Challenging Dogma - Fall 2009

Sunday, December 13, 2009

The Healthy Families Model as an Outdated Approach to Reducing Child Abuse and Neglect—Kira W. Taj

In 2007, approximately 800,000 children were abused or neglected in the United States and 1,760 children died because of maltreatment. Children from birth to one year of age were the most likely to be victimized (1). Although many interventions have focused on supporting parents who are at risk for abuse, a greater number of social scientists and practitioners are beginning to realize the impact of the social environment on the problem of child abuse and neglect (2,3). Long-standing programs such as Healthy Families America lack this broader, contextual approach and may need to reconsider the narrow theoretical bases on which they are built.

Healthy Families Background
Healthy Families America, founded in 1992 by the agency Prevent Child Abuse America, is a newborn home visiting program designed to prevent child abuse and neglect. It focuses on families with the highest risk factors for child abuse and neglect, including new parents, young parents, single mothers, and households with low incomes. Its intended outcomes include:
1) Reducing child maltreatment;
2) Ensuring healthy child development;
3) Encouraging school readiness;
4) Promoting family self-sufficiency; and
5) Demonstrating positive parenting (5).
Based originally on a pilot program in Hawaii, the program is now running in over 440 communities across the United States. It serves a mix of families in rural, semi-urban and urban locations (6).
Healthy Families Massachusetts has 27 sites across the state and focuses on serving first-time parents aged 20 years and younger. Home visitors, trained specifically for Healthy Families MA, provide prenatal and parenting education for families from pregnancy until the child turns three years old. All home visits and services are provided at no cost to the family. Home visitors work hard to establish a relationship of trust and mutual understanding. They attempt to engage all members of the family unit in learning about the child’s growth and development in the hopes of reducing child abuse, which is seen as the outcome of family stress and a misunderstanding of the child’s natural developmental processes.
Healthy Families home visitors are well trained in child development and social service work. They are able to connect families to supports in the community such as WIC, financial assistance, housing, and health care access. They develop Individualized Family Service Plans with each family to monitor progress and goals. They attempt to provide as much relevant information as possible, spanning all areas of child health, family planning, child safety, economic self-sufficiency and overall health. Healthy Families programs in Massachusetts all provide group activities and workshops so as to create an extended support system among these young parents.

The Healthy Families Theoretical Model
The Healthy Families approach is largely based on theories of child development, individual psychology, and principles of social work. Twelve "critical elements" taken from evidence-based research shape the program. These twelve elements address three main areas of service initiation, service content and staff characteristics. The program believes in the power of early initiation of services in a child’s life, as is supported broadly in early childhood literature. Services to families are offered voluntarily, based on family need and investment. Finally, the program attempts to achieve culturally competent services by matching language and social traits of home visitor and client (7). The Healthy Families approach sees home visiting as intrinsically more effective than clinic- or center-based services because the intervention happens in the family’s home context. The home visitor works as a bridge between the family and the outside world of service delivery and regulations. The success of the program lies in the relationship built between home visitor and client, and ultimately between parent and child.
The Healthy Families model sees the health of a single child as being influenced profoundly by his/her home environment. It attempts to educate parents on positive parenting and healthy discipline in order to influence belief systems surrounding how to raise a child. Home visitors care strongly about the families they serve. However, the Healthy Families model is based on three faulty premises. It remains an individual level model, it places a value judgment on “good” and “bad” parenting, and it fails to look at fundamental causes of child abuse and neglect.

