Objectives: To assess the impact of home visiting in preventing child abuse and neglect in the first 3 years of life in families identified as at-risk of child abuse through population-based screening at the child's birth. Methods: This experimental study focused on Hawaii Healthy Start Program (HSP) sites operated by three community-based agencies. From 11/94 to 12/95, 643 families were enrolled and randomly assigned to intervention and control groups. Child abuse and neglect were measured by observed and self-reported parenting behaviors, all hospitalizations for trauma and for conditions where hospitalization might have been avoided with adequate preventive care, maternal relinquishment of her role as primary caregiver, and substantiated CPS reports. Data were collected through annual maternal interviews (88% follow-up each year of all families with baseline interviews); observation of the home environment; and review of CPS, HSP, and pediatric medical records. Results: HSP records rarely noted home visitor concern about possible abuse. The HSP and control groups were similar on most measures of maltreatment. HSP group mothers were less likely to use common corporal/verbal punishment (AOR=0.59, p=0.01) but this was attributable to one agency's reduction in threatening to spank the child. HSP group mothers reported less neglectful behavior (AOR=0.72, p=0.02), related to a trend toward decreased maternal preoccupation with problems and to improved access to medical care for intervention families at one agency. Conclusions: The program did not prevent child abuse or promote use of nonviolent discipline; it had a modest impact in preventing neglect. Possible targets for improved effectiveness include the program's implementation system and model.