An Upstream Approach: Using Data-Driven Home Visiting to Prevent Child Abuse

While largely administrative, the development sets the nation’s largest child welfare system ­­up for a much broader discussion about how public health strategies can help break the intergenerational cycles of abuse that result in preventable child maltreatment.

In particular, data identifying heightened maltreatment risk for children born to young mothers who have experienced abuse themselves provides an opportunity to better target the county’s home visiting programs. While the county appears to be getting it right with pregnant foster youth, two premier home visiting programs do not triage their severely limited service capacity based on families at the highest statistical risk for abuse.

Targeting Risk

If Los Angeles County were to do something new on this front, it would be following the lead of the federal Commission to Eliminate Child Abuse and Neglect Fatalities. That body issued a report in March calling for the expanded use of home-visiting programs to prevent child maltreatment.

The commissioners, appointed and by members of Congress and the White House, recommended that the federal government “permit Medicaid reimbursement for evidence-based infant home visiting services provided to youth in foster care who are parents (Medicaid-eligible by definition) to promote expansion of home visiting services to this high risk population.”

In addition, the commission called for deployment of home visiting programs to all children under the age of 5, and to those with prior reports of child maltreatment.

The commissioners were largely influenced by groundbreaking research coming out of the University of Southern California School of Social Work’s Children’s Data Network.

In 2013, the data network released a set of studies that pointed to the heightened likelihood of child abuse for babies born to teen mothers who had experienced abuse when they were children themselves.

To accomplish this, a research team led by USC’s Emily Putnam-Hornstein engaged in some complex data-linking. The team looked at all the birth records of babies born to first-time mothers ages 15 to 19 in Los Angeles County in 2006 and 2007.

Excluding the 532 young mothers who were already in or were placed in foster care after conception, the data network determined that 24,767 babies were born to first-time teen mothers.

More than a quarter of those young mothers had either been reported or substantiated victims of child abuse between age 10 and the age when they gave birth.

Then the researchers followed the lives of the babies born to those moms. The results were startling.

Nearly 40 percent of children born to young mothers who had been substantiated victims of child abuse would be referred to L.A.’s child welfare system for possible abuse. One in five would be substantiated victims.

Babies born to young mothers who had been substantiated victims of abuse were 2.5 times more likely to be reported for maltreatment than their peers.

The findings offered an opportunity to “risk-stratify adolescent parent populations for targeted maltreatment prevention services,” Putnam-Hornstein wrote in the 2013 report.

An Administrative Move in Context

The motion that L.A.’s supervisors will mull today would direct a handful of county agencies to report back after spending 30 days studying the “feasibility, benefits and detriments, if any, and fiscal viability” of moving more than 100 public health nurses currently employed by the Department of Children and Family Services (DCFS) to the Department of Public Health (DPH).

This matters because the motion comes in response to a report that had a much broader set of recommendations, including a re-envisioning of the role of public health in child protection.

The original recommendation was made by the county’s Office of Child Protection (OCP), which was created to orient all child-serving agencies toward better preventing and responding to child maltreatment.

Another one of OCP’s recommendations was to terminate an experimental program that paired public health nurses with social workers on investigations of child abuse for babies and toddlers under age 2.

The idea there was to use the nurses to target the children at most risk for subsequent child maltreatment and death: those under age 2. But, as the OCP report and reporting in The Chronicle of Social Change suggest, the program’s implementation seems to have impeded its ability to live up to expectations.

In a letter accompanying the report, OCP Director Michael Nash wrote that the county should engage in further discussions “as to how PHNs [public health nurses] can be more efficiently and effectively used within existing resources.”

Narrowing Home Visiting’s Focus

When it comes to preventing child abuse, there are very few programs that have been proven effective through rigorous research. Among the most promising are home-visiting programs.

So, as the county supervisors consider Nash’s recommendation to rethink the role of public health nurses, they should also consider the use of those involved in the county’s highly impacted home-visiting programs.

Home visiting encompasses a range of strategies designed to provide health-related services to high-risk pregnant mothers and families with very young children. They are voluntary, meaning that participants have to opt in to receive services.