Individual Level
The Healthy Families model reflects social learning theory, which emphasizes the human inclination to learn from others (8). The child is seen as prey to the interaction between his/her parent(s), the immediate social environment of the family, and the resultant behavior of the parent(s). Despite the focus on family context, the larger social environment plays no role. The ultimate emphasis is on the relationship between the home visitor and the parent(s), and between the parent(s) and the child. With the proper knowledge, tools and beliefs, the Healthy Families model believes that families can transcend their social situation and raise their child just as any other loving parent would. Fundamental attribution error therefore prevails.
The social context of the neighborhood, the educational system and the extended social reality that surrounds the family is completely neglected. If it is culturally accepted within a certain social circle to beat children, a family may find it more difficult to break from these social norms. Even if the immediate family treats a child with respect, a child care facility or school teacher may not. The program ultimately does little to change the larger environmental context of child rearing and community health. Some Healthy Families programs in Massachusetts serve families in as many as 13 neighborhoods, spread across large geographic regions and each having distinct social contexts. Because the program is not set up to consider the neighborhood context, each family is treated as an isolated unit. This diffusion of efforts inhibits any greater environmental or institutional changes in the communities where families live.
Additionally, the individualized focus adds a stigma to those enrolled in the program. Many families may not participate because the program is framed as a program that helps families who are at risk for abusing their children. To start from a deficit perspective may be limiting the families that can be served, as well as disempowering them on the basis of the initial assumption that they are somehow predisposed to abuse their child.

Based on Presumably Universal Norms
The Healthy Families model relies on the mostly Western idea of effective parenting. Anything deviant from what is considered good parenting, defined by dominant society, means abuse. This implicit neglect of differing social values means that low-income, minority parents are sometimes labeled more often as being abusive without the consideration of why they may choose certain types of disciplines because of their social environment (9).
In a study comparing communities with varying levels of defiant youth behavior, Ronald Simons’ research found that parental control decreases as the amount of deviant behavior in a community as a whole increases. Therefore, he argues, a particular parenting strategy that might be effective in a middle class neighborhood may prove ineffective in a lower-income community with differing social norms (10). Although the fundamental human right that underlies child protection is non-negotiable, the parenting strategies and techniques used may be more effectively tailored according to community-specific contexts. Healthy Families fails to challenge its basic assumption that there is one correct philosophy towards parenting.

Compartmentalized focus
Thirdly, the Healthy Families program focuses narrowly on the issue of child abuse and neglect during early child rearing, without showing how the intervention is sustained after a child turns three years old or how it interacts with broader issues such as poverty, mental illness, and health. The hope is that after 2 or 3 years of the intervention, parents have developed crucial bonds with their child and the health of the family unit is strong. Although early intervention is an important time to intervene in a child’s life, the social forces that pull on a parents and children after the age of 3 can be massive. The school and peer environment exert considerable influence on child behavior and the stressors facing parents of 10 or 15 year olds continue. Without a change in the larger neighborhood or social context of the family, the threat of child abuse remains. With so many related, multi-faceted social issues facing American families, it is time for interventions to reflect this multidimensional reality.


Although Healthy Families America has established 12 critical elements, its objectives and anticipated impacts are unclear. Is the intervention simply focused on lowering the rate of child abuse and neglect or will that be expected to lead to the increased overall health of children in the nation? What is the real cause of child abuse and neglect? The program has yet to clarify their focus in regards to these questions.
Existing research on the Healthy Families program remains inconclusive. One of the few randomized control trials done with Healthy Families New York reports results based solely on parent-reported assessments. There were no demonstrated changes in the incidence of child abuse and neglect as reported to Child Protection Services (11). The California Evidence-based Clearinghouse for Child Welfare has conducted a review of the Healthy Families America model and rated it “4 - Evidence Fails to Demonstrate Effect” on its scientific rating scale, 1 being the best and 5 being the worst (12). Indeed, even a recent evaluation of the Healthy Families Massachusetts program failed to produce measurable and reliable outcomes measurements (13).

Although Healthy Families has the potential to support families emotionally and to connect them to needed services, the program’s individual focus, cultural bias and narrow approach prevent the program from achieving meaningful impacts on a large scale. Its approach grows out of the individual level model of social learning theory and relies heavily on childhood development knowledge to change behavior. The program has found it difficult to demonstrate clear effectiveness because of the lack of broad social change and the challenge of measuring the impact of changes in family attitudes towards child rearing. There is much that contemporary social theory could improve with regard to the Healthy Families theoretical approach.

