Program Profile: Nurturing Families Network (NFN) Home-Visiting Program

This is a home-visiting program for first-time mothers in high-risk families that promotes positive parenting to prevent child maltreatment and out-of-home placements. The program is rated Ineffective. Treatment group families had a statistically significant lower number of substantiated child maltreatment and neglect cases, compared with the comparison group, but there was no statistically significant effect on out-of-home placements, and substantiated physical abuse.

An Ineffective rating implies that implementing the program is unlikely to result in the intended outcome(s).

Program Goals/Target Population

The Nurturing Families Network (NFN) home-visiting program is a voluntary, statewide program in Connecticut, which provides families with a continuum of services to address parents’ vulnerabilities throughout their children’s early development. The program screens first-time mothers in obstetricians’ offices, community partner sites, and birthing hospitals to identify socially high-risk families for participation. The goal is to prevent child maltreatment, including abuse and neglect, and out-of-home placements by Child Protective Services (CPS).

Program Components/Key Personnel

NFN home visits are 1-hour sessions conducted weekly by family support providers in participating families’ homes. Family support providers have at least a high school degree and are responsible for demonstrating, modeling, and teaching parents life development skills, including self-advocacy, problem solving, and negotiation. During home visits, NFN staff members deliver the Parents as Teachers curriculum (Winter and McDonald 1999).

The Parents as Teachers approach to home visitation focuses on the following three main areas:

1. Parent-Child Interaction: Enhancing child development and supporting the development of positive parenting behaviors
2. Development-Centered Parenting: Understanding parents’ perspectives and facilitating parenting decisions around developmental topics
3. Family Well-Being: Recognizing the impact of the family system on child development and partnering with parents to strengthen protective factors

Prior to the first home visit, NFN staff administer the Kempe Family Stress Inventory (a psychosocial assessment of both parents, if possible) to provide a more detailed profile of participating families. The goal of the first home visit is for family service providers to start to establish rapport with the family and gain a better understanding of their needs through baseline/enrollment form documentation and assessment, including HIPAA consent.

During subsequent visits, family support providers discuss healthy relationship choices, parenting education, and child and family safety. Together, NFN staff and families develop and update (as needed) life action plans that include progress information and identify areas for family growth and support. Family service providers also refer parents to community resources, including Parents as Teachers Family Group Connections, if additional support is needed. They also report to the Department of Children and Families when substantial risk factors, or abusive or neglectful behaviors, are present. Home visits may continue until the child reaches 5 years of age.

Program Theory

The NFN home-visiting program is epoch-based, which means that the home visits address the unique needs of both the parent and child during each new stage of child development, including prenatal, birth to 3 months, 3 to 6 months, 6 to 9 months, 9 to 14 months, 14 to 24 months, 24 to 36 months, 3 to 4 years, and 4 to 5 years (Chaiyachati et al. 2018).

Study

Chaiyachati and colleagues (2018) used a quasi-experimental design with propensity score matching to assess the effect of the Nurturing Families Network (NFN) home-visiting program on child maltreatment, including neglect or physical abuse and out-of-home placements. The program was implemented in individual family homes across the State of Connecticut.

Socially high-risk families who had a child born between January 1, 2008, and December 31, 2011, were eligible for this study. During this period, NFN intake coordinators sought to screen every first-time mother in the state either prenatally or in the early postnatal period at obstetricians’ offices, community partner sites, and birthing hospitals to identify these families. The Revised Early Identification (REID) screening instrument, adapted from the Early Identification Instrument (Duggan et al. 2000) was used to identify socially high-risk births by assessing 17 factors associated with an increased risk of child maltreatment, including teen motherhood, single motherhood, social isolation, and housing instability. Families who had any 3 of the 17 risk factors, or who had any history of substance abuse, psychiatric care, depression, or marital/family problems, were considered to be high risk and therefore eligible for home visiting. NFN administrative records were then reviewed, and eligible families that participated in NFN were considered for participation in the study treatment group. The comparison group included families who either declined participation or were unable to enroll in NFN services. Eligible families were excluded from the treatment group if there was missing information regarding the mother’s or the child’s date of birth.

