect.service delivery, adequacy of medicalcare, use of community resources, homeenvironment, child health, child develop-ment, and school readiness. It will also in-clude a cost/benefit analysis. Some datawill be available in 3 years, but the entirestudy will not be completed until 1999.

Current Issuesin Home VisitationHeading into the late 1990's. home visita-tion programs like Hawaii Healthy Startface significant questions regarding pro-gram structure and service delivery. Al-though much research remains to heconducted. several indepth studies pro-vide evidence of the effectiveness of somehome visiting programs and indicate whatfactors may lead to their success.

Breadth of services. Among the manyprogram issues being discussed and re-searched are the breadth of services of-fered and the qualifications of staff whodeliver the services. Although there ap-pears to he a general consensus among re-searchers that home visitation programsshould attempt to address a wide range of

icnts' needs, this view is tempered bN

10 National Institute ofjustiee

Indicatorsof Success for theHaiirai i HealthyStart ProgramBetween July 1987 and June 1991,2,254 faMilies were served by HealthyStart. Indicators of the program's suc-cess over this 3-year period include:

Ninetk percent of 2-yearzOlds infamilies receiving senices were fullyimmunized.

Eighti-five percent of the childrenin served families had developed ap-prOpriately for their ages.'3

IllOthe90 families (4percent) ITownto CgSwat or prior,to intake:with aconfirmed combined abuse/neglect re-port for siblings or imminent dangerstatuS, no further reports occurred dur-ingthegefamilies' programearollment.Three Cases were reported after thefamilies{left the program.

NOUStances of domestic' homicide. ,

have bean recorded since the program' sinception.

the opinion that programs should have re-alistic expectations of what they can ac-

complish." One review of randomizedtrials of home visitation programs de-

signed to prevent child abuse and neglect

found that programs with the most posi-tive effects used comprehensive ap-proaches to address a number of familyneeds." Moreover, the successful pro-grams provided both prenatal and postna-

tal services. (Recognizing theshortcoming of delaying outreach untilbirth, Hawari Healthy Start is currentlyplanning a statewide program to provideprenatal care to all who need it.) !tomevisitation programs that, for instance, con-

ii

centrate primarily on teaching mothershow to stimulate their infants' educationaldevelopment or on providing only basicemotional support have shown little sue-cess.' It has been suggested that homevisitation programs collaborate exten-sively w ith other community resourcesand service providers to address families'needs.r

Staff qualifications. Perhaps one of themore widely acussed questions regard-ing home visitation programs is whetherprofessionals (particularly nurses) orparaprofessionals (usually individualsfrom the community with little advancededucation) should be the primary servicedeliverers. Researchers and practitionerspoint to a number of advantages and dis-advantages to using either professionalsor paraprofessionals. It should be noted.however, that no systematic study com-paring the two types of home visitors hasbeen completed yet.

In general. professionals' expertiseandthe confidence this inspires among clientsand in themselvesseems to promote ef-fective service delivery and more easilyforestall job stress. One review indicatedthat programs with the most positive ef-fects employed nurses as home visitors.However, it remains unclear whether thegreater success stemmed from nurses'

, qualifications and training, clients' per-ceptions of nurses' qualifications, thecomprehensiveness of sers ices that pro-grams with nurses tend to provide, orsome other factor or combination ofthese.'' The main disadvantages of nurses

and other professionlls are that they areexpensive and scarce.

The majority of new home visiting pro-grams. including Hawai'i Healthy Start.employ primarily paraprofessionals asservice providers. Disadvantages of using

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paraprofessionals as home visitors includetheir relative lack of expertise and cred-ibility, increased staff turnover due to jobburnout, and need for extensive trainingand supervision. Also, although parapro-fessionals may command smaller salariesthan professionals, the level of trainingand supervision required may cancel outany potential financial savings to a pro-gram.'9 However, paraprofessionals fromwithin the community being served maybe better able to recruit families and com-municate with thembecause of sharedbeliefs, language or dialect, and experi-encesthan professionals outside thatcommunity. Paraprofessionals also maybetter serve as role models for clients.20

For example, Hawail Healthy Start staffsay that the program's paraprofessionalsestablish rapport with families easily andare not threatening (as, staff say, profes-sionals can be). Staff recruitment inter-views specifically screen for people whoare warm, caring, and nonjudgmental.Paraprofessionals are taught to accept thefamily "as it is" and to be patient withslow progress. In general, service deliver-ers from the community are considerednecessary to obtain participants' trust.

SummaryAs the criminal justice system increas-ingly focuses its attention on crime andviolence reduction, the prevention ofchild abuse and neglect has become acritical priority. This approach takes onadded urgency in light of research docu-menting the cycle of violence that beginswith child mistreatment and can lead tolater delinquency and criminal behavior.By providing comprehensive home visita-tion services to families at risk for childabuse and neglect, Hawaii Healthy Startis taking an important step toward reduc-

M

ing both child abuse and later crime bymany of its victims. As such, HawailHealthy Start and similar home visitationprograms may warrant the support of thecriminal justice system and society.

NotesCathy 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 SexualAbuseLater 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, "TheNature and Consequences of the PsychologicalAbuse of Children: Evidence from the SecordNational Family Violence Survey." Paperpresented at the Eighth National Conferenceon Child Abuse and Neglect, Salt Lake City,Utah, October 24, 1989.

' Source: John Walters, Hawai'i Department ofHuman Services.

'National Committee for Prevention of ChildAbuse, Child Abuse: Prelude to Delinquency?Research Conference Findings, April 7-10,1984, Washington, DC: Office of JuvenileJustice and Delinquency Prevention, U.S.Department of Justice, September 1986.

