Poverty

Neglect is more directly associated with poverty than other types of child maltreatment. ^, Children living in high poverty areas are six times as likely to experience neglect, compared with children living in low poverty areas. Impoverished neighborhoods are often characterized by high levels of unemployment and vacant housing, which are associated with high maltreatment rates. Population loss in some impoverished neighborhoods leads to low levels of social contact and support, which are associated with neglect. Families living in impoverished neighborhoods often have fewer opportunities to meet children’s needs than families living in middle-income communities, particularly if population loss is accompanied by reductions in services such as hospitals, schools, playgrounds, and transportation. Families in low-income communities also have few resources to adequately meet their children’s physical needs of nutrition, clothing, and personal hygiene. Poverty exacerbates other risk factors for neglect, such as food insecurity, poor maternal nutrition, maternal depression, and stressful life events.

Food Insecurity

Food security is defined as access to enough food for an active, healthy life for all household members, and food insecurity is defined as limited or uncertain access to enough food to meet basic needs for household members at all times. ^, These definitions capture both the availability of food and the anxiety or concern regarding limited food availability. Food insecurity has been associated with negative consequences for children in the first 3 years of life, including worse caregiver-reported health, more hospitalizations, a higher likelihood of developmental risk, and behavioral problems. The mechanisms linking food insecurity with negative consequences for children include both nutritional pathways (compromised with both the quantity and quality of food available) and nonnutritional pathways (increased anxiety and stress related to the inconsistent availability of food). Thus, food insecurity threatens children’s physical and psychological health, serving as a form of both physical and emotional neglect.

Poor Maternal Nutrition

Recent research has suggested that maternal nutritional status may be related to parenting behavior, and specifically to child neglect. For example, iron deficiency, the most prevalent single nutrient deficiency in the world, is associated with reduced work capacity, poor immune function, and changes in cognition, emotions, and behavior. Although most of the research has focused on young children, there are reports of altered cognition and behavior in iron-deficient women of reproductive age. Behavioral symptoms associated with iron deficiency in adults include irritability, apathy, fatigue, depressive symptoms, and hypoactivity. Two reports from South Africa included anemic and nonanemic mothers evaluated at 10 weeks and 9 months postpartum. ^, Not only was iron status associated with measures of cognition, anxiety, stress, and depression, but anemic mothers who received iron treatment experienced a 25% improvement ( P < .05) in measures of cognition, depression, and stress, compared with anemic mothers who received placebo. In addition, infants of anemic mothers demonstrated developmental delays at 10 weeks that were sustained through 9 months in spite of iron treatment. At 9 months, anemic mothers were significantly more negative toward their babies, with less goal setting and responsivity than nonanemic mothers. In contrast, anemic mothers who received iron treatment had similar behavioral observation scores to nonanemic mothers, suggesting the protective effects of iron on maternal parenting behavior. Thus, iron-deficient mothers appear to be at risk for neglecting their children.

Maternal Depression

Maternal depression has been identified as a predictor of neglect. ^, Between 10% and 15% of postpartum women experience depressive symptoms, and postpartum depression has been identified as a predictor of neglect. Depression can interfere with mothers’ ability to provide consistent affectionate and stimulating contact to their infants; in extreme cases, mothers are unable to respond to their children’s needs at all. In a metaanalysis, Lovejoy and colleagues found that the relation between maternal depression and negative maternal parenting behavior was moderated by timing of the depression, with the strongest effects for current, as opposed to past, depression. In addition, effects were strongest for low-income women and mothers of infants, highlighting the vulnerability early in life when women are transitioning to a new role and can have limited support and confidence, particularly in low-income communities.

Stressful Life Events

Stressful life events are predictors of neglect. Kotch et al found an interaction between stress and social support, such that children in families with high stress and low social support were the most at risk for child maltreatment. Financial difficulties, substance abuse, illness, and daily stressors strain a family’s resources, exacerbate family conflict, and potentially lead to neglect.

Interpersonal Violence

Interpersonal violence has consistently been identified as a life event that is a predictor of neglect. More than one third (35%) of neglect cases also include reports of interpersonal violence. Perpetrators of interpersonal violence might not be focused on the physical or emotional needs of their children, and victims of interpersonal violence might be fearful and unable to adequately meet their children’s needs.

