Reducing Risks for the Development of Antisocial Behavior in Childhood

How does the nurse home visitation program reduce risks for antisocial behavior that begins in childhood? This section summarizes how the program reduces three major risk factors: adverse maternal health-related behaviors during pregnancy that are associated with neuropsychological impairment in children, child abuse and neglect, and a troubled maternal life course.

Neuropsychological Impairment

Children who exhibit antisocial behavior very early in life are more likely than other children to have impaired neurological functioning. Signs of neurological impairment include poor motor functioning, attention deficits, hyperactivity, impulsivity, and impaired language and cognitive functioning (Moffitt et al., 1996). In many cases, these problems can be traced to poor prenatal health conditions that interfere with the development of the fetal nervous system (Olds, 1997; Wakschlag et al., 1997; Fergusson, Horwood, and Lynskey, 1993; Milberger et al., 1996; Weitzman, Gortmaker, and Sobol, 1992).

The nurse home visitation program helps pregnant women improve their diet and cut down on cigarette smoking or the use of alcohol or illegal drugs that can hurt the developing fetus (Olds, Henderson, Tatelbaum et al., 1986). Cigarette smoking during pregnancy is especially dangerous because it is related to intellectual impairment in young children. In the Elmira trial, which served primarily Caucasian families, the 3- and 4-year-old children of women who did not receive a nurse home visitor and who smoked 10 or more cigarettes per day during pregnancy had impaired intellectual functioning compared with children of women who did not smoke (Olds, Henderson, and Tatelbaum, 1994a). Children of mothers who smoked 10 or more cigarettes when they signed up for the program and then received a nurse home visitor during pregnancy were not intellectually impaired. Data indicate that these women improved their diets and reduced their smoking by approximately three cigarettes a day (Olds, Henderson, and Tatelbaum, 1994b).

Cigarette smoking by a mother during pregnancy also has been linked to an infant’s compromised neurological functioning. Compromised neurological functioning makes it harder for infants to signal their needs and regulate their emotions and behavior (Olds, Pettitt et al., 1998). When asked to evaluate how fussy and irritable their children were at 6 months of age, mothers who did not receive nurse home visitors and who smoked 10 or more cigarettes per day during pregnancy reported more fussiness and irritability in their children than did nonsmoking mothers without a nurse home visitor. In contrast, mothers who smoked 10 or more cigarettes per day when they started the program and who received home visits by a nurse during pregnancy reported far less irritability and fussiness in their children than did their counterparts in the control group (Olds, Pettitt et al., 1998). These findings suggest that the guidance mothers received from their nurse home visitors not only helped them cut down or stop smoking, it also improved their infants’ soothability, which made infant care much easier.

Child Abuse and Neglect

Abused and neglected children are at higher risk for developmental pathways marked by persistent behavior problems and academic failure, followed by chronic delinquency, adult criminal behavior, antisocial personality disorder, and violent crime (Widom, 1989; Maxfield and Widom, 1996; Kelley, Loeber et al., 1997; Kelley, Thornberry, and Smith, 1997). The program studied in the Elmira clinical trial has reduced the rates of child abuse and neglect and less serious forms of caregiving problems by helping young parents deal with depression, anger, impulsiveness, and substance abuse problems. It also helped them reflect on how they were parented themselves; learn about normal child development; and develop the skills needed to “read” their baby’s signals, anticipate their baby’s needs, and parent effectively (Olds, Henderson, Chamberlin et al., 1986; Olds, Eckenrode et al., 1997).

For children from birth through age 15, the Elmira program reduced State-verified cases of child abuse and neglect by 79 percent among mothers who were poor and unmarried (Olds, Eckenrode et al., 1997). In the second year of life (age 13 to 24 months), nurse-visited children had 56 percent fewer visits to an emergency room for injuries and ingestions than children not receiving home visits by nurses (Olds, Henderson, Chamberlin et al., 1986). During the 2-year period after the program ended (from the second through the fourth year of life), children from nurse-visited families were 40 percent less likely to be seen in a physician’s office for injuries, ingestions, or social problems, and they had 35 percent fewer visits to the emergency room.

In the Memphis test of the program, which served African-American families, corresponding positive effects on parental caregiving and reductions in childhood injuries were seen during the first 2 years of the children’s lives. Because Memphis has a very low rate (approximately 3 percent) of officially verified cases of child abuse and neglect, it was not possible to make valid
and reliable comparisons between program participants and control group families. The data obtained from the nurse-visited families, however, strongly suggest a reduction in poor caregiving practices or behavior, including a reduction in child abuse and neglect (Kitzman et al., 1997).

Troubled Maternal Life Course

A mother’s personal development and lifestyle choices influence whether her child will develop antisocial behavior. Young women who become parents as adolescents and have recent welfare experience are more likely to have children who engage in a variety of antisocial and delinquent behaviors and who are expelled from school than are their low-income, nonwelfare, adolescent–mother counterparts (Furstenberg, Brooks-Gunn, and Morgan, 1987). Mothers who are unmarried, do not graduate from high school, and have three or more children are more likely to have children who exhibit behavioral problems.

The nurse home visitation program reduces these risk factors by helping young parents develop the confidence and skills necessary to set and achieve goals such as completing their education, finding work, and avoiding unplanned subsequent pregnancies (Olds, Eckenrode et al., 1997). The nurses help young parents consider multiple options, make good choices about the environment in which they will raise their children, and take steps to create the kind of lives they want for themselves and their children.

During the first 15 years after delivery of their first child, low-income, unmarried women in the Elmira trial who received nurse home visits had fewer subsequent children (1.1 versus 1.6), longer intervals between the births of the first and second children (65 versus 37 months), 30 fewer months on welfare (60 versus 90 months), 44 percent fewer behavioral problems because of their use of drugs and alcohol, 82 percent fewer arrests, and 81 percent fewer convictions than those in the control group, as shown by State records. Results of the first phase of the ongoing Memphis replication study indicate that the program’s effects on maternal life course (especially reductions in the rates of subsequent pregnancies and births) are being reproduced (Kitzman et al., 1997).

Prenatal and Early Childhood Nurse Home Visitation	OJJDP Bulletin • November 1998