When Stacy Hartzler visits a pregnant teenage girl to counsel her about her health and how to care for her child, she thinks of what she is doing as promoting healthy families, but she is also on the front line of the fight to end child abuse.
Hartzler left a position as the director of neurology and orthopedics at an Arizona hospital more than three years ago to join the Best Babies Initiative in Denver, one of a growing number of programs based on the Nurse-Family Partnership.
She visits young unwed women and teenagers in their homes and offers counseling on their own health, infant health, parenting skills and family planning as well as more general issues such as continuing education and job hunting.
The idea that training young women in healthy parenting skills could be the best way to prevent most cases of child abuse and neglect is not new, but at a time when far-too-frequent horror stories suggest a crisis in the child welfare system, there is growing acceptance that prevention is the key to solving the problem.
That acceptance has come not only from child welfare advocates, who point to the results of studies done over nearly three decades, but also from the federal government.
The Bush administration has recently asked Congress to double the funding provided to states for child abuse and neglect prevention programs, seeking to boost funding to $65 million.
Dr. Wade Horn, the assistant secretary for children and families in the U.S. Department of Health and Human Services, said part of what has helped convince him of the role that promoting a young mother's health, parenting, social and job skills can play in cutting down on child abuse is the result of the studies done of the Nurse Family Partnership.
"While it is true there are some parents who abuse kids because they are psychologically disturbed, in the majority of cases it's because of other factors," Horn said. "What the Nurse Family Partnership program does is take care of some of those other factors."
Those "other factors" include ignorance about proper child care and parenting, isolation from family members, health care professionals or counselors, and despair about the situation they are in, Horn said.
When a mother is an unwed teenager from a poor family, the risk that all the stresses could result in neglect or abuse of a child are increased, experts say.
A Preventable Problem
The vast majority of parents who abuse or neglect their children have no intention of hurting them; they just either do not know any better or react to their child's behavior without thinking, child welfare professionals say.
Those are the cases that can be prevented, and according to some studies they already are being reduced.
Horn said studies have found that the Nurse-Family Partnership program brought about a 70 percent reduction in the cases of abuse over the life of a child. The studies looked at populations of families considered to be at risk for child abuse, randomly assigned members to either receive or not receive counselling under the program, then followed the children until they were 16 years old.
That reduction in cases of abuse translates into substantial savings. Studies have found that for every dollar spent on a program like the Nurse-Family Partnership, as much as $5 is saved on the cost of dealing with the problems created by abuse.
And those problems strike society on many levels. Studies have shown that children who suffer abuse are more likely to have problems in school, more likely to exhibit antisocial behavior including violence and crime, more likely to wind up on social assistance and more likely to abuse their own children than those who are not abused.
What makes the results all the more impressive is that parents receive counseling for less than three years, ideally beginning at the time the woman is 16 weeks pregnant and continuing until the child is 2 years old.
"There are some clients you wish you could help longer, but that's mostly the younger ones, the 12- and 13-year-olds," Hartzler said.
With what studies have found about the Nurse-Family Partnership model, you might think that David Olds, the University of Colorado psychologist who developed the program, would have been trumpeting its success for years. Instead he has been cautious.
"We wanted to know that the evidence would be solid," he said. "This is complex, and we wanted to be sure we had our program model sufficiently developed and our method sufficiently articulated to be able to communicate it to others."
And he is realistic about the prospects for success.
"This program does not wipe out child abuse and neglect," he said. "There are cases that this program will not affect, but I am convinced partly because the nurses are able to get to young families early, before the baby's even been born. It won't eliminate child abuse and neglect, but it will have a significant effect."
Another effect could be that by reducing the number of cases of abuse or neglect that child welfare agencies have to deal with, the overworked agencies would be able to respond more effectively to cases when they arise, Olds said.
All too often, when horrible cases of abuse are discovered — such as the 15-year-old Tennessee boy whose father and stepmother were charged last week with chaining him to his bed and starving him until he weighed just 49 pounds — it turns out that child welfare services had been alerted to concerns about possible abuse but had failed to follow up thoroughly.
Focus on High-Risk Families
The Nurse-Family Partnership, the model for the programs Horn would like to see boosted around the country, is focused on high-risk families — unwed, low-income teenagers having their first child, Hartzler said. The average age of her clients is 15, she said.
Most are referred by agencies such as the county health system, school districts, Planned Parenthood or the state Department of Health Services, but some refer themselves, and she said a growing number are referred by former clients.
Beginning the counseling before the child is born — and as early as possible in the pregnancy — is important because of the impact that the mother's behavior can have on the baby's health and behavior, Olds said.
For example, he said, at least seven longitudinal studies have found that children whose mothers smoked during pregnancy are more likely to be inconsolable as infants, more likely to have worse "terrible twos" and more likely to exhibit antisocial behavior when they reach school age than youngsters of mothers who did not smoke.
"To the extent that women take better care of themselves during pregnancy, the child is going to be easier to care for, and it is going to be more enjoyable to care for the child," Olds said.
Hit by Reality
The program is only open to first-time mothers for two reasons: Because they are more receptive to the counseling provided, and because the skills a young woman learns during her first pregnancy and the early years of child rearing carry over to subsequent children, Hartzler said.
Mothers are also counseled in family planning, so that they don't burden themselves with multiple children before they are ready emotionally and financially.
Though she said that many of the young women she has counseled refer their friends to the program, when they start they often have a long way to go before they will become good parents.
Many smoke cigarettes, drink alcohol, smoke pot and do other drugs, she said. Some have histories of psychiatric problems, either personally or in their families, many have unsupportive families and some are even homeless, she said.
On top of those kinds of issues, many are simply emotionally unprepared to have a child and do not understand the reality of what it means to care for an infant day in and day out.
"When the baby is born they love it," Hartzler said. "They're the center of attention, everyone is coming to see them and they love it, but then when that wears off they tend to lose interest. The baby's crying, needs to be fed, needs to be changed, and that can be frustrating."
Young mothers are counseled to connect with their babies by breast-feeding, by reading to them and playing with them instead of "plopping them down in front of the TV."
"That way, the children are ready for school," she said. "The children have fewer behavior problems."
And happier children make happier parents, and together that should make for less child abuse.