5 See William DeJong, Building the Peace:The Resoli ing Conflict Creatively Program(RCCP), National Institute of Justice ProgramFocus, Washington, DC: U.S. Department ofJustice, 1994; DeJong, Preventing Interper-sonal Violence Among Youth: An Introductionto School, Community, and Mass MediaStrategies, National Institute of Justice Issuesand Practices in Criminal Justice, Washington,DC: U.S. Department of Justice, 1994.

6 Healthy Sturt: Hawail's System of FamilySupport Services, Honolulu: Hawai'i Depart-ment of Health, 1992, i.

12

' "Healthy Families America Third YearProgress Report," National Committee toPrevent Child Abuse, Chicago, IL, March1995.

g Craig W. LeCroy and José B. Ashford,Arizona Healthy Families First Year OutcomeEvaluation Report, Tucson, AZ: LeCroy,Ashford & Milligan, 1994, 13-14.

9 The program hired an epidemiologist todetermine this score. Using the results of theKempe Family Stress Checklist as themeasure of high and low risk, a score of twoor more negative factors produces interviewsof the largest percentage of high-risk familieswhile avoiding interviews of the largestpercentage of low-risk families (i.e., itmaximizes the sum of specificity andsensitivity). About 4 to 5 percent of true high-risk families are missed by this criterion andare later reported to Child Protective Services.Even with these cases included, however, theConfirmed Abuse and Neglect ratc of thenoninterviewed families is less than 0.5percent, which indicates that the criterion isvery efficient.

'° Vicki A. Wallach and Larry Lister, "Stagesin the Delivery of Home-Based Services toParents at Risk of Child Abuse: A HealthyStart Experience.' Reprinted with permissionof the Journal of Scholarly Inquiry forNursing Practice, 9, no. 2, 1995 (in press).Published by Springer Publishing.

" Kempe found five confirmed cases in 25controi group families in Denver, and Oldsfound a 19 percent rate of confirmed abuseand neglect among a control group of poor,unmarried teenagers in Elmira, New York.See David Olds and Harriet Kitzman, "CanHome Visitation Improve the Health ofWomcn and Children at Environmental Risk?"Pediatrics, 86, no. 1, 1990: 112.

°Loretta Fuddy, "Outcomes for the Hawai'iHealthy Start Program, 1992 (revised 1/94),"Honolulu: Hawail Department of Health,1994. See also Gail Breakey and Betsy Pratt,"Healthy Growth for Hawai`i's Healthy Start:Toward a Systematic Statewide Approach tothe Prevention of Child Abuse and Neglect,"Zero to Three, April 1991.

Program Focus 11

' 1 myna I udd% t )utconws tot the HaoIlea MN Sfart hograin 1992 (revised 1/941

Hcanna S tionth. Carol S. Larson, EugeneM Leo it, and Richard E Behrman, "HomeVisiting Analsis and Recommendations,/4. I /owe Clolilt cm Cones for the Foini eid Children. I Os Altos, CA. 3, no. 3. Winter

IN. I leather li Weiss, "Home VisitsNVA'sai \ Not Sulticrent,' The Future of

hildten, Center tot the flnlife of Children.Altos C 1. no 1. Winter 1993: 120

id I Old,. MO I bri let Kit/man,Re% lev. of Research on Home Vicifing for

Pregnant Women and Paients of Young'hildren,' The t wive of Clufdren. Center for

the 1-unne of Children: Los Altos, CA. 3.Hit \\ inter 1991 XS

( fids. -C,111 I low Visitation Imprme thelealth ot W omen and Children at Environ-

mental Risk r' 113-114, Weiss, "Home Visits:\ es:11 hut Not Sufficient," 120, 122.

Weiss, "Home Visits. Necessary but NotSalk:rent.- 122- 123

I lids. "Can {{time Visitation Improse theot 51 omen and Children at Environ-

mental Risk 115

Douglas R "Inshle [Ionic VisitingHie Future of Children, Center for

Me I uture ol Children, Los Altos, CA 3,no 3. Winter 1991 1S-36

Barbara Ilanna Wasik, "Staffing Issues for!tome Visiting Programs." T/u Future alChildren. Center foi the Future of Children.1.o. Alio.. CA, 3, no. 3, Wrnter 1993: 144-4S

Abou.'111-0s!Study"iii-.4.Ralph: 1;ii11` An;i,n, ern-

dent eVii,iiiatO4fiyins:000.kai,tii.,The

auOlteJjew41 thauugnassessni4nfinshiniktita;:*nd.40elop-mentalTinateriais Healthy

tor of :thel-lawarl Eriste a4et with ir

.supertort and .s JnjiEselman, aresearCnalyit atin Maikiahuseffs,

Fortnitlier,informOlon,,On141,01ailysWong ;1',.iOgram Wail forelthy ,Startoit:(808) 946-4711.,

COVER: The relaxed pose of thcseHeakhy Start participants demonstratesthat the program's goalsto reducefaintly stress and improve family func-t nmingare achievable and effect ive(Photo by Dannette Lyman)

I inklings and conclusions replied here are tho.e01 the author and do not neee!.saril) reflect theift.icial position or policies of the LI S.

Ds:pal-mem of Justice.

(The National institute of Justice It a compo-nent of the Office of Justice Programs. whichalso includes the Bureau o Justice ,-Ltsi.s-ronce, Bureau of Justice Sunistics. Office alJmenile Justice and Delinquency Pro-ention.imd the Office for Victims of Crime.

NCJ 156216 October 1995

1 .S. Department of Justicenti, e Justice Program.

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