In 2010, as part of the Affordable Care Act, the federal government enacted the Maternal, Infant, and Early Childhood Home Visiting program, known as MIECHV. Since FY 2010, MIECHV has provided over $2 billion to fund state-run implementation of 16 evidence-based home visiting programs. The program’s goals are broad, ranging from improved newborn health to reducing crime and domestic violence.

Karen Howard, vice president of early childhood policy at the D.C.-based advocacy organization First Focus Campaign for Children, said that while the program was a substantial boost to the federal government’s investment in home visiting, it only serves about 2 percent of the families who meet income eligibility criteria.

Howard’s answer to the gaping shortfall is to dramatically increase funding to the program, not to more narrowly focus it on a particular outcome like child maltreatment prevention.

“You don’t want to turn MIECHV into a child welfare program because it is larger than that,” Howard said. “But, states and communities have broad leverage to address what they want.”

In Los Angeles, a small portion of that money partially funds two county-based programs: the Nurse Family Partnership (NFP) run out of the Department of Public Health and Los Angeles Unified School District; and Healthy Families America, offered through a network of private providers.

NFP has been shown to improve outcomes for children through early and long-term engagement with families. Nurses start visiting at-risk mothers in the first trimester and meet with them as frequently as every week, with visits tapering off as needed until age 2.

Through a series of random control trials, the program has been consistently shown to reduce child abuse rates and even maltreatment-related fatalities.

Of the two programs, NFP is more targeted, but a source within L.A.’s program said that who they serve comes down to referrals. Their client base is not derived from a formalized effort to proactively target the pregnant mothers whose children are at the highest risk of being abused.

Unlike NFP, Healthy Families America uses a mix of nurses, social workers and early childhood experts to provide home-visiting services to at-risk families either before or after birth.

Kathleen Strader is the Healthy Families America’s (HFA) national director of implementation and accreditation. Strader said that there is no real rubric to decide which families receive services.

Instead, the 100 or so home visitors in the county field referrals. They then go out and conduct an assessment with the family, called the Parent Survey.

Through a structured interview, the Parent Survey helps the home visitor decide whether the family’s needs are great enough to warrant the intervention.

Strader was intrigued by the idea of using the data uncovered by the Children’s Data Network to better streamline HFA’s work, but had some reservations.

“How could that data better inform and help in a stronger next edition of a tool like the Parent Survey?” Strader said. “Where I get concerned is in labeling around particular metrics.”

In many cases clients will refuse services if they are offered in a way that is stigmatizing, Strader said.

“We need to be sensitive to the way we approach families,” she said. “We want to take the path of trust-building, because we see it work. It is only through relationships that parents experience positive outcomes.”

Going Further Upstream

Despite this lack of targeting by the federally recognized home-visiting programs in the county, it seems that the county’s Department of Children and Family Services (DCFS) has had success in referring pregnant and parenting foster youth to home-visiting programs.

In an email statement, Donna Fernandez, a manager with DCFS’ Child Welfare Health Services Section, said that her unit was focused on ensuring the department’s pregnant foster youth are at least offered home-visiting services.

In a separate statement, DCFS said that there were 400 parenting foster youth, and that another 60 were currently pregnant. Fernandez said that 62 percent of pregnant youth had been linked to a home-visiting program over the past six quarterly assessments. In the latest assessment the number went up to 73 percent, she said.

“It is impossible to link all pregnant youth because the home-visitation programs are voluntary and not all youth agree to participate,” she said in the email. “Furthermore, some youth have more challenging circumstances, such as the babies being detained after birth, the mothers being runaways who cannot be linked until they agree to return to placement, or youth who reside outside of L.A. county.”

DCFS’ apparent attentiveness to the home-visiting needs of the most vulnerable young parents is a promising first step. Working in concentric rings of risk, starting with pregnant foster youth, and then moving to those mothers who had experienced abuse themselves, the county could focus its highly limited home-visiting service slots.

To accomplish this will require overcoming real concerns about the stigma attached to those mothers who are offered services – even if voluntary.

The question remains: will county leaders use the current debate about the role of public health in child maltreatment prevention to go further upstream?