Child Temperament

Child characteristics have been identified as factors associated with neglect, although the direction of the association is not clear. Neglect is associated with maternal report of difficult temperament. ^, Mothers who described their infants as temperamentally difficult were more likely than other mothers to have a reported incident of neglect 2 years later. Harrington et al found that maternal reports of temperamental difficulty were associated with emotional neglect, but not physical neglect. It is not clear whether mothers who neglect are more likely to perceive their child as difficult, or whether children with a difficult temperament make it more difficult for mothers to meet their emotional and physical needs.

Child Development and Behavior

Multiple investigators have found that children with disabilities are at increased risk for maltreatment, possibly through the challenges and stress facing their families. ^, A recent investigation of the administrative records of over 100,000 children under age 6 years in Illinois receiving Medicaid between 2000 and 2006 found that children with chronic health conditions or behavioral/emotional problems were at increased risk for abuse and neglect, particularly if they had been maltreated in the past. A diagnosis of developmental delay/mental retardation, however, did not increase the risk of maltreatment. In contrast, other investigators have found that infants with low mental and motor development scores at 9 months of age were more likely to have experienced neglect by age 2 than other infants. The discrepancy may be partially explained by the data source. Administrative records include diagnosed problems, rather than caregiver-identified problems, that might be as yet undiagnosed among children under age 6.

Infancy

Most of the maltreatment that occurs during infancy is neglect, given the dependency needs of infants. The interdependence between infants and their primary caregivers is well documented. Early infancy begins as a period of dependence as infants learn about their social-emotional environment through interactions with their primary caregivers. As infants and caregivers develop mutuality through a reciprocal process of looking to one another for affective cues and responses, they develop a synchrony in which responses stimulate expectations for subsequent interactions. Under ideal conditions, infants and caregivers develop a mutually satisfying pattern of interactions that facilitates healthy physical and psychological development in the infant. Infants learn that their needs will be met according to predictable cues, and they learn to trust their caregivers. When caregivers are not consistent in their responses, infants can be denied models to imitate and contingent feedback. Without satisfying interactions, infants might have difficulty developing trust and a secure attachment with their primary caregivers and are at risk for subsequent emotional and relational problems.

Research from the 1940s demonstrated that institutionalized infants experienced severe and often permanent declines in their health and development, even when they had adequate food. The lack of nurturance and stimulation disrupted the children’s cognitive and psychological development. Data from Romanian orphanages characterized by few staff and limited opportunities for nurturance and stimulation have shown that by age 3 years, infants experience poor growth, cognitive delays, and multiple psychological problems including attachment disorders, autistic-like behaviors, and poor social skills. These findings highlight the negative consequences of severe emotional neglect on children’s psychological functioning very early in life.

In a recent application of developmental-ecological theory among very low income, inner-city families of infants and toddlers, the relationships between neglect and child and family functioning differed by the type of neglect. Emotional neglect was associated with a path from family functioning through perceptions of child temperament. There were no direct links from family functioning, support, or life events to emotional neglect, but mothers who were involved in well-functioning families were more likely to regard their child as having an easy temperament, and children who were perceived as being relatively easy were less likely to experience emotional neglect. These findings illustrate the importance of conceptualizing neglect from a developmental–ecological perspective that incorporates the family and the child’s contributions through their temperament. The link between mothers’ perceptions of their children’s temperament and child neglect suggests that maternal perceptions of children’s temperament are an important component of neglect that should be incorporated into intervention strategies. In contrast, when physical neglect was considered, there were no associations with child temperament and family context. Thus, different factors are associated with physical and emotional neglect.

School-Aged Children

Several investigators have shown that neglected children are more likely to exhibit developmental, emotional, and behavioral problems than are nonneglected children. There is variation, however, in the specific behavior problems shown by neglected children. Investigators have noted that at times neglected children are passive and withdrawn, and at other times, they are aggressive. Thus, children who have been neglected might have dysfunctional working models of social interactions, and in response to routine peer play, display both withdrawn and aggressive behavior.

Egeland et al ^, followed four groups of mother–child pairs (abusive, neglectful, psychologically unavailable, and non-maltreating controls) and reported that children of neglectful and psychologically unavailable mothers were more likely to be anxiously attached when compared with non-maltreated children. Without a secure attachment relationship with the primary caregiver, the tasks of autonomy and self-development and the ability to form trusting relationships with peers are threatened. Neglected children have fewer positive social interactions with peers than do non-neglected peers and are often less self-assured.

