Preventing Child Abuse

Is there a way to prevent child abuse and neglect by creating a community-wide, coordinated approach that supports families and their children? To explore this question, The Duke Endowment designed a multi-million dollar project that included two pilot programs in Durham, North Carolina, and Greenville, South Carolina.


Dr. Ken Dodge, director of the Center for Child and Family Policy at Duke University, discusses the Durham Connects nurse home visiting program. View the video.

In addition to the negative effects on the child and family, abuse and neglect is now the top reason why children are placed in residential care facilities. In fact, the preponderance of children in residential care are there as a result of abuse and neglect.

Coordinating Efforts to Prevent Child Abuse

The Duke Endowment's founder mandated that the Endowment should serve "orphans and half-orphans." Today, the Endowment defines these children as those who are without the benefit of support by family, or who are at risk of losing such support. In keeping with the goals of its Child Care program area, the Duke Endowment wanted to explore the question: "What if there was a way to create a more coordinated effort within a community to prevent child abuse and improve parenting practices?"


Although there are many agencies and individuals dedicated to protecting child welfare, The Duke Endowment provided "philanthropy venture capital" to two leading universities — Duke University in North Carolina and Clemson University in South Carolina — to design new approaches. The Endowment encouraged each university to develop its own theory of change and strategies for its project, but requested that the projects share common objectives:

  • A measurable reduction in child abuse rates
  • An improvement in parenting practices and behaviors
  • The strengthening of community services systems (formal supports)
  • An improvement in a community's capacity to protect children and support parents (informal supports)

The two universities created very different approaches for tackling the challenge of community-based child abuse preventionthe Durham Family Initiative and Strong Communities.

Durham Family Initiative

Under the leadership of Dr. Kenneth Dodge, Duke University created the Durham Family Initiative, focused on strengthening the people and institutions that support parents. The theory of change at work within the program is based on the belief that stronger, more coordinated efforts from myriad direct service providers will result in healthier parent-child relationships and therefore a lower incidence of child abuse.

The Durham Family Initiative concentrates its efforts in four main areas:

  1. Fostering inter-agency cooperation to create a coordinated and consistent system of care for families and children
  2. Placing outreach workers in targeted communities and creating community engagement activities within those communities
  3. Developing and testing innovative new ways to identify and support high-risk families or those already involved in abusive behaviors
  4. Helping to create or change county and state policies to better support child welfare and child protection services

Since 2002, Durham Family Initiative has implemented several protocols to help support healthier parent-child relationships, including:

  • Conducting home-visits to high-risk mothers by professional family support workers (as opposed to registered nurses or paraprofessionals) who focus on teaching parents activities to promote their children's development
  • Delivering proven therapies for families in which child maltreatment has already occurred
  • Helping mothers of toddlers with health care, parenting advice and respite care
  • Placing a community partner in target neighborhoods to help create stronger institutions and encourage individual involvement
  • Conducting prenatal screenings to identify and assist women with risk factors for maltreatment (stress, low income, dependency, etc.)
  • Creating and implementing an award-winning System of Care that coordinates management and service delivery among child-serving community agencies
  • Helping to enact legislation supporting efforts to strengthen child abuse prevention activities
  • Creating a social marketing campaign to help reduce the social stigma of participating in parent support programs and activities

In 2006, Dodge formed a complementary program, Durham Connects, which works to increase child well-being by bridging the gap between parent needs and community resources. Durham Connects provides in-home health assessments of mothers and newborns in Durham County. The visiting nurses follow a standardized protocol, developed through research and planning. Visits start when the babies are 2 to 12 weeks old. Assessments cover health care arrangements, caring for an infant, safe homes and parental support. If nurses identify a need and the family wants support, parents are connected with community resources.

Results from the Randomized Control Trial

Enrollment in the Durham Connects randomized control trial ended December 31, 2010. Eligible subjects included all live births occurring at either Duke Hospital or Durham Regional Hospital to a family residing in Durham County between July 1, 2009 and December 31, 2010. The births were randomly assigned (even-numbered birth dates to the intervention group and odd-numbered birth dates to the control group).

