The power of wishful thinking: The continued promotion of Healthy Families America as a child abuse prevention program

by Marie Cohen

The original version of this post was published on April 4, 2022. I decided to update and re-publish it after reading a press release from Prevent Child Abuse America stating that “PCAA’s signature home visiting program, Healthy Families America, has been proven to reduce child abuse and intimate partner violence while improving long-term health and educational outcomes.” While I cannot evaluate the claim about domestic violence, the post below show that Healthy Families America has not been “proven” to reduce child abuse.

I have written before about the power of wishful thinking and how it causes people to disregard research and real-life results. A program called Healthy Families America (HFA) offers a good example of the power of wishful thinking. The nation’s oldest and largest charity (now called Prevent Child Abuse America or PCAA) dedicated to the prevention of child abuse launched HFA based on weak evidence that a program in Hawaii could prevent child maltreatment. The first experimental study of the Hawaii program found no impact on child maltreatment but did nothing to derail the launch of HFA, which grew into the centerpiece of PCAA. Studies of HFA programs around the country have found little evidence of reductions in child maltreatment, but the program has continued to grow. The story of HFA is a lesson in the power of wishful thinking and the failure of evidence (or lack thereof) to counteract it.

As told in a helpful history of home visiting, all modern programs can trace their origins to Henry Kempe, whose book, The Battered Child, brought about the recognition of child maltreatment as a national problem. To address child abuse, Kempe called for universal prevention through a network of home health visitors. Inspired by Kempe, modern home visiting began with Hawaii’s implementation of the Healthy Start Project (HSP) in 1975. HSP was developed on the island of Oahu. It had two components: early identification (at the birthing hospital) of families with newborns at risk of child abuse and neglect and home visiting by trained paraprofessionals for those families classified as at-risk who agreed to participate. This initial program was never evaluated, but anecdotal information suggested it was successful in promoting effective parenting, and six similar programs were established on neighboring islands.

The Hawaii Legislature authorized a three-year pilot program focusing on one neighborhood in Oahu, which began in 1985. There was no control group in the pilot study, and the researchers used CPS reports and changes in family stress in participating families to measure program effectiveness. During the three-year pilot, there were few reports of physical abuse, neglect or imminent harm for program participants. Because evaluations of other home visiting programs had found much higher rates of reported maltreatment in comparison group families, these results were viewed as evidence that the program had a positive impact. According to the authors of the first rigorous evaluation of HSP, “The pilot study results might have been given too much weight, given the lack of a control group and the short period of follow-up for most families.” Nevertheless, the results of this unpublished study were enough evidence for the Legislature to expand HSP throughout Hawaii starting in 1989.

Home visiting in general was gathering steam in the 1980s and early 1990’s. In 1990, the U.S. General Accounting Office (GAO) issued a report promoting home visitation as a “promising early intervention strategy for at-risk families.” In its summary of research evidence, GAO focused mostly on health and developmental benefits for children, rather than maltreatment prevention. In 1991, the U.S. Advisory Board on Child Abuse and Neglect issued a report recommending a pilot of universal voluntary neonatal home visitation, stating that the efficacy of home visiting as a preventive measure was “already well-established.” The Board cited the results of a federally-funded demonstration begun 17 years earlier as well as the the nurse home visitation program started by David Olds in 1977. But HSP was not mentioned.

Despite the lack of a rigorous evaluation, the National Committee to Prevent Child Abuse (NCPCA, now called Prevent Child Abuse America), which bills itself as the nation’s “oldest and largest organization committed to preventing child abuse and neglect before it happens,” had become interested in using HSP as the nucleus of a national home visiting program. But first, NCPCA conducted a one-year randomized trial of HSP. The trial suffered from severe methodological limitations, including “less than ideal followup,” differential dropout rates in the program and control groups, the failure to blind interviewers to experimental or control status, and reliance on program staff rather than researchers to measure some outcomes. Nevertheless, the trial concluded that HSP reduced child maltreatment, and this apparently gave NCPCA the assurance it needed to invest in the model.

NCPCA launched Healthy Families America in 1992, with financial support from Ronald MacDonald House Charities. Rather than impose a single service model, HFA was based on a set of principles or critical elements, which included initiation of services prenatally or at birth, assessment of the needs of all new parents in the target area, voluntary nature of services, at least weekly services for families with the highest needs, availability of services for three to five years, comprehensive nature of services, and cultural competence, among others. The typical HFA program included an assessment of all new or first-time parents in a given community at the time their babies are born or prenatally.”