The vulnerability of neglected children has been well described in a longitudinal follow-up study. By early school age, neglected children had deficits in cognitive performance, academic achievement, classroom behavior, and personal social interactions with peers and adults. The neglected children rarely expressed positive affect and demonstrated more developmental problems than any other subgroup of maltreated children. Several authors have found that children with a history of neglect have more school absences, more retentions, and lower grades than do non-neglected children.

Risk and compensatory factors also influence children’s adjustment to neglect. For example, a child who is intelligent, attractive, or talented may be more able to withstand neglectful situations than one who is not intelligent, not attractive, and has low self-esteem. Although protective factors can mitigate against some of the negative sequelae associated with neglect, Farber and Egeland argued that the environmental challenges associated with maltreatment, and particularly with neglect or psychological unavailability, tend to overpower these protective factors, thereby increasing children’s vulnerability.

Adolescents

The adolescent period is marked by transition as the dependency of childhood evolves into the independence (or interdependence) of adulthood. The primary tasks of adolescence are to form multiple attachment relationships, to internalize standards of morality, and to assume responsibility for personal actions. Adolescents who have experienced prior neglect are at risk for emotional and behavioral problems if they have not mastered earlier developmental tasks successfully.

Neglect during adolescence can be particularly difficult to define, because the boundaries between adolescent independence and parental responsibility are unclear. As children age, the influence of parents is supplemented and sometimes replaced by the influence of peers and other forces in the community. Although adolescents do not require the close supervision required by younger children, they continue to require parental guidance and monitoring. Adolescents benefit from clear parental demands that are established using a warm, democratic, and respectful approach. Without access to parents who provide both supervision and nurturance, adolescents can be at increased risk for behavioral and emotional problems, such as engaging in high-risk behaviors (e.g., early initiation of sexual activity, substance abuse).

Biological Stress Response

Animal studies have suggested that neglect in the form of maternal deprivation is associated with disruptions to the development of the biological stress response. DeBellis explains that children process neglect as intense anxiety and stress, which activates their neurotransmitter systems, neuroendocrine system, and immune system. The major brain catecholamine neurotransmitters are serotonin and dopamine. Serotonin plays an important role in mood and behavior regulation. Low and dysregulated levels of serotonin have been associated with depression, aggressiveness, impulsivity, and suicide. Primate studies have shown that in response to chronic stress, serotonin levels in the prefrontal cortex drop, although they might increase in other areas of the brain. In response to stress, dopamine prefrontal cortical function is enhanced to prepare for a response to the stress. In response to chronic stress, however, there can be an overproduction of dopamine-impairing prefrontal cortical functioning rather than enhancing it, leading to inattention, hypervigilance, cognitive problems, and paranoia.

Recent advances in behavioral neuroscience have shown the important role that experiences, such as neglect, can have on brain development. Brain development begins prenatally with an overproduction of neurons and continues through school years. Brain development begins with the formation of brain cells, followed by cell migration and differentiation, the development of synapses to enable cells to communicate with one another, and the formation of myelin, supportive tissue that protects the nerve cells and facilitates communication. During the first 4 years of life, there is selective pruning of synapses, along with myelination.

The process of forming and eliminating synapses is influenced by individual experiences. Greenough and colleagues argue for the distinction between two types of experiences: experience-expectant and experience-dependent. Experience-expectant refers to species-specific development, such as sensory and motor systems. The maturational influences that guide development are operationalized by experiences that are expected, such as adequate care. Expected experiences “influence the brain by causing chemical changes within cells that influence cell function and structure.”

In contrast, experience-dependent development occurs in the context of unique experiences. They enable children to adapt to specific cultures and the demands of their environment. When children are denied such experiences (e.g., through neglect), they might not develop the synapses necessary for optimal functioning. Structural changes in synaptic formation appear to be dependent on neurochemical-receptor systems that, in turn, are influenced by basic caregiving experiences.

The timing of early developmental experiences has been a central issue in studying behavioral neuroscience. The critical or sensitive period hypothesis suggests that if an event, such as neglect, occurs during a specified period, often during periods of rapid development, it will have specific effects on the organism. In addition, since components of the central nervous system develop along differing schedules, the sensitive periods of the components likely vary with respect to onset and duration.

The field of behavioral neuroscience is emerging with the development of safe procedures to conduct neuroimaging studies in children (see Chapter 54, “Effects of Abuse and Neglect on Brain Development” ). In a recent review, DeBellis identified several studies using magnetic resonance imaging (MRI) to examine brain structure in children who experienced child neglect. The adverse effects of neglect on brain structure appeared to be particularly prominent among children (especially males) with maltreatment-related PTSD. Future research, using techniques such as functional MRI, will be helpful in understanding differential patterns of brain activation related to neglect.

