Convinced that a lack of basic child-rearing knowledge is leading to increased infant-mortality, child-abuse, and school dropout rates, policy analysts from a variety of sectors are advancing a strategy that rests on the tenet of neighbor helping neighbor: home visits.
The idea springs from a recognition across the child-serving professions that babies raised in isolation by young, disadvantaged, and disconnected parents often suffer from abuse, neglect, and health and learning problems.
Though advocates differ over the specifics of how such programs should be structured and who should be targeted for services, there is broad agreement that the use of home visits can increase the odds that at-risk youngsters will thrive and lead productive lives. “A skilled home visitor can create a partnership and nurturing relationship with families” while offering “a rich service that conveys a great deal of information and support,” said Heather Weiss, director of the Harvard University Family Research Project.
Because of its convenience for families, she added, home visits are “more likely to reach more people and have the possibility of connecting with them in some meaningful way than anything else.”
In the past two months, two Congressionally mandated panels--the National Commission to Prevent Infant Mortality and the U.S. Advisory Board on Child Abuse--have urged the spread of home visits by health workers and aides to help educate and support new parents.
But home visits have long been a part of a wide range of “family resource” programs designed to offer support services to help families prosper.
Home visits are an integral part of a number of programs designed to teach parents child-development principles they can use to stimulate their children’s learning. Such programs-Missouri’s Parents as Teachers program is among the most well-known have gained increasing favor in recent years as a tool to ensure children’s readiness to enter school. (See Education Week, May 9, 1990.)
Other initiatives, including the federal Even Start program and Kentucky’s Parent and Child Education program, meanwhile, incorporate home visits into programs that combine parenting support and literacy classes. Such programs seek to raise parents’ educational attainment, job skills, and self-sufficiency while breaking the cycle of illiteracy that too often passes from parent to child.
Home visits are “one of the most promising vehicles we have” to make a positive impact on parents’ and children’s lives, Edward F. Zigler, the Sterling Professor of Psychology and the director of the Bush Center in Child Development and Social Policy at Yale University, said in an interview.
‘Never Seen a Baby’
Home visitors offer a range of services, including guidance on health, nutrition, child development, and parenting, as well as referrals to other agencies and services.
Some programs begin with prenatal care for pregnant mothers, while others start in the neonatal period; some target vulnerable populations, while others extend to all interested parents. Home visitors range from volunteers and aides to trained nurses, social workers, and educators.
But the “common element” is their overall goal, Mr. Zigler said.
While the health, human-services, and education personnel promoting home visitation generally have not coordinated their efforts, they all see home visits as a way to mend an eroded network of support for families.
“Over the last 15 years in this country, we have lost the support of the infrastructure that used to be in place for families,” said Richard Krugman, a former chairman of the child-abuse panel who is an associate professor of pediatrics and the acting dean of the University of Colorado School of Medicine.
Extended family clans have broken up and “disbursed all over the country,” he noted. At the same time, he said, visiting services by public-health nurses, as well as counseling and support services linked with the child-welfare and mental-health systems, have been felled by the budget ax. He also citing rising numbers of families headed by single parents.
“It is now possible for you and your wife to have never seen a baby before you take one home from the hospital,” Mr. Zigler said.
Child abuse in such circumstances, he noted, can arise from a parent misunderstanding why a young child defecates in his diapers or drops a rattle out of his crib.
Byron Gold, the executive director of the child-abuse panel, cited a case in which a mother did not bathe her baby out of fear that it would harm his circumcision scar.
“All this woman really needs is somebody who is an authority figure to say it’s O.K.,” he said.
“Infant mortality,” added Madeline Baggett, a spokesman for the infant-mortality panel, “is not a health problem; it’s a social problem with health consequences.”
‘Most Valued Component’
Home visits, said Howard A. Davidson, the current chairman of the child-abuse panel, offer a “non’intrusive” way to support young families--and constitute “the best-studied prevention program in terms of its proven impact.”
“It’s clear to us, and to others who deliver services to families, that what they really want and need is to focus on their individual concerns,” said Mildred Winter, the director of the Parents as Teachers National Center at the University of Missouri. “You don’t get that in a group setting.”
A recent evaluation of Missouri’s Parents as Teachers program, which offers parent-education services statewide and has served as a national model, showed that, “across all socioeconomic and educational levels, home visits were the component valued most,” she said.
The study also showed that, by age 3, children in the program scored significantly above national norms on measures of school-related accomplishment, and that more than half overcame developmental delays. Parents also showed significant gains in their child-rearing skills.
After reviewing research and studying several programs, investigators for a 1990 General Accounting Office study concluded that “home visiting is a promising strategy for delivering or improving access to early-intervention services that can help at-risk families become healthier and more self-sufficient.”