In the meantime, the Hawaii Department of Health recognized the limitations of both the pilot study and the NCPCA study and initiated a more rigorous evaluation of HSP in 1994. This was a randomized controlled trial, with at-risk families identified at the hospital and randomly assigned to the experimental and control groups. In 1999 the results of the Evaluation of Hawaii’s Healthy Start Program were released as part of an issue of the Future of Children journal containing evaluations of six different home visiting models. No overall positive program impact emerged after two years of service in terms of child maltreatment (according to maternal reports and child protective services reports). Early HFA evaluation results, published in the same issue, also failed to find effects on abuse and neglect in three randomized trials, which included the HSP evaluation discussed above and another Hawaii HSP study.

David Olds had had begun testing his Nurse Home Visiting Program in 1977 and already had long-term results on the program in Elmira, NY, as well as shorter-term results for a replication in Memphis, Tenn. That program, now known as Nurse Family Partnership, was very different from HFA. It was restricted to first-time teenage mothers and the home visitors were nurses rather than paraprofessionals. The nurses followed detailed protocols for each visit. The researchers found that among low-income unmarried women (but not other participants), the program reduced the rate of childhood injuries and ingestions of hazardous substances that could be associated with child abuse or neglect. Follow-up of the Elmira group when the children were 15 found that the nurse-visited mothers were significantly less likely to have at least one substantiated report of maltreatment. These results are particularly impressive because they overrode a tendency for nurse-visited families to be reported for maltreatment by their nurse visitors. The researchers concluded that the use of nurses, rather than paraprofessionals, was key to the success of the program.

In their analysis of all six studies published in the Future of Children volume on home visiting, Deanna Gomby et al. concluded that while the HFA and HSP evaluations showed some change in maternal attitudes and self-reported behaviors related to abuse and neglect, only the Nurse Home Visiting Program showed impacts on abuse and neglect other than from self-reports. Gomby and her co-authors also concluded that the results of all six home visiting evaluations were discouraging for those who had high hopes for home visiting for solving an array of problems. All the programs “struggled to enroll, engage and retain families.” Program benefits generally accrued to only a subset of enrolled families and were often quite modest. The authors explained the disappointing results by concluding that human behavior is hard to change, particularly when problems are community-wide. They recommended that “any new expansion of home visiting programs be reassessed in light of the findings presented in this journal issue” and stated that home visiting services are “best funded as part of a broad set of services for families and children.”

But the home visiting juggernaut was already in motion nationwide. And NCPCA, renamed Prevent Child Abuse America in 1999, had already made HFA its centerpiece program. Home visiting grew, and HFA grew with it. In 2010, Congress created the Maternal, Infant and Early Childhood Home Visiting Program (MIECHV), which was re-authorized in 2018 with funding of $400 million per year through FY 2022. HFA is one of the models that are most frequently implemented with MIECHV dollars. Home visiting programs can also receive funding through Medicaid, Title IV-B and IV-E of the Social Security Act, and many other funding sources. HFA now serves over 70,000 families per year at an average cost of over $3,000 for a family in its first year of home visiting.

The infusion of funding for HFA research resulted in a multitude of research projects (both randomized trials and less rigorous studies) and resulting publications. Nevertheless, research has yet to find solid evidence that these programs have an impact on child maltreatment: The California Evidence-Based Clearinghouse for Child Welfare (CEBC), the pre-eminent child welfare program clearinghouse, reviewed 19 research reports on HFA. Its website as of April 2022 gave the program a rating of “4” on a scale of 1 to 5 for prevention of child abuse and neglect, meaning the evidence fails to demonstrate that HFA has an effect on abuse and neglect. Interestingly, that rating no longer appears on the CEBC website, but the earlier version is preserved by the Wayback Machine. As of April 2025, HFA is no longer listed at all in the CEBC’s document titled Home Visiting Programs for Prevention of Child Abuse and Neglect. When I emailed the CEBC to ask about the missing rating, I received an email stating that Healthy Families America “is still currently under review in the Prevention of Child Abuse and Neglect topic area. The rating for this topic area was pulled from the website during the rereview process. Some programs take longer to review due to the amount of research and other factors.”