Developmental Systems Theory

Developmental systems theories (DSTs) ^, can also be helpful in understanding the multiple mechanisms linking neglect with children’s psychological functioning. DST is based on ecological theory and conceptualizes interactions across multiple levels, extending from basic biological processes to interactions at individual, family, school, community, and cultural levels. As with any systems model, interactions are bidirectional, such that changes in one aspect of the system may affect relations and processes throughout the system.

Play Therapy

Allin et al conducted a systematic review of the literature on the treatment of child neglect between 1980 and 2003. They identified 54 studies that met the content-specific selection criteria of (1) including children and families who had experienced neglect, (2) describing an intervention, and (3) measuring an outcome. Only 14 studies had an observational or experimental design that included a comparison group; two were rated as good, three as fair, and nine as poor. Both of the studies rated as good evaluated play therapy for children who had been neglected.

First, Fantuzzo et al conducted a randomized controlled trial of resilient peer treatment. Their sample included 46 African American children from Head Start centers who had been identified as socially isolated by teachers and independent classroom observers. Twenty-two children in the sample had a documented history of physical abuse, neglect, or both. Children in the experimental group were each matched with a resilient peer. Resilient peers were identified by observers as engaging in high levels of positive play with other children in the classroom. Head Start parent volunteers served as play supporters, and they encouraged peer dyads to play in a designated corner of the classroom for 15 sessions over 2 months. Play supporters observed the play and offered supportive comments to the dyad. Children in the control condition were matched with a peer with average play ability for 15 sessions and the play supporter observed the play sessions, but did not encourage peer play. At 2 weeks after intervention, classroom observers blind to the treatment condition rated children in the experimental group (both those with and without a history of maltreatment) as engaging in more positive play and less solitary play than children in the control condition. At 2 months after intervention, teachers rated children in the experimental group as exhibiting fewer internalizing and externalizing behaviors than children in the control condition.

Second, Udwin completed a randomized controlled trial of imaginative play with a sample of 34 preschool children who had experienced neglect, abuse, or both, and had been removed from their homes. Half of the sample was assigned to the experimental condition, which consisted of 10 30-minute imaginative play sessions led by a facilitator. The other half of the sample was assigned to a control condition that consisted of 10 30-minute play sessions with no active training in imaginative play. At 4 weeks after intervention, independent student observers rated children in the experimental group as exhibiting better peer interactions and cooperation, imagination, positive affect, divergent thinking, and less aggressive play, compared with children in the control group.

Family Interventions

Brunk et al compared multisystemic therapy (MST) and parent training (PT) in the treatment of child abuse and neglect. Families who were court-ordered to receive counseling following an incident of child abuse or neglect were offered the opportunity to participate in the research study, and half of the families agreed to participate. The 43 participating families were randomly assigned to either MST or PT. Both groups received 1.5-hour therapy sessions once a week, lasting for 8 weeks.

Families in the MST group received individual therapy at their home or in a health clinic. MST was tailored to the family’s needs; for example, neglectful parents received instruction on performing executive functions. Most families received education about child management strategies and behavioral expectations. Therapists served as advocates with outside agencies with about half of the families. PT was conducted with groups of parents in a health care clinic. Multiple therapists were present during PT, and sessions focused on instructing parents about human development and child management techniques. Families identified specific problem behaviors and therapists discussed behavior management programs.

Families were assessed before entering treatment and within 1 week following their final therapy session. Parents completed self-report questionnaires and were videotaped interacting with their child completing block design tasks. Results indicated that parents in both treatment groups reported reduced overall stress and a reduction in the severity of family problems. Independent coding of the parent–child observational task suggested that following the intervention, parents in the MST group showed increased effectiveness in their attempts to control their children’s behavior, children in the MST group were less passive, and neglectful parents became more responsive to their children’s behavior.

