Protective Services

Published in the Fall 2007 issue of SSA Magazine

We know that helping moms and dads be better parents helps prevent maltreatment of very young children. But what works best?

by Carl Vogel

Kisha Lemmons spends a lot of time riding the CTA. Lemmons doesn't drive, but a big part of her job at the University of Chicago Doula Project is to make a weekly home visit to each of her dozen or so clients, all first-time teenage mothers.

So she crisscrosses through some of Chicago's most distressed neighborhoods via train and bus to sit on family couches and at kitchen tables, providing support, answering questions, and giving reminders to young girls just starting parenthood. Lemmons isn't an archetypal doula, and not just because her clients are low-income moms, rather than middle-class expectant mothers who have hired a doula to help during labor and delivery. In that more typical arrangement, the mother/doula relationship ends more or less once the baby is born. The paraprofessionals in the University of Chicago Doula Project, however, keep visiting the mom for weeks after the birth. And their job isn't just to ease labor—it's to help support a healthy family and prevent child maltreatment.

By giving mothers someone to talk with about the new baby in the house, Lemmons and her colleagues offer parents what has proven to be a powerful mix of emotional support and practical advice. "They ask questions like, 'Can you spoil a baby?' and 'How long should a baby cry?'" Lemmons says. "I work with the youngest moms in the program, so a lot don't understand what it will take to be a mother yet."
"It's a strengths-based program, working with parents who are at high-risk, promoting good parenting behavior," says SSA Professor Sydney Hans, who launched the University of Chicago Doula Project in 2000. "A really important part of the underlying philosophy is to work with the family before anything bad happens, the earlier the better."

The most lurid tales of child abuse—parents who have systematically starved their own children or burned them with cigarettes—sicken us when they make the headlines. But these horrific cases are only a small part of the issue. Many more children are abused in smaller but still hurtful ways, and more still are neglected: not adequately fed or left with someone who cannot care for their needs. Abuse can strike once or repeatedly, while neglect tends to be a chronic condition. Both can be terribly damaging to a young child.Nearly 900,000 children were determined to be victims of abuse or neglect by a caretaker from referrals to child protective service agencies nationwide in 2005, according to the U.S. Department of Health and Human Services (HHS). More than 60 percent of those cases were neglect, and another 17 percent were victims of physical abuse (the remainder were cases of sexual abuse or emotional maltreatment). And nearly eight times out of 10, the perpetrator of this kind of child maltreatment was a parent.

Designed to support mothers, home-visitation programs, particularly for parents of new infants, have proven to be an effective way to lower rates of child maltreatment. "Few people intentionally injure a child, but many can and do lose control when they are unable to stop a baby from crying or find themselves simply overwhelmed. We want to create a sense in the parent that you have to take hold of yourself before you take hold of a child," says Deborah Daro, a Chapin Hall Research Fellow and the former director of the National Center on Child Abuse Prevention Research.

"Most cases of neglect in this country are parents who are struggling and just can't handle the challenges of parenting. They're not responding adequately to their child's needs," says Neil Guterman, a professor at SSA who is in the process of running several research studies on the issue of child maltreatment. "There's growing empirical research that in many cases we can prevent child maltreatment before it ever starts, avoid unnecessary trauma to the child, and avoid all the costs that accrue, socially and economically, when the child protective services system becomes involved."

Concentration and focus of child maltreatment prevention these days concerns babies and toddlers. In large part, that's because it's the age when many children are abused or neglected: HHS has found age 0-3 to have the highest rate of victimization, at 16.5 per 1,000 children.
Babies can't report that they're living in unhealthy conditions or have been hit, and very young children are also more likely to suffer serious injuries due to abuse—a vigorous shaking that can cause a fatal case of Shaken Baby Syndrome would leave a 10-year-old scared and crying but unhurt. Guterman points out that about 80 percent of fatalities related to child maltreatment occur in children age 3 or younger.

What we've learned in the last decade or so about the importance of the first years of a child's life—the impetus to fund Head Start and similar programs— has also lead to more efforts to protect babies. For example, research has shown that, starting prenatally, exposure to abuse and neglect can affect brain development in children. "We know a lot more about how the brain develops until age 3. You can literally see the difference in brains of children who have been hurt or exposed to violence," says Ben Tanzer, the director of strategic communications at Prevent Child Abuse America, which works with chapters and Healthy Family America home visiting sites focused on the prevention of child abuse and neglect in 41 states, Washington, D.C., and Canada.