Of the eligible families, 4,560 were included in the final, matched sample analysis: 2,280 were in the home-visiting treatment group, and 2,280 were in the comparison group. Demographics and reported risk factors were used to match treatment and comparison groups using propensity-score matching. After matching, no statistically significant differences were found between families in the home-visiting treatment group and families in the comparison group on any measured risk factor. The average age of mothers was nearly the same in both groups: 22.3 years old in the home-visiting treatment group, 22.2 years in the comparison group. Nearly 90 percent of the treatment group families had mothers who were single, separated, or divorced, compared with 88.8 percent of the families in the comparison group. In the treatment group, 41.7 percent of mothers had less than or equal to 12 years of education, compared with 42.4 percent of mothers in the comparison group. Mothers in both the treatment and comparison groups had histories of psychiatric care (22.4 percent versus 21.2 percent, respectively); depression (37.1 percent versus 35.9 percent, respectively); and substance abuse (14.7 percent versus 14.9 percent, respectively). The study authors did not include race as a variable in their analysis, as this information was only available for families with a Child Protective Services (CPS) report.

CPS data were collected for the study sample from January 1, 2008, to December 31, 2013. Matches were identified between CPS records and NFN records by both the mothers’ and children’s birthdates. CPS records included the child’s age at the time of the CPS investigation, whether the report was substantiated, the type of suspected and substantiated maltreatment, and whether the child was placed in out-of-home custody. The length of follow up was considered the time between a child’s birth and the end of the CPS monitoring window (December 31, 2013).

Primary outcomes of interest included 1) investigated reports of maltreatment (categorized as physical, medical, emotional, educational, or moral neglect; and physical abuse); 2) substantiations of maltreatment; 3) out-of-home placements; 4) the time to each of these events; 5) types of maltreatment for first substantiation; 6) duration of out-of-home placement; and 7) percentage of out-of-home placements with reunification. The CrimeSolutions review of this study focused on the investigated reports of maltreatment; the substations of maltreatment, neglect, and physical abuse; and out-of-home placements. The other outcomes (time to substantiated maltreatment, time to out-of-home placement, duration of out-of-home placement, and family reunification following out-of-home placement) are considered subgroup analyses because these outcomes were not examined for the entire study sample. The time to substantiated maltreatment outcome was only examined for youth in the home-visiting treatment group and comparison group who had substantiated reports of maltreatment, and time to out-of-home placement, duration of out-of-home placement, and family reunification following out-of-home placement outcomes were examined only for treatment and control group youth with out-of-home placements.

To analyze the outcomes, bivariate associations between NFN participation and CPS outcomes in the matched sample were assessed using chi-squared tests. To account for the timing at which substantiations and out-of-home placements occurred, Cox proportional hazards regression was used to generate hazard ratios; the time to first substantiation and out-of-home placement were assessed using Kaplan-Meier survival analysis.

Nurturing Families Network (NFN) staff must thoroughly document participant enrollment and engagement in home visiting. Required documentation includes 1) the Revised Early Identification (REID) tool for the mother and father; 2) the Kempe Family Stress Checklist; 3) Role of Father Questionnaire; 4) Edinburgh Postnatal Depression Scale; 5) Parents as Teachers (PAT) Health Record; 6) PAT Goal Setting Tool; 7) Ages & Stages Developmental Questionnaire (ASQ-3) and Social and Emotional (ASQ-SE2); 8) Life Skills Progressions; 9) the Hurt, Insult, Threaten and Scream–HITS intimate partner violence screening tool; 10) Parent Satisfaction Survey; 11) PVR Documentation/ECIS home visit documentation (data systems); and 12) an exit form (Nurturing Families Network Policy Manual, Summer 2018). NFN home visits can be conducted in English or Spanish (Chaiyachati et al. 2018).

All NFN staff are required to complete a number of trainings in their first 2 years of employment depending on their roles in the implementation. More specific information can be found in the Policy Manual.

Subgroup Analysis

Chaiyachati and colleagues (2018) conducted subgroup analyses on time to substantiated maltreatment, time to out-of-home placement, duration of out-of-home placement, and family reunification following out-of-home placement. These outcomes were only examined on the portion of the study sample that had Child Protective Services (CPS) substantiations of maltreatment and out-of-home placement; they were not examined for the entire sample.