Alternative Intervention
In order to address the contextual issue surrounding child abuse and neglect, an intervention must be carried out at the community-level. The theoretical focus of the intervention should be on the societal factors influencing the general well-being of children (4). The Harlem Children’s Zone (HCZ) serves as a model program.
The Harlem Children’s Zone in New York City aims to provide comprehensive services to families and children in Harlem. It grew out of a truancy-prevention program started in 1970. Then the program expanded community centers and piloted a project that provided holistic services to one neighborhood block. It grew to a 24-block area and now to a 100-block area. The program aims to build a “pipeline” of services for children from birth to college. Its “Baby College” offers parent education classes to young parents and begins the trajectory for a child’s education. There is also an asthma initiative, an obesity initiative and community-building activities to address broader public health needs (15). The Harlem Children’s Zone does not run a specific program to combat child abuse and neglect, but it is designed to strengthen the social fabric of the community and change social norms—two things that directly impact child abuse and neglect (2,3).
The proposed program would not strive to provide comprehensive services to fight poverty as HCZ does, but would utilize the same theoretical principles. Project CENTER will target three communities in Massachusetts with the highest rates of reported child abuse and neglect. New, comprehensive and community-run social service centers will be built in each of the three target communities. Community Advisory Boards will identify key social services in the community related to families and children that should be physically moved to the social service centers, if possible, or that should be involved in the CENTER partnership. Agencies housed in the new community centers will receive with subsidized rent costs. Project CENTER will fund and staff bi-annual conferences for these identified agencies, with a focus on community capacity building and integration of services for children.
Each target community will implement free “Baby College” classes for all new parents, held at the community centers. Based on the Harlem Children’s Zone model, these classes will educate parents on child development theories and will serve as a support group for parents, to share their challenges and suggestions. Parent ambassadors from the community will be hired to recruit participants and begin the dialogue around child health in the context of their community. Four parent case managers will be hired to work with families for one year after the “Baby College” course ends in order to offer their support and to help families connect with appropriate community services. Participants who complete the program will receive discounts in local retail shops and will also receive subsidies to help pay for childcare.
Three approaches to Project CENTER contrast with the Healthy Families model. It is ultimately implemented at the group/community level, it is community driven and embedded, and it views child abuse within the larger context of community support for children in general.

Group level
The first premise of this intervention is that behavior is largely determined by the group. The program and HCZ model follow the Diffusion of Innovations Theory by attempting to create a “tipping point” in the community served (16). The idea is that once a critical mass of parents and families begin to focus on child education and positive outcomes, the social fabric of the neighborhood will tip towards a change. Fathers attending parenting classes will become the norm, instead of fathers dealing drugs or getting involved in violence. Children succeeding academically will become a societal expectation, not an exception. Mothers reading to their children every night will be more common than mothers leaving children alone to hang out with friends. By focusing on a definable neighborhood and social context, the program utilizes the power of imitation and social pressure to transform the environment that children live within.
Communities influence parental attitudes and behaviors in many ways. The social environment sets norms for how parents should act towards their children. Community supports either improve or diminish parental mental health, and children’s services aid a parent in continuing to raise his/her child outside of the home (2). Therefore, interventions aimed at reducing child abuse and neglect may not need to explicitly address the issue, rather they might attempt to provide services that increase the ability of parents to act responsibly toward their children and to influence other parents to do the same. In fact, the emphasis on community building helps to de-stigmatize the problem and to provide families with more relevant services.

Culturally Competent
Project CENTER and HCZ are community-specific and culturally competent. They are staffed and advised by community members themselves, instead of by those outside of the community imposing ideals of the model parent-child relationship. The programs realize that parents who yell at their two year old are not bad or simply ill-informed people. They have grown up in a culture in which certain styles of discipline were accepted. They are living in an environment with multiple stressors. Project CENTER mobilizes the community together to say, “It’s tough out there, so we’re going to learn together on how to make our lives better.” Parenting classes explore different theories of early childhood education, but emphasizes the important synthesis of ideas within the classroom, as families learn together. Instead of focusing on the individual home context, families in a community learn together and join to make their community better for children.
The Project CENTER program targets those communities with high levels of child abuse and neglect and/or high risk. Through piloting efforts in these communities, the intervention is focused on specific social contexts. The vast diffusion of services to individual families, as seen with the Healthy Families program, ignores the influence of the environment within which families live. If these pilot programs prove successful, they can serve as a model for other communities and can spread throughout the state based on need.