Parents themselves are the other part of the equation. Raising a baby can be stressful, and stress is a major precursor for abuse. "No expectant mom imagines that her baby will be fussy, or that the baby will be resilient to her soothing," says Larry Gray, a development and behavioral pediatrician at the University of Chicago Comer Children's Hospital. In fact, the need for help for parents to cope with a screaming baby can be so acute that Gray and colleagues have launched the Fussy Baby Network based at the Erikson Institute. "Parents can start seeing a child in a negative way, and that can get locked in," says Linda Gilkerson, the founder of the Fussy Baby Network and a second- year master's student at SSA. The network offers an 800 number for parents at the end of their rope and home visitations for parents who need extra help. "Parents who shake a baby aren't trying to kill the baby," she says. "They're trying to stop the crying."

Many new parents are also misinformed about how babies act and their developmental stages, and bad expectations can lead to more stress. If a mom or dad doesn't know that a baby will cry more a few weeks after birth—when an infant's sleep patterns change—they can get frustrated. Parents who expect a toddler to potty train before the child is a year old will be stymied again and again, and perhaps take out their anger on the child.

On the other hand, programs like the home visitation option at the Fussy Baby Network show success because of the positive side of working with parents of very young children: They can be more receptive to advice about parenting. "During pregnancy or right after the birth, parents are especially open to new ideas. It's a real window of opportunity," Hans says.

Home visitation for new parents has a long history, dating back to the earliest years of social work and child protection more than a century ago. In the last few decades, variations on the practice have been studied closely and research has shown they help some parents avoid hurting their children. The best-known research on home visitation was launched in Elmira, N.Y., in 1977. David Olds, now a professor of pediatrics, psychiatry, and preventive medicine at the University of Colorado, began to operate and study a program that sent highly trained nurses to visit at-risk young mothers at home repeatedly, before birth and two years after their first child was born.

The results were impressive. In the group of low-income, unmarried teen mothers who did not receive nurse visits, the incidence of child neglect or abuse was 19 percent. For those who did receive visits, the incidence was 4 percent. In a 15-year follow- up study, the moms who had been served by the nursefamily model had 79 percent fewer verified reports of child abuse or neglect—and the results paid dividends in other ways as well. There were 56 percent fewer arrests of the adolescent children whose moms had worked with the nurses, for instance, and 44 percent fewer maternal behavioral problems due to alcohol and drug abuse.

Over the years, similar home visitation programs have been launched throughout the country and internationally, and many of these have shown similar success in a wide variety of socioeconomic, geographic, and racial settings. A 2003 report by the Centers for Disease Control, which reviewed 21 studies of early childhood home visitation on child maltreatment, found a median reduction of cases of child abuse or neglect of approximately 40 percent. Based on this "strong evidence of effectiveness," the report recommended home visitation for families at risk for maltreatment, including disadvantaged populations and families with low-birth weight infants. "We believe we have something that works with home visitation," Daro says. "Now the struggle is how to take it to scale." 

In the late 1990s, Sydney Hans learned about several community service organizations in Chicago that were providing a variation on home visitation that utilized a doula rather than a nurse. With the support of the Irving Harris Foundation, she established a doula home visiting program based at the University of Chicago. A federal Maternal and Child Health grant allowed her to initiate a five-year study of how well the program helps young families.

The focus of the University of Chicago Doula Project, like the nurse-family model, is on young, at-risk mothers, but Hans says that outreach conducted by a doula creates a different program in several ways she thinks may be very important. For starters, since the doulas are paraprofessionals, the cost is lower than using nurses—a notable distinction when considering how to build a program that, if proven to be effective, can be more widely replicated. The type of care provided by a doula is also distinct. "In the Olds method, it's more about health and parenting education. The doula project works more from a family support model, offering support and information as a way of empowering," Hans says. "The doulas become surrogate family members, like an older sister."

Each of the doulas has grown up herself in the same urban neighborhoods as her clients; most were teenage mothers themselves. The mothers, who are referred to the program from local clinics and social service agencies, usually enroll in the program when they're six or seven months pregnant. The time the doula spends with the mom preparing for birth is important, both to support strong prenatal care for the child and to become a trusted ally. The comfort and emotional assurance the doula provides at the birth further builds that bond.