There was no statistically significant difference in time to first out-of-home placement between the home-visiting treatment group and the comparison group. The first CPS substantiation of maltreatment occurred later in the child’s life for the home-visiting treatment group, compared with the comparison group. The difference was statistically significant. There was no statistically significant difference in length of out-of-home placement (once initiated) between the home- visiting treatment group and the comparison group. Finally, there was no statistically significant difference in the percentage of families who were reunited following out-of-home placement between the home-visiting treatment group and the comparison group.

These sources were used in the development of the program profile:

These sources were used in the development of the program profile:

Black, Timothy, Mary Patrice Erdmans, and Kristina Dickinson. 2004. Life Stories of Vulnerable Families in Connecticut: An Assessment of the Nurturing Families Network Home Visitation Program. Hartford, Conn.: The Children’s Trust Fund, Department of Social Services.

Black, Timothy, Meredith C. Damboise, Madelyn Figueroa, Dawn Fuller-Ball, and Kevin Lamkins. 2007. Nurturing Families Network 2007 Annual Outcome Evaluation Report. Hartford, Conn.: The Children’s Trust Fund, Department of Social Services.

Damboise, Meredith C., Marcia Hughes, and Tim Black. 2009. Nurturing Families Network: 2009 Annual Evaluation Report. Hartford, Conn.: The Children’s Trust Fund, Department of Social Services.

Duggan, Anne, Amy Windham, Elizabeth McFarlane, Loretta Fuddy, Charles Rohde, Sharon Buchbinder, and Calvin Sia. 2000. “Hawaii’s Healthy Start Program of Home Visiting for At-Risk Families: Evaluation of Family Identification, Family Engagement, and Service Delivery.” Pediatrics 105(1 Pt. 3):250–59.

Hughes, Marcia, Meredith C. Damboise, Mary P. Erdmans, Kevin Lamkins, and Tim Black. 2008. Nurturing Families Network: 2008 Annual Evaluation Report. Hartford, Conn.: The Children’s Trust Fund, Department of Social Services.

Hughes, Marcia, Karen Steinberg Gallucci, Kathy Novak, and Barbara Chaiyachati. 2015. Report on the NFN Depression Improvement Study: A Clinical Trial Testing In-Home CBT. Hartford, Conn.: Office of Early Childhood, Family Support Services.

Joslyn, Allison, and Marcia Hughes. 2012. Nurturing Families Network: 2012 Annual Evaluation Report. Hartford, Conn.: Children’s Trust Fund, Department of Social Services.

Joslyn, Allison R., Marcia Hughes, and Anne Pidano. 2016. Nurturing Families Network: 2014 Annual Report. Hartford, Conn.: Connecticut Office of Early Childhood, Family Support Services Division.

Joslyn, Allison R., Marcia Hughes, and C. Wesley Younts. 2016. Nurturing Families Network: 2016 Annual Report. Hartford, Conn.: Connecticut Office of Early Childhood, Family Support Services Division.

Winter, M., and D. McDonald. 1999. “Parents as Teachers.” The Future of Children 9(1):179–89.

Younts, Wesley C., Allison R. Joslyn, and Marcia Hughes. 2017. Nurturing Families Network: 2017 Annual Report. Hartford, Conn.: Connecticut Office of Early Childhood, Family Support Services Division.

Following are CrimeSolutions-rated programs that are related to this practice:

Preventive Child Maltreatment Programs

Preventive child maltreatment programs are designed to prevent physical child abuse or neglect by educating expectant and new parents in parenting skills, coping with stressors, and stimulating child development. This practice is rated Effective for preventing child abuse, neglect, and maltreatment.

Evidence Ratings for Outcomes

Victimization - Child abuse/neglect/maltreatment

Early Family/Parent Training Programs

This practice includes programs that seek to provide families and parents with training and skills to help promote their children’s physical, mental, and social skills. The practice is rated Effective for reducing child problem behaviors for children whose families participated in early family/parent training programs, compared with control group children whose families did not participate in programming.

Evidence Ratings for Outcomes

Juvenile Problem & At-Risk Behaviors - Multiple juvenile problem/at-risk behaviors

Why might a practice's outcome ratings differ from the ratings of specific programs encompassed by that practice?