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Part II:
Status of Research-Based Programs

Early Childhood Programs

A multitude of studies document that preschool programs that are supportive of and helpful to parents, that foster mother-infant attachment, and that enable children to learn pre-academic and social skills can increase the children's success in elementary and high school (Karoly et al., 1998). Some of these programs are described below.

Zero to 3 Years Old

I. Kempe Prevention Research Center for Family and Child Health Dr. David Olds and Colleagues, University of Colorado Health Sciences Center Denver, Colorado

In the early 1960s, Dr. David Olds and his colleagues began an extensive, well-designed,randomized study of a comprehensive program of in-home visits by nurses to high-risk young women, beginning during their first pregnancy and continuing through the second year of their child's life. This first project was conducted with low-income, unmarried, white women in the semi-rural community of Elmira, New York, and has been replicated with low-income African American populations in Memphis, Tennessee, and Denver, Colorado. The status of these trials as of October, 1998, is shown in Table 7.

Table 7. Status of Trials in 3 Cities

Source: (Hill, P., 1998). The state of knowledge: Family in-home support in pregnancy and early childhood. Presentation at CSAP conference, October 5-6, 1998.

In the Elmira study, families received a mean of 9 home visits during pregnancy and 23 from the child's birth through his 2nd birthday. During the home visits, nurses promoted three aspects of maternal functioning: health-related behaviors during pregnancy and the early years of motherhood, care provided to their children, and maternal personal life-course development, such as family planning, education, and employment. The young women and other family members were taught how to give effective physical and emotional care to their children, and how to deal successfully with the challenges of education, finding work, and planning future pregnancies (Olds et al., 1997; Kitzman et al, 1997)

Compared to the control group, pregnant women in the home visitation group:

• Reduced their smoking
• Improved their diet
• Had fewer kidney infections
• Increased their social support
• Increased their use of formal services
• Had 75% fewer preterm deliveries
• Gave birth to infants with higher birth weights (Hill, 1998)

At the end of the first 2 years, the treatment group showed an 80% reduction in child maltreatment and a 56% reduction in emergency room visits. At the end of 4 years, the treatment group, compared to the control group, showed a 43% reduction in subsequent pregnancies and an 84% increase in employment (Hill, 1998). When this group was again studied 15 years after the initiation of the project, the results were as shown in Table 8.

Table 8. 15-Year Follow-up of Elmira, New York Program

Source: Olds, D.L., Eckenrode, J., Henderson, C.R., Kitzman, H., Powers, J., Cole, Robert, Sidora, K., Morris, P., Pettitt, L.M., luckey, D. (1997). Long-term effects of home visitation on maternal life course and child abuse and neglect: Fifteen-year follow-up of a randomized trial. Journal of the American Medical Association, 278(8), 637-643.

Moreover, the Elmira 15-year follow-up child outcomes show a significant impact on some of the most serious forms of adolescent behavior:

• Reductions in adolescent cigarette and alcohol use
• Reductions in adolescent run-away
• Reductions in adolescent arrests and convictions/probation violations (Hill, 1998)

Regarding the costs and benefits of this program, Olds and his colleagues (1997) note that "the reduction in family size, use of welfare, incidence of child abuse and neglect, and maternal criminality 15 years after the birth of the first child...will lead to substantial savings to government in several domains of spending. In considering the cost of the program (estimated to be $3,300 in 1980 dollars and $6,700 in 1997 dollars for 2 1/2 years of service), it is important to note that the investment in the service, from the standpoint of government spending, was recovered for low-SES families before the child reached 4 years of age" (p. 642).

A recent replication of this program in Memphis, Tennessee, with a sample of 1,139 primarily African American women at less than 29 weeks' gestation, with no previous live births, and with at least two sociodemographic risk factors (unmarried, less than 12 years education, unemployed). The goal was to determine whether home-visitation services provide a way to improve maternal and child outcomes, including whether any reduction occurred in risks posed by limited intellectual functioning, mental health, and mastery on the part of caregivers (mothers' ability to anticipate and deal with their children's needs). As in the Elmira study, the women were randomly assigned to the intervention group or the control group. Nurses made an average of 7 (range=0-18) home visits during pregnancy and 26 (range 0-71) visits from birth to the children's 2nd birthday. Table 9 shows the results at the two year follow-up.

Table 9. 2-Year Follow-up of Memphis, Tennessee Project

Source: Kitzman, H.. Olds, D., L., Henderson, C.R., Hanks, C., Cole, R., Tatelbaum, R., McConnochie, K.M., Sidora, K., Luckey, D.W., Shaver, D., Engelhardt, K., James, D., & Barnard, K.. (1997). Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing: A randomized controlled trial. Journal of the American Medical Association, 278(8), 644-652.

In addition, women in the intervention group were more likely to use other community services, more likely to be working, attempted breast feeding more frequently, and held fewer beliefs about child-rearing associated with child abuse and neglect (i.e., lack of empathy, belief in physical punishment, unrealistic expectations for infants). They reported higher levels of perceived mastery, and their homes were "more conducive to children's development." The mothers were taught how to recruit other family members and friends to help with the pregnancy, birth, and early care of the child. They came to trust the nurses who helped them set small, achievable goals that increased their confidence in their own self-management skills and their sense of self-efficacy (Kitzman et al., 1997, p. 650).

It must be emphasized that this program involves carefully structured protocols and educational materials designed for different levels of intellectual functioning. Olds and his colleagues stress that the results of their studies may be applied only to other home-visitation programs that are based on their model. However, while most other such programs have failed, theirs provides substantive data regarding the efficacy of their approach.

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