Complete picture; fundamental cause
HCZ realizes that to focus on one part of the puzzle—child abuse, substance abuse, violence, education—is to treat symptoms of the disease. As Bruce Link pointed out in 1995, interventions must target “fundamental causes” (17). The larger picture in many communities is one of poverty and a culture of failure rather than a culture of success. By focusing on lifting up the entire community and through focusing on educating children and families comprehensively, the social fabric is strengthened. Although Project CENTER does not specifically focus on the issue of child abuse and neglect, it implements a parenting education program within the context of existing services. It improves the service delivery infrastructure by connecting key community services physically and professionally. It hires and trains community members to act as “early adopters” and role model messengers for social change. Finally, it paves the way for larger community collaboration around children’s overall health.

Final Summary
The outcomes of HCZ’s work have already begun to show. Its clear program design and evaluation process reflect its strong theoretical basis. The appeal of the model has already spread. President Obama has announced the future funding of 20 “promise neighborhoods” to be built throughout the nation, based specifically on the HCZ model (18). On a smaller scale, the HCZ approach can be used to bolster community participation and organization, as Project CENTER does. The community-level focus, culturally relevant content, and the comprehensive scope make Project CENTER’s approach more effective than that of Healthy Families. Only when social norms begin to shift does the behavior of families change substantially. Programs focused on the specific family context may find themselves merely treading water.


1. United States Department of Health and Human Services, Administration on Children, Youth and Families. Child Maltreatment 2007. Washington, DC: U.S. Government Printing Office, 2009.
2. Daro D, Dodge KA. Creating Community Responsibility for Child Protection: Possibilities and Challenges. The Future of Children 2009;19(2):67-93.
3. Slep AM, Heyman RE. Public health approaches to family maltreatment prevention: resetting family psychology's sights from the home to the community. Journal of Family Psychology 2008;22(4):518-28.
4. Greeley CS. The Future of Child Maltreatment Prevention. Pediatrics 2009;123(3):904-5.
5. Healthy Families America. Research Findings. Chicago, IL: Healthy Families America.
6. Healthy Families America. About Us. Chicago, IL: Healthy Families America.
7. Prevent Child Abuse America. Healthy Families Program Facts and Features. Chicago, IL: Healthy Families America.
8. Bandura A. Social Learning Theory. New York, NY: General Learning Press, 1977.
9. Baumrind D. The Social Context of Child Maltreatment. Family Relations 1994;43(4):360-68.
10. Simons R, Lin KH, Gordon LC, Brody G, Murry V, Conger R. Community Differences in the Association between Parenting: Practices and Child Conduct Problems. Journal of Marriage and Family 2002;64(2):331-45.
11. DuMont K, Mitchell-Herzfeld S, Greene R, Lee E, Lowenfels A, Rodriguez M, Dorabawila V. Healthy Families New York (HFNY) randomized trial: effects on early child abuse and neglect. Child Abuse & Neglect 2008;32(3):295-315.
12. The California Evidence-Based Clearinghouse for Child Welfare. Healthy Families America. San Diego, CA: The California Evidence-Based Clearinghouse for Child Welfare.
13. Tufts University. Healthy Families Massachusetts Final Evaluation Report. Medford, MA: Tufts University, 2005.
14. Harlem Children’s Zone. 2008-2009 Biennial Report. New York, NY: Harlem Children’s Zone, 2009.
15. Harlem Children’s Zone. The Harlem Children’s Zone Project. New York, NY: Harlem Children’s Zone.
16. Link BG, Phelan J. Social conditions as fundamental causes of disease. Journal of Health and Social Behavior 1995; 35(special no):80-94.
17. Aarons DI. President Envisions Anti-Poverty Efforts Like Harlem's 'Zone'. Education Weekly 2009;28(24):6.

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