HFA was not designed to work with families that have already been found to abuse or neglect their children but that did not stop child welfare agencies from spending federal and state funds delivering HFSA to families under the Family First Prevention Services Act (FFPSA). Despite the lack of evidence of its impact on maltreatment, HFA received a rating of “Well Supported” from the clearinghouse established by FFPSA to determine whether a program can receive federal funding under Title IV-E of the Social Security Act. To get such a rating, the program must show improved outcomes based on at least two randomized trials or rigorous quasi-experimental studies. But these outcomes could be any sort of “important child and parent outcome,” (not just reduction of child abuse or neglect) and there is no standard for how to measure each outcome. Based on its review of all HFA studies that met their criteria for inclusion, the Clearinghouse found 23 favorable effects, 212 findings of no effect, and four unfavorable effects across 16 outcomes. This included five favorable effects on child safety based on parents’ self-reports of maltreatment, with no favorable effects on other measures of child safety. Self-report is generally frowned upon as a measure of child maltreatment, for obvious reasons. A positive impact of HFA might reflect that participants in HFA were more eager than control group members to provide the “right answer” to questions about maltreatment.

The “well-supported” rating from the Title IV-E clearinghouse allowed states to spend Title IV-E funds on services to families with a child welfare in-home case. To take advantage of this new market, HFA announced in September 2018 that families referred by the child welfare system were now able to enroll as long as the child in question was 24 months of age or younger, as opposed to the original requirement that services start at or before birth. To serve these families, HFA introduced special child welfare protocols. HFA advertises these protocols on its website, stating that “HFA’s evidence and the flexibility of enrollment make HFA a great prevention choice for states and child welfare organizations seeking to strengthen families and reduce the number of children placed in foster care.” (Note that there is no mention of reducing abuse and neglect!)

Today, the diversity of HFA programs makes evaluation of the program as a whole impossible. According to the website, “HFA puts communities in the driver’s seat. Local HFA programs are able to choose their eligibility criteria, parenting materials, and hire the staff they deem best to do the job. With the amount of flexibility offered, HFA has been able to be successfully implemented in a wide variety of communities.” It is hard to imagine what the evaluation of one HFA program means about the effectiveness of other programs under the same name.

Critical examination of the HFA website shows that the organization skews its portrayal of available research to present it in the most favorable light and avoids direct statements that the program prevents child abuse and neglect. On its Evidence page, HFA claims the “highest rating possible from CEBC in the category “Home Visiting Programs for Child Well-Being,” without mentioning that in the category “Home Visiting Programs for the Prevention of Child Abuse and Neglect,” HFA is currently unrated after the statement that it was unable to demonstrate an effect was removed. The page goes on to group the effects of HFA into three categories, stating that participants “build nurturing relationships with their children,” “champion their children’s health and development,” and “cultivate a flourishing future for their family.” Reductions in abuse and neglect are not mentioned in the description of how parents “build nurturing relationships with their children.”

It is disappointing that an organization that defines its mission as child abuse prevention, decided to fund HFA before it was proven to prevent child maltreatment and continued with this commitment even after the disappointing evaluations of 1999 might have led them to diversify their investment. That PCAA continues to use charitable contributions made for the prevention of child abuse and neglect to fund a program that has not been proven to accomplish this goal, raises serious ethical questions. Twenty-three members of the 45-person staff (which has grown by five staff in three years !) listed on the Prevent Child Abuse website have duties linked to Healthy Families America.

The story of HFA is not an unusual one. I have written about the similar disregard for evidence in the promotion of models such as Homebuilders and blind foster care removals. Such stories are all too frequent. They show us how wishful thinking can drive leaders to disregard research, especially after they have made a premature decision to commit to one program or course of action.

Family First at five: Not much to celebrate

When the Family First Prevention Services Act (FFPSA) passed as part of the Bipartisan Budget Act of 2018, it was hailed by many as a revolutionary step in the history of U.S. child welfare. Five years after the Act took effect, child welfare leaders have been weighing in with statements like this one from Rebecca Jones Gaston, Commissioner of the Administration on Children, Youth and Families: “Following its passage five years ago, the Family First Prevention Services Act has transformed our approach to child welfare and benefited families across the many states that have used it to provide concrete support and services.”¹ But for those closer to ground-level and less invested in demonstrating the act’s success, there’s not much to celebrate.

FFPSA had two major goals: to keep children out of foster care altogether through services to families and to keep more of those who do have to enter care in family homes. In terms of the first goal, the law’s impacts on services to families have been almost negligible. And in its effort to keep foster children in families, FFPSA has exacerbated the critical shortage of appropriate placements for our most troubled youth, many of whom may need placements in larger settings. In this post, I examine these two goals and their outcomes in greater detail.

FFPSA’s Part I made it possible to allocate funds under Title IV-E of the Social Security Act, previously directed mainly to foster care, to services aimed at keeping children out of care. The law allowed spending on mental health, substance abuse prevention and treatment, and in-home parenting services, “when the need of the child, such a parent, or such a caregiver for the services or programs are directly related to the safety, permanency, or well-being of the child or to preventing the child from entering foster care.”