Final data analysis of the randomized trial showed that Durham Connects is associated with:

  • more family connections to community resources;
  • higher quality of childcare placements;
  • more positive mother parenting behavior;
  • more positive father-infant relationships; and,
  • safer home environments.

Further, Durham Connects families had fewer visits to the emergency room, overnight hospital stays and unplanned visits to pediatric offices.

Specific findings for Durham Connects families six months after the intervention (when compared with control families) included:

Service utilization:

  • Durham Connects families were 18 percent more likely to access community resources.
  • Children of Durham Connects families were 15 percent more likely to be placed in high quality child care settings.
  • Non-Medicaid Durham Connects families were 17 percent more likely to have back up child care plans.
  • Durham Connects families were 3 percent more likely to have recently seen a pediatrician.
  • No differences were found between the treatment and control groups on measures of accessing family resources and social provisions. Similarly, no difference was found regarding the use of respite child care.

Parenting and family well being:

  • Durham Connects parents were 18 percent more likely to report positive parenting practices such as hugging, offering encouragement and providing warmth to their infant.
  • Durham Connects parents were 50 percent more likely to report talking to their infant.
  • On three separate measures, Durham Connects fathers were 10 percent more likely to be involved with the infant.
  • Medicaid-eligible Durham Connects parents were 24 percent more likely to demonstrate knowledge about infant crying.
  • In-home interviewers (unaware of whether the family was in the treatment or control group) were 8 percent more likely to rate Durham Connects homes as safe.
  • Though there was no difference between the treatment and control groups when measuring the mother’s overall mental health, Durham Connects mothers were 33 percent less likely to report clinical depression and 32 percent less likely to report clinical anxiety. As with the overall mental health measure, there was no reported difference in substance abuse.
  • No differences were found on measures of domestic violence in the home.

Health care utilization:

  • Durham Connects families experienced 17 percent fewer emergency medical visits.
  • Durham Connects families experienced 60 percent fewer overnight hospital stays.
  • On all measures of emergency care, Durham Connects families were 30 percent less likely to use emergent care (either with a physician or in the hospital emergency department) and Medicaid-eligible Durham Connects families were 39 percent less likely to do so.

On two measures, the control group outperformed Durham Connects families:

  • Medicaid-eligible control families were 8 percent more likely to still be using community services after 6 months; and,
  • All control families were 3 percent more likely to report knowledge of infant development. (This difference, however, is not statistically significant).

A second randomized control trial completed enrollment in 2014 and the 12-month follow-up is underway. Meanwhile, the program is being replicated in six North Carolina counties and four Iowa counties.

Durham Connects is a partnership of the Durham County Health Department and the Durham Family Initiative. The Department of Social Services provides a coordinator to make follow-up home visits to parents needing social services.


Area of Work

  • Prevention and early intervention for at-risk children

Program Area

  • Child & Family Well-Being

Grantmaking Status

The Endowment is continuing to work through current grantees and is not accepting new applications.

Areas of Work

  • Prevention and early intervention for at-risk children

    To equip children and families with skills to ensure that children reach developmental milestones to lead successful lives.

  • Out-of-home care for youth

    To drive child welfare systems toward greater accountability for child well-being.

  • Quality and safety of health care

    Improving the quality and safety of health care delivery

  • Access to health care

    Improving health by increasing access to comprehensive care

  • Prevention

    Expanding programs to promote health and prevent disease

  • Academic excellence

    Enhancing academic excellence through program and campus development

  • Educational access and success

    Increasing educational access and supporting a learning environment that promotes achievement

  • Campus and community engagement

    Promoting a culture of service, collaboration and engagement among schools and communities

  • Rural church development

    Building the infrastructure and capacity of United Methodist churches to enhance ministry and mission

  • Clergy leadership

    Strengthening United Methodist churches by improving the quality and effectiveness of church leadership

  • Congregational outreach

    Engaging United Methodist congregations in programs that serve their communities