Meezan and O’Keefe ^, compared the effectiveness of a multifamily group therapy with the normal course of family therapy available to families with a history of child maltreatment. The sample included 81 families with an open case of child abuse or neglect with the Los Angeles County Department of Children and Family Services. The multifamily group therapy, Family-to-Family, was designed to alter intrafamilial interaction patterns and increase parental responsiveness to prevent and treat child maltreatment. The program was tailored to meet the needs of the individual family. Families in the Family-to-Family group met with a team of four clinicians for 2.5 hours per week over 8 months. Family-to-Family included six themes: (1) physical, emotional/social, and cognitive development, (2) discipline, responsibility, and self-regulation, (3) value, character building, and self-respect, (4) focus on feelings, (5) person, partner, and parents … plus, and (6) productive communication and relationship building. The program also included a case management approach that linked families to community resources, such as food banks.

Families in the comparison group received the course of family therapy that was typically available to families with an open child maltreatment case. The comparison treatment included structural family therapy, behavior modification, cognitive-behavioral therapy, and case management. Families attended about 10 1-hour individual family therapy sessions. The main outcome of this study was child abuse potential and appropriate discipline, measured by the Child Abuse Potential Inventory (CAP). These data were collected through self-report questionnaires completed at pre- and post-intervention. Both therapy groups had high child abuse potential scores above the clinical cutoff at pretest. After the intervention, CAP scores in the experimental group decreased significantly, ending below the clinical cutoff. Scores in the comparison group decreased slightly but remained above the clinical cutoff.

Home Visitation

The Nurse Home Visitation Program designed by Olds and colleagues ^, is one of the most well-known long-term follow-ups of a randomized trial to prevent problems among new mothers, including child abuse and neglect. The original sample included 400 first-time mothers recruited before the 30th week of pregnancy, 85% of whom were unmarried, adolescent, or poor. Families were randomly assigned to one of four treatment conditions: (1) no services during pregnancy, and infant screening between 1 and 2 years of age, (2) free transportation to prenatal care and well-child visits, and infant screening, (3) biweekly nurse home visitation during pregnancy, transportation, and infant screening, and (4) nurse home visitation during pregnancy and through 2 years postpartum, transportation, and infant screening. Nurse home visitors provided family support and education regarding fetal and infant development and linked families with services.

During the first 2 years postpartum, Department of Social Service records indicated that 19% of highest-risk mothers (poor and unmarried adolescents) in the comparison group had an officially reported incident of child abuse or neglect, compared with 4% of highest-risk mothers in the nurse visitation group. Among participants in the comparison group, incidence of maltreatment was associated with low maternal sense of control. This association was not statistically significant among mothers in the nurse visitation treatment groups.

Project SafeCare is a home visiting program that was designed to address three factors closely linked with child neglect: (1) home safety, (2) infant and child health care, and (3) stimulation/bonding or parent–child interaction. ^, Families in the intervention were either referred by a child protective service agency following a report for child abuse or neglect or referred by a local hospital’s maternal health education office. Children of families in the latter group were identified as at risk for maltreatment, because parents were young, single, and/or poor. More than 40% of the participants in Project SafeCare spoke Spanish exclusively. Project SafeCare families were matched with comparison families from the same child protective service offices that were referred to other services.

The Project SafeCare model includes 15 weeks of intervention with 5 weeks concentrating on each area, conducted on a one-on-one basis with nurses or research assistants. Interventionists provide education about developmentally appropriate skills and activities, safety hazards, cleanliness, locks, and how to respond when a child is ill. Substantiated incidents of abuse and neglect were used as the outcome measure in this study, and program evaluations indicate that families in Project SafeCare were less likely to experience neglect during the intervention period and during the 2 years following the intervention.

Family Connections

Few interventions have specifically targeted child neglect, so it is unclear how successfully the programs presented above prevented different forms of child maltreatment. To our knowledge, Family Connections is the first prevention program expressly targeting child neglect. One-hundred fifty-four families were randomly assigned to receive a 3-month (FC3) or 9-month (FC9) intervention. Targeted families lived in Baltimore, Maryland’s Westside Empowerment Zone, an area experiencing extreme poverty, unemployment, and economic distress. Eligible families had the following characteristics: (1) a referrer was concerned that neglect was occurring at a low level not yet reportable to CPS, (2) at least two risk factors for neglect related to the child (e.g., behavior problems, disabilities) or caregiver/family (e.g., substance abuse, homelessness), (3) no current CPS involvement, and (4) a willingness to participate. Prior CPS involvement was not an exclusion criterion for inclusion in the study. Families were referred by schools, community-based organizations, clinics, public social services, or self referred. After a baseline assessment, families were randomized into a treatment group and then connected with their interventionist, a social work intern. Families in both treatment groups received approximately 1 hour of services per week. Self-report data were collected via an audio computer-assisted self-interview.