As I explained in my 2019 post, Family First Act: a False Narrative, a Lack of Review, a Bad Law, Part I was based largely on the false premise that current law, by allowing TItle IV-E funds to pay for foster care and not for services to prevent it, incentivized states to remove children rather than keep families together. While it is true that IV-E funds were not available to pay for services to children and families in their homes, that does not mean that no money was available to help keep families together or that states had an incentive to place children in foster care. In fact, states had long been using Medicaid and other funds for services to prevent placement of children in foster care. In Federal Fiscal Year 2017, according to federal data, out of the children who received services after a CPS investigation or alternative response, only 201,680 were placed in foster care, while 1,332,254 (or more than five times as many children) received in-home services such as case management, family support, and family preservation services.²

Disregarding the role that other funding already played in child welfare, the framers of FFPSA required that Title IV-E would be the “payer of last resort,” so that any services already paid for by Medicaid could not be paid for by Family First. By doing this, they ensured that states with a generous Medicaid programs would be hard-pressed to find any service already existing in the state on which to spend their TItle IV-E money. If not for this provision, such states might have chosen to supplement Medicaid funding for some of these services. Perhaps some states would have allowed Title IV-E funds to be used to pay high-quality providers who do not accept Medicaid funding due to the program’s low reimbursement rates and high paperwork burden. (During my time as a foster care social worker in the District of Columbia, we had contracts with high-quality providers who did not accept Medicaid in order to provide therapy for our most complex clients).

The choice to fund only parenting, mental health and drug treatment services by the framers was another design flaw of FFPSA. The absence of a domestic violence service among the funded services is striking. It is universally acknowledged that drug abuse, mental illness and domestic violence are the “big three” factors that result in foster care placement. But for some reason, the words “domestic violence” are nowhere to be found in FFPSA. Perhaps even more striking is the failure to include one of the most promising services to prevent foster care–high-quality child care. As I have written, not only does quality early care and education prevent foster care placement through multiple pathways, but it also provides an extra set of eyes on the child in case of continued abuse or neglect–greatly needed if FFPSA is to achieve its goal of keeping children both safe and out of foster care. Think of what a difference Congress could have made by providing matching funds to provide quality child care to all families with in-home cases!

Perhaps the most unfortunate feature of FFPSA’s Part I is the requirement that all funds must be spent on “promising, supported or well-supported practices,” with 50 percent of the total spent spent on “well-supported practices” — a percentage that increases after 2026. The law imposes strict requirements for designating a program as promising, supported or well-supported. It set up a clearinghouse to assess the data on existing programs and approve those that met the criteria. As Dee Wilson points out in one of his essential commentaries, the law gets it exactly backwards. We have very little evidence about what works to prevent foster care placement. What we need is to invest in innovative approaches to doing this safely. But FFPSA prevents the use of TItle IV-E funds for this purpose.

Thanks to the various restrictions imposed by FFPSA, the clearinghouse is woefully incomplete. For example, Cognitive Behavioral Therapy (CBT), the therapy of choice for depression and anxiety, which has not been approved nor is it on the list of programs to be examined by the clearinghouse. (“Trauma-Focused CBT,” a newer and much narrower and short-term model, has been approved.) No residential drug treatment program has been approved or is even slated to be considered. The requirement that the practice have a manual may be at fault for the failure to include CBT and residential drug treatment programs, but I’d like to hear from readers who may be better-informed. Buphenorphine therapy for opioid use disorder, which is often preferred to methadone therapy (which is approved by the clearinghouse)because it does not require daily clinic visits, has not been approved and is not slated for consideration, according to the Clearinghouse.. Of course, these popular programs are often funded by Medicaid anyway, so they would be ruled out by the last resort provision as well.

With all these restrictions on Title IV-E spending, it is not surprising that states have been hard-put to find useful ways to spend Title IV-E funds to keep families together. In an important article, Sean Hughes and Naomi Schaefer Riley cited the latest available federal data showing that just 6,200 children across the entire country received an FFPSA-funded service in FFY 2021, costing a grand total of $29 million. That is truly underwhelming given that about 600,000 children were found to be victims of maltreatment in FFY 2021.

