Missed Opportunities for Child Maltreatment Prevention: Adverse Childhood Experiences, Mental Health and Substance Use Among Home Visiting Clients

Background: Child maltreatment and entry into the foster care system is largely tied to mental health and substance use issues of parents. Recent child maltreatment efforts in Texas have funded home visiting programs as a means to prevent child maltreatment, yet home visiting programs often leave little space for discussing more complex issues related to adverse childhood experiences (ACES) such as substance use and mental health.  Home visitors are in a unique position to discuss the impact of ACES on parenting behaviors and parent’s risk behaviors.  This study uses data from home visiting programs in Texas that are intended to prevent child maltreatment.

Methods: Over a nine month period, parents who entered home visiting programs in 16 counties in Texas (n=332) were asked to complete a survey detailing their risk and protective factors for child maltreatment.  Clients were given a survey on their second home visit and asked to complete it and place it in a sealed envelope prior to their third home visit.  The Adverse Childhood Experiences measure developed by researchers at the Center for Disease Control was utilized.  Mental health was measured by the the Mental Health Inventory 5 (MHI-5) and substance use was measured by the UNCOPE (6-item substance use screen).

 Results:  Participants in the home visiting program were overwhelming mothers.  66% of the mothers were unemployed, 12% had no health insurance and 11% had previously been in jail.  62% reported more than one ACE occurring during their childhood. 25% reported scored an MHI-5 score of 60 or below representing frequent difficulties with mental health. 7% scored above 1 on the UNCOPE.  ACES scores were significantly correlated with higher scores on the MHI-5 (r=-.40, p<.001) and higher scores on the UNCOPE (r=.19, p<.01).

Conclusions: Findings suggest that home visiting clients have high rates of childhood trauma, mental health and substance use issues compared to the average adult populations.  Initial ACES research conducted with middle class, primarily white populations found that 75% of adults reported one ACE and 20% reported three or more ACES. Home visiting clients reported slightly higher ACES.  Nationally, 18.5% of adults experience a mental illness and 8.4% experience substance use issues, but rates in this population suggest higher levels of mental health and substance use issues.  The fact that ACES is significantly correlated with both mental health and substance use for home visiting clients suggests a link between childhood trauma and later issues in adulthood. Given that mental health and substance use are driving factors in child maltreatment, any home visiting program purporting to address child maltreatment needs to actively engage parents in discussions of substance use, mental health and childhood trauma.