The kindness of strangers: family-based early intervention and improved outcomes for children.

• Author: Robilliard, Tina E.

Abstract

This paper presents the findings of a study examining the relationship between family-based early intervention services provided through home visitation and improved outcomes for children, in order to determine the effectiveness of these programmes. This pre-test/post-test design study examined a sample of families (n = 297) across three California-based early intervention home visitation programmes. The findings of the study provides lessons for New Zealand on how early intervention programmes for families can be successful at protecting children from negative outcomes such as abuse and neglect. Programme effectiveness was studied by analysing individual family data to determine the relationship between programme involvement (duration and intensity) and changes in outcome indicators for children pre-intervention and post-intervention. Of the six child outcome indicators examined across three programmes, early intervention services had a significant positive relationship with only one outcome--healthy child birth weight. The key finding of this study was that greater programme involvement, measured by longer and more intense home visitation early interventions, did not result in improved child outcomes. The lessons for New Zealand from this California-based study are that effectively intervening early in a family to enhance a child's wellbeing is complex and seems to require interventions that are part of an integrated model providing quality services that are based on some flexibility in the intensity and duration of services provided.

INTRODUCTION

Society has a solemn responsibility to protect its young. When children are failed by their families then the onus clearly rests with the state and wider society to ensure that children do not suffer or die from violence, abuse or neglect (McClay 2000:25). A significant number of New Zealand children die as a result of deliberate acts of violence against them by family members. A 2001 report by the United Nations Children's Fund, which compared the rate of child death from injuries among OECD countries, ranked New Zealand as having the fifth highest rate of child death out of the 26 countries studied, with 13.7 child deaths per 100,000 children aged 1-14 years old during 1991-1995 (based on unintentional or intentional injuries, since intention and definitions of neglect are not always clear). Comparably, this was just behind the United States, which ranked fourth among OECD countries at 14.1 per 100,000 children (UNICEF 2001). When we consider that only a relatively small percentage of child abuse and neglect cases end in death and how difficult it has been to correctly identify even these most severe cases, it is sobering to contemplate how many less obvious cases of abuse go unheeded and unchecked.

The trend among all OECD countries in recent decades has been a steep decline in child death rates from injury, with New Zealand's rate of 13.7 children per 100,000 during 1991-1995 down from a rate of 23.7 during 1971-1975. However, New Zealand's child abuse and neglect rate since 1995 has changed very little and the fact remains that New Zealand children continue to die as a result of abuse, often at the hands of family members (Doolan 2004).

The child abuse and neglect figures for New Zealand are also disproportionate across ethnicities. In the year to June 2003, 7,361 children aged 0-16 were assessed by Child, Youth and Family as abused or neglected following a notification, which equates to an overall rate of 7.4 children for every 1,000 under 17 years of age. However, when broken down by ethnicity, the rate per 1,000 was 11.9 children for Maori and 5.9 for non-Maori. (2) Maori families also have much higher rates of the family vulnerability factors discussed in this study, including low socio-economic status, teenage childbearing, low educational attainment and health problems in children (Ministry of Social Development 2004).

It is important that further research continues to be carried out to identify the most effective ways to intervene in families to break the cycle of abuse and neglect. The study presented in this paper focused on the effectiveness of family-based early interventions in achieving positive child outcomes by using empirical evidence from three case studies of family-based early intervention programmes using home visitation. Family-based early intervention is defined as any social service intervention in the life of a child from pre-birth to school-aged, consisting of family-centred services (including care, support or education services) that target parents and children. Home visitation is one form of early intervention where a public nurse, home visitor or behavioural specialist enters the home of a family on a regular basis and works with the family to help improve their situation. In these programmes, home visitors provide support and information to mothers in areas such as child health and development, mother-child attachment and parental strategies. By "intervention" we do not mean involvement by child protective services, although this may happen at times.

It is hoped that this paper sheds some light on the impact of early intervention approaches on the functioning of the family and adds to our knowledge on effective approaches in a way that will strengthen the use of early intervention, and improve the wellbeing of all children.

FAMILY-BASED EARLY INTERVENTION IN NEW ZEALAND

The family plays a crucial role in shaping the wellbeing and development of a child. In recent years there has been a growing interest in New Zealand in family-based early intervention and prevention programmes to address the needs of vulnerable children aged zero to five years. This has been fuelled in part by recent tragic child deaths and the increased awareness by practitioners of the strong relationship between the family situation and child outcomes.

In New Zealand, current early interventions in families with vulnerable children have had varying levels of effectiveness, or their effectiveness is unknown because programme evaluations have not been carried out. It has been recognised that there is a need to continue developing a continuum of effective interventions that provide the right support at the right time to families. Policy around early intervention has identified that initiatives, both at the national level and local level, need to build on the research and evidence of effective interventions and has identified four key areas that need to be addressed together:

* improving effectiveness of services for families raising children

* achieving service co-ordination by promoting local co-ordination, governance and funding

* improving the identification, referral and assessment of families with children with additional needs

* ensuring that families and children have access to support services and remain engaged when these services are used (Ministry of Social Development 2005).

The key lesson learnt from work in New Zealand is that to improve outcomes for young children we need to consider all of these issues of quality, coordination, identification, access and engagement in services together. This is to ensure that all families who need additional support are identified, are able to access services, and are provided with the support services they need while raising their young children.

Research in the area of early intervention has focused on identifying risk factors that contribute to negative outcomes for children, as well as arriving at a consensus on the positive results of early intervention programmes such as home visitation. However, many questions remain about which forms of early intervention are the most effective in achieving these improved outcomes and what focus these interventions in the family unit should take. Since there is little empirical evidence available in New Zealand on the effectiveness of early interventions in the family, this study largely draws on the literature and findings of research carried out in the United States, where more longitudinal data are available. This study also focuses specifically on three case studies of established family-based early intervention home visitation programmes in Sacramento County, California, to provide empirical evidence from the United States on the effectiveness of these interventions. The high-level findings of this study are likely to have relevance to New Zealand and will contribute to our knowledge base about how best to intervene early in the family to improve outcomes for New Zealand children.

THE CASE FOR FAMILY-BASED EARLY INTERVENTION

There is a significant body of research on the different early intervention approaches used by social support services to help improve outcomes for children, particularly in the areas of home visitation and family-based interventions. The family has been identified in the literature as the primary setting for the development of the child and the primary entity through which the community influences this development. Numerous studies in developmental psychology have identified family-level protective factors to be closely linked to improved outcomes for vulnerable children (Cunningham and Zayas 2002, Ethier et al. 2000). There is also increasing evidence to show that a child's experiences in the early years from pre-birth to six years critically shape outcomes across health, education and welfare throughout that individual's life span. This evidence creates a case to provide social service investment in families with children from pre-birth to school age (Duncan and Brooks-Gunn 1997, Karoly et al. 1998, Brooks-Gunn et al. 2003, MacLeod and Nelson 2000).

Recent emphasis in the research on effective early interventions has focused on family-centred programmes that target parents and children, their interactions with each other, as well as their interactions with other social variables. A great deal of this research centres on...