The other major purpose of FFPSA was outlined in Part IV, entitled “Ensuring the Necessity of a Placement that is not in a Foster Family Home.” The purpose of this part was to keep more children out of “congregate care,” a term used to designate settings other than foster homes, such as group homes and residential treatment centers. FFPSA made it more difficult to place a child in a congregate placement by imposing conditions on Title IV-E reimbusement for such placements, and by limiting reimbursement after two weeks to facilities that qualify as “Quality Residential Treatment Programs (QRTP’s), a new category defined by the act. QRTP’s must meet strict criteria that many facilities that were caring for foster youth at the time of FFPSA’s passage could not meet without major changes. The act also (perhaps inadvertently) further restricted the number of congregate care beds available to foster youth by creating a conflict with a Medicaid provision called the “Institutions for Mental Diseases (IMD) exclusion” that prevents Medicaid paying the cost of care for children who are placed in facilities with more than 16 beds.“

Like Part I, Part IV of FFPSA was in large part based on a false narrative. The myth this time was that every child does better in a family rather than in a more institutional setting. But as I described here, there are many foster youths who cannot function in an ordinary foster home, at least until after a stay in a high-quality residential treatment program or group home. These are the same young people who bounce from home to home and end up in hotels, offices, jails, and other inappropriate settings, but FFPSA made no provision for them.

Even if too many children had been placed in residential care without sufficient clinical justification (which is probably the case in at least some states), it would not be responsible to shut down congregate care placements before ensuring that appropriate foster homes were available for all the children being displaced. But just as the deinstitution movement of the 1960s closed mental hospitals before putting alternatives in place, FFPSA disregarded the question of where children would go when congregate settings disappeared.

As I described here, FFPSA exacerbated trends that were already underway. Group homes and residential treatment centers were already shutting down due to growing publicity about abusive incidents at some facilities, failure of reimbursement rates to keep up with costs, and resignation of staff due to poor pay and working conditions. Tragically, this reduction in residential capacity coincided with increased demand for care due to the youth mental health crisis and increasing levels of need in the foster care population due at least in part to delays in removing children from abusive and neglectful homes. The restrictions put in place by FFPSA added to the problem. As Hughes and Schaefer Riley put it, “If you want to understand why foster children across the country are being housed in a range of inappropriate temporary settings, including county and state offices, hospitals, hotels and shelters, FFPSA is a significant factor.”

The trends just mentioned have contributed to a foster care placement crisis that has if anything worsened since I described it last October. In Illinois, the Department of Children and Family Services (DCFS) is being sued by the Cook County Public Guardian for allowing foster children to remain locked up in juvenile detention even after they’ve been ordered released. In Maryland, a disability rights group has just filed suit against the Department of Human Services and other agencies for keeping foster children in hospitals and restrictive institutions beyond medical necessity for weeks, months, or even as long as a year. In a must-read article, Dee Wilson documents a 370 percent increase in hotel/office stays in his state of Washington since 2018 despite a federal court order to stop the practice. At an average cost of up $2,000 per night (including the cost of paying two social workers and a security guard), overnight hotel placements cannot possibly be cheaper than group homes or residential treatment centers. Similar problems are reported around the country, differing only in which inappropriate settings each state is relying on.

As is often the case, California paved the way for FFPSA by passing its Continuum of Care Reform, designed to curb the use of congregate placements, in 2015. A new article in the Los Angeles Times recounts the results. The number of children living in congregate care has dropped from 3,655 to 1,727 since implementation of the law, but the state has failed to find the foster homes to replace the congregate care settings. As a result, Los Angeles County has placed more than 200 foster youths in hotels, sometimes for months. County officials report that two social workers have been assaulted by foster youths in separate incidents this year at hotels. Moreover, it appears that care at the existing congregate facilities has grown worse as larger numbers of troubled youths are placed together in fewer facilities. The results of California’s reform and of FFPSA were predictable and indeed predicted by some commentators (including this writer), but these predictions were ignored.

As Dee Wilson puts it, “The implementation of Family First legislation has accelerated the demise of residential care, which has decreased 25% nationally during the past five years. It has been the goal of the federal Children’s Bureau and influential foundations to reduce the use of residential care (which has a bad reputation among advocates and most scholars) and they have succeeded; but without developing — or sometimes even proposing – viable alternatives.”

Anyone who chooses to celebrate the “revolution” wrought by FFPSA is living in a dream world. It’s time for Congress to recognize and correct the many errors it made in passing the law. At a minimum, Congress should add funding for early care and education and domestic violence programs to the models that can receive funding under Title IV-E, loosen the standards for evidence-based practices, modify the last-resort provision to allow payment for services to providers who do not accept Medicaid, eliminate some of the restrictions on congregate care, and provide incentives for states to boost their capacity of quality residential programs. Until such changes are made, there will be nothing to celebrate.

Alexia Suarez (asuarez@wearerally.com), [YOU’RE INVITED] Expert panel on the Family First Prevention Services Act. Email message, May 15, 2023.
These are duplicated counts as children are counted again each time they are the subject of an investigation and receive post-response services.