"It's not an effective strategy to approach a teenage mother and say, 'I know more than you, and I'll teach you.' If I was in the hospital myself with a new baby and someone came in and said, 'Let me make you a better mother,' I don't know how well I'd listen," Hans says. "First there needs to be a relationship."

For six weeks after the baby is born, the doula continues to make a weekly visit to the mom, maintaining the themes that the doula and mother were discussing before the child arrived—the importance of breastfeeding, how to return to school and care for her baby, how to read the baby's cues, how to lower the stress.

"We go through scenarios of what will happen with a new baby and say, 'What will you do in that situation?' We try to help them understand that you're dealing with a newborn baby, and a big part of that is the parent/ child bond. We're big proponents of reading to the baby, interactions you can have with a baby," says Deborah Bump, the program's clinical supervisor. "And we're there for them beyond the home visits. Sometimes they call and want to talk, and we just listen."

Hans has finished gathering the data from the five-year study and is in the process of analyzing it for publication. "We're very pleased with what we've found so far," she says. "We've seen improved mother/infant interaction, as measured by how much they talk with their babies, hold their babies, take pleasure in their babies' accomplishments. The findings suggest that the moms think differently about their roles as mothers. We've also found some limited positive health-related outcomes, such as more initiation of breastfeeding."

Although the University of Chicago Doula Project is past the federal grant support period for operation, Hans has been able to continue to provide services by connecting to funding from the Illinois Ounce of Prevention Fund, a partnership between private donors and the state of Illinois that supports programs to help children who are born into poverty. "The idea of using doulas for this work originated with community agencies here in Chicago, and the model is spreading throughout the state and nationally," Hans says.

The power of social contexts in which early child rearing occurs is just beginning to receive greater attention. Fathers, for instance, are over reported in most severe cases of abuse and neglect, and their role in the family can also be an important factor in cases where the mother is the perpetrator. For example, confirmed incidents of child abuse and neglect among Army families increased significantly when a father is deployed specifically to a combat zone, according to a study from the University of North Carolina at Chapel Hill School of Public Health released this summer. When soldier-husbands left mothers at home to care for the children in these circumstances, the rate of physical abuse nearly doubled, and the rate of neglect was nearly four times higher.

Despite findings such as this, research into the role of fathers in abuse cases has been rare, says Neil Guterman, who has been involved in collecting data from 4,800 families in 20 cities over the first three years of the babies' lives for the first national longitudinal study on the topic. "We're trying to figure out what it means for dads to be an economic resource, what is the relationship with the mom, how do they relate to the children— and how all these kinds of factors impact risk for child maltreatment," he says.

Guterman and his team currently have several articles under review from the study, which was funded by the National Institutes of Health and the Centers for Disease Control, and some of the findings could have an impact on public policy. For example, Guterman's team found that while married mothers are less likely to abuse or neglect their children than non-married moms, it appears that marriage to fathers, per se, is not responsible for the lower risk. Rather the factors that make a difference are the "psychosocial resources" that fathers bring to the marriage, such as his positive interactions with the child, his supportive behaviors toward the mother, and his higher educational level.

"Another interesting finding is somewhat counterintuitive. Contrary to what we might think, the economic resources a father brings to the family do not seem to impact the mother's maltreatment risk. Along with what we found in terms of the impact of social resources, it suggests that a policy to promote marriage in and of itself might not necessarily have the anticipated impact in reducing cases of abuse and neglect," Guterman says. Guterman is also examining how tapping social networks can complement home visitation services and leverage even greater reduction of the risk of child abuse and neglect. Participants in the University of Chicago Doula Project now have the option of meeting regularly with other mothers in the program to discuss parenthood with each other, and augmenting the one-on-one home visitation model with this kind of connection with peers is becoming increasingly common.

Also funded by the CDC, Guterman's research on the idea brings together a dozen or so young mothers to meet together weekly. There, they develop new skills aimed at improving the relationships in their lives, even turning a situation that can challenge parenting into an asset. "The mothers work together and support each other, ultimately developing into their own self-sustaining mutual support networks. They learn to see their own strengths and how important social networks are to their mothering," Guterman says.

The program is currently in the clinical trial stage, with three sites in New York City and two in Chicago. In initial research Guterman says that they're already seeing significant improvements in lowering mothers' stress and child abuse risk, beyond home visitation services, even with a relatively modest six-week set of professionally led sessions. "One of the clearest risks for abuse and neglect is whether the mother is isolated or involved in undermining relationships," he says. "Giving and getting support from other moms is a way to counteract that."