Child maltreatment comes with serious long-lasting consequences for its victims, including physical and mental health problems, and poor academic and employment outcomes [
1‐
5]. Home visiting programs are among the most widely implemented programs for the prevention of child maltreatment [
6,
7]. Yet, these programs tend to yield only modest effects on reduced risk for child maltreatment, on average around Cohen’s
d = 0.24–0.29 [
8‐
10]. This means that of one hundred families receiving home visitation, only seven to nine actually benefit more from such programs than from care as usual [
11]. Although it is common for prevention programs to yield relatively small effects [
10,
12], because only a subset of the families will develop towards child maltreatment, these numbers highlight the need to increase the effectiveness of home visiting programs to prevent child maltreatment.
On average, home visiting programs are less manualized than other parenting programs (e.g., parenting group programs) [
13]. As such, they allow for flexibility – professionals can decide how to support each family, based on clinical experience and perceived individual family needs [
14]. Many scholars argue for this flexible approach [
15,
16]. Other scholars, however, argue for manualized programs, based on scientific evidence of effective ways to address key risk factors to increase the likelihood of program effectiveness [
17,
18]. Although these standpoints may seem incompatible, manualizing a program does not necessarily have to compromise the flexibility that professionals have in delivering the program [
19]. Adding a limited set of manualized components that target key risk factors to flexible, largely non-manualized home visitation, may increase program effectiveness, by ensuring that certain key risk factors are targeted in all families, while allowing professionals to maintain flexibility. For example, professionals can still decide, based on clinical experience and individual family needs, how to organize their sessions (e.g., the content of what they discuss with parents). Indeed, home visiting programs that ensure that specific program content is delivered, for example using fidelity checks, tend to yield larger effects than home visiting programs that do not use such checks [
20]. In this experimental study, we will test whether adding manualized components that target four key risk factors increases the effectiveness of a home visiting program to ameliorate these risk factors, and to reduce risk for child maltreatment.
Risk factors targeted in the current study
We selected four dynamic (i.e., malleable) key risk factors for child maltreatment to explicitly target in a home visiting program to prevent child maltreatment: compromised feelings of parental self-efficacy, high levels of perceived stress, parental anger, and post-traumatic stress symptoms [
21‐
23]. First, lower parental self-efficacy, i.e., the belief to be less able to perform the parenting role successfully and to have less control over a child’s behavior and development, may limit mothers’ ability to persist in parenting practices that take more effort [
24,
25]. Mothers who feel less self-efficacious tend to be less warm towards their children and use less positive and sensitive parenting practices [
26,
27]. Instead, they are more inclined to engage in harsh and inconsistent parenting practices [
27,
28]. Therefore, increasing parental self-efficacy may support mothers in sensitive parenting, reducing the risk for child maltreatment. Meta-analytic data support this hypothesis, by showing that child maltreatment prevention programs that include components to increase parental self-efficacy tend to be more effective in reducing mothers’ risk for child maltreatment than programs without such a component [
10].
Second, mothers who perceive high levels of stress experience more mental health problems [
29,
30], which can lead to engagement in more intrusive, punitive and harsh parenting practices [
31‐
33]. Increasing mothers’ skills to cope with stress, might help them to relieve their stress, giving them more mental space to adopt positive parenting practices in challenging situations and reducing their risk for child maltreatment. Indeed, a meta-analysis shows that child maltreatment prevention programs that explicitly include components to enhance personal skills (e.g., stress management skills) tend to be more effective in reducing mothers’ risk for child maltreatment than programs without such a component [
10].
Third, mothers who have difficulty regulating their anger are more inclined than other mothers to express their anger in ways that are harmful for their children [
29,
34]. Anger regulation difficulties may be caused by both the extent to which mothers experience feelings of anger, and the extent to which they express their anger in harmful ways [
35]. Feelings of anger in mothers at risk for child maltreatment are often intensified by mothers’ dysfunctional attributions about their child’s behavior [
36]. For example, mothers might believe that their child’s challenging behavior is intended to upset or annoy them, which may intensify their feelings of anger. Strong feelings of anger can then make them resort to harmful ways of expressing their anger [
36]. Thus, altering parents’ dysfunctional attributions and supporting them to express their anger in non-harmful ways, may help to reduce risk for child maltreatment. Indeed, adding a program component focused on dysfunctional attributions and anger management to a parent group training reduced risk for child maltreatment at termination of the program and reduced long-term dysfunctional attributions [
37]. This could also apply to home visiting programs.
Last, mothers at risk for child maltreatment tend to have experienced more traumatic events than the general population, increasing their risk for post-traumatic stress symptoms (e.g., emotional numbness and increased arousal) [
38,
39]. These symptoms may hamper mothers’ emotional availability to their children and may make it difficult for mothers to be aware of their own emotions until they are so strong that they resort to harsh and punitive behavior [
40,
41], increasing the risk for neglect and aggression [
42,
43]. In addition, post-traumatic stress symptoms may interfere with intervention effects and increase the risk for drop-out [
38,
39,
44‐
46] . Adequate recognition of these symptoms and referral by home visitors to professional help may therefore reduce mothers’ risk for child maltreatment [
40].
In this study, we test whether manualized components designed to target these four key risk factors for child maltreatment ameliorate these risk factors and whether they improve parenting practices and reduce risk for child maltreatment. To further improve our understanding of the role of these four risk factors in the reduction of risk for child maltreatment (i.e., our theory of change), we will also test whether amelioration of these risk factors explains (i.e., mediates) the effects of the components on reduced risk for child maltreatment.
Potential differential effects
Not all mothers may benefit equally from these components. On the one hand, mothers who are at highest risk considering the targeted risk factors may benefit more as they have the largest room for improvement [
47,
48]. On the other hand, mothers who are at lower risk may benefit more, as they may be more able to engage with program content [
49]. Other aspects may also influence the degree to which mothers benefit from the components, such as children’s temperament. For mothers whose child is often frustrated or hard to soothe, it may be more difficult to apply newly learned behaviors (e.g., stay calm when their child upsets them) [
50]. However, these mothers may be in greater need for strategies to deal with this child behavior, and thus benefit more from components that target their stress and anger regulation [
51]. Furthermore, the accumulation of life events (e.g., quitting one’s job or death of a family member) may either hinder mothers to benefit from the components, if it makes mothers less able to engage with program content [
52], or may increase the effectiveness of the components, if they buffer the adverse effects of accumulation of life events [
53]. In this study, we will therefore examine maternal (initial levels of targeted risk factors), child (temperament), and family (life events) characteristics as putative moderators of the effects of the manualized components on the targeted risk factors and on risk for child maltreatment. Knowledge on differential effects of the added components can serve to guide personalization of programs. In other words, it can support home visiting programs in their goal to serve individual family needs in an evidence based way.
Study aims
In this study, we will test (1) whether manualized components designed to target four key risk factors for child maltreatment (low parental self-efficacy, stress, parental anger, and post-traumatic stress symptoms) indeed ameliorate these risk factors; (2) whether adding these manualized components to a home visiting program improves parenting practices and reduces the risk for child maltreatment; (3) whether any effect of the manualized components on reduced risk for child maltreatment can be explained (i.e., is mediated) by amelioration of the four targeted risk factors; (4) whether some mothers benefit more from the manualized components than other mothers in terms of ameliorated risk factors and reduced risk of child maltreatment.