Family Connections was developed using Bronfenbrenner’s theory of social ecology. The nine principles of the program are community outreach, individualized family assessment, tailored interventions, helping alliance, empowerment approaches, strengths perspective, cultural competence, developmental appropriateness, and outcome-driven service plans. The program has four core components. First, emergency assistance allowed interventionists to quickly assess a family’s critical needs and provide resources during a time of crisis (e.g., eviction notice). Goods and services were provided by resource directories, in-kind resources, and an emergency fund. Second, the home-based family intervention was tailored to the needs of each family after determining their specific risk factors. Third, service coordination was provided by interventionists who helped families access services. Fourth, multifamily supportive recreational activities were held at least four times a year to promote local, cultural, and recreational activities. Families also received newsletters with parenting tips and advertisements for free or low-cost family events. Family Connections is a unique program that combines graduate student education with service to the community. Graduate student social work interns serve as interventionists, with supervision provided by faculty members.

Three risk factor domains were assessed at pre- and post-intervention: caregiver depressive symptoms, parenting stress, and everyday stress. The four protective factor domains assessed included parenting attitudes, parenting sense of competence, family functioning, and social support. Child safety and child behavior were assessed through caregiver report. Child abuse or neglect reports were assessed by searching official child abuse and neglect records.

Prior to the Family Connections intervention, CPS had received 274 reports related to 87 of the 154 families in the sample. There were no significant differences in pre-intervention CPS reports between the FC3 and FC9 families. Twenty-four CPS reports were made related to 17 families during the intervention period and 11 reports were made regarding 11 families during the 6 months after intervention. There were no differences in the number of reports made regarding FC3 or FC9 families.

Caregiver depressive symptoms and parenting stress scores decreased over time in both treatment groups. Some improvements were noted in social support, parenting attitudes, and parenting sense of competence. Family functioning did not change over time in either group. Independent observers noted improvements in crowding and household sanitation over time in both groups. Children’s behavior problems decreased across both groups, although caregivers in the FC9 group reported greater improvements in child internalizing behavior than caregivers in the FC3 group.

DePanfilis and Dubowitz noted few differences in risk or protective factor changes between the FC3 and FC9 groups. Families in the FC9 condition reported being less satisfied with the program than FC3 families, and fewer FC9 families completed the program. The authors note that the burden of participating in a 9-month intervention might have been excessive for some families. Alternatively, interventionists might have worked with greater intensity among FC3 families, given the shorter intervention period.

Between 30% and 80% of families most at risk for child maltreatment complete prevention programs. Eighty-nine percent of families in the FC3 condition and 46% of families in the FC9 condition completed the Family Connections intervention. Girvin et al explored predictors of program completion. Results of multivariate quantitative analyses revealed that FC3 families were more likely to complete the program than FC9 families, but few depressive symptoms and high satisfaction with the service provider also increased the odds that a family would adhere to the program. Family Connections staff attributes their success to focusing on concrete needs first and then continuing to develop higher level skills that reduce the risk of child maltreatment. Future research is needed to measure less tangible factors that may be associated with adherence, such as motivation and engagement.

DePanfilis and colleagues have also investigated the cost-effectiveness of Family Connections. During one typical month of the intervention, staff spent 20.9 hours serving a typical FC3 family and 15.9 hours serving a typical FC9 family. During that month, 54 families were served at a total cost of $28,955. The total cost includes three staff salaries ($13,923), salaries for 12 social work interns ($13,206), rent and utilities ($722), supplies and copying ($298), transportation ($163), and client family expenditures ($643). The monthly cost per family was $607 for FC3 families (or $1,821 for 3 months) and $477 per FC9 family (or $4,194 for 9 months). Many of the pre- to post-intervention gains were similar between the FC3 and FC9 groups, which may suggest that the FC3 intervention was more cost-effective. Differences in child behavior scores were greater in the FC9 group, and the cost of a one-unit change in the child behavior score among FC9 families ($276) was slightly lower than the cost of the same change among FC3 families ($337).

Family Connections is an exemplary program for combining education with service, using a theoretical foundation, and conducting rigorous empirical testing. Without a comparison group that did not receive a Family Connections intervention, however, it is difficult to attribute changes over time to the program. Family Connections is currently undergoing a 5-year multisite replication. The cross-site evaluation will provide further empirical testing of the intervention.