It also cited evidence that home visits can reduce “later serious and costly problems,” especially for those at risk of “such poor outcomes as low birthweight, child abuse and neglect, school failure, and welfare dependency.”
Hawaii Program Cited
In the health sector, advocates cite a study that followed 400 families in Elmira, N.Y., from the mid-1970’s to the mid-1980’s, headed by David Olds, an associate professor of pediatrics at the University of Rochester.
It showed that low-income teenage parents who were visited by public-health nurses from pregnancy until age 2 had higher-birthweight babies and were 80 percent less likely to neglect or abuse their children than those in a control group. They were also more likely to delay subsequent pregnancies and pursue education and jobs.
To test home visits in an urban setting, Mr. Olds is heading another study of 1,100 families in Memphis.
Its backers include the federal Family Support Administration, which is eyeing home visits as a tool for reducing welfare dependency and “addressing important policy questions related to the well-being of low-income mothers and their children,” according to an agency statement.
The U.S. Advisory Board on Child Abuse has suggested that Hawaii’s “Healthy Start” program serve as a model for a national network of home-visiting programs.
The program, which experts say is the most extensive statewide effort of its kind, screens women in hospitals before their babies are born and extends home-visiting services to those identified as at risk until their children reach age 5.
A 1988-89 review revealed only one reported case of abuse and six of neglect--figures three to six times lower than projected for that population, said Gladys M.L. Wong, head of the Healthy Start program.
The program, which now reaches more than half of Hawaii’s new mothers, offers services ranging from child-development screening and health and parenting education to male home visitors working with fathers.
Message to Policymakers
While advocates note that home visiting has long been used widely in Europe, the approach has received more “lip service” than support in this country, said Rae Grad, executive director of the National Commission to Prevent Infant Mortality. The panel recently launched a project to offer communities guidelines and materials to start their own “resource mother” programs.
The Healthy Birth Act passed by the Congress in 1989 would have offered localities aid to set up such programs under the Maternal and Child Health Block Grant, Ms. Grad noted, but it was never funded.
The Congress did, however, provide $25 million for a program backed by President Bush launching 15 demonstration projects to explore ways to reduce infant mortality.
“What we need is not 15 demonstration projects,” Ms. Grad said, “but an application of what we know works.”
“If people from so many different sectors” are promoting home-visiting programs, Mr. Krugman said, “the government ought to be stimulating this kind of effort.”
Added Ms. Grad, “One would think policymakers would get the message that this approach has some kind of merit.”
Capacity to Empathize
Among those touting home visits, however, there are differences of opinion over approach.
While the child-abuse panel has proposed using paraprofessionals as home visitors, some researchers, such as Mr. Olds, say the data on program success are more conclusive for those employing professionals.
“The evidence suggests that professionally trained nurses are more effective in improving outcomes,” he said. “The problem is that we have a nursing shortage.”
Burton L. White, whose parenting research formed the basis for the pilot project that led to Missouri’s Parents as Teachers program, has frequently questioned the wisdom of allowing people with limited training to conduct home visits.
“To think somehow or other untrained people visiting the home are going to turn into magic is sad,” said Mr. White, who directs the Center for Parent Education in Waban, Mass.
Bernice Weissboard, president of the Family Resource Coalition, a national network of people and groups involved in family-support programs, agreed that “the quality of the home visitor is the key element to how successful they will be.”
But the “character of the person,” she said, is more important than the dosage or discipline of training. In addition to expertise in child and adult development, she said, success rests on “the capacity of the person to empathize and also to be a resource and a guide.”
Ms. Weissboard also urged that home visits be “more focused on relationships” than on adhering to a set curriculum, and that even programs with structured guidelines for home visitors “be responsive to what the family needs are.”
She also cited a need for approaches targeted more directly and intensively at families at risk as well as more universal efforts to initiate contact with every new mother.
Making Connections
Ms. Weissboard emphasized, however, that home visits should be part of a broader “complex of services families need.”
“One of the goals of home visiting is to get people away from their isolated situations and connect them to other programs,” she said, noting that home-visiting efforts linked to established centers tend to promote more of that kind of outreach.
“if you are trying to build peer support, it’s tough to do that in one-to-one home visits,” added Ms. Weiss of Harvard University. The G.A.O. also concluded in its report that “successful programs usually combined home visiting with center-based and other community services adapted to the needs of their target group.”
The report also noted that success in home visiting “stems from connecting clients to a wider array of community services.”
While programs that address the broadest range of family needs have the best chance of success, a lack of coordination among the health, education, and human-services sectors has limited program comprehensiveness, experts say.
“We have to get this information out so people who mount these programs know about each other,” Mr. Zigler said. That way, he added, they can tap each others’ experience and pool resources.
To spur that kind of exchange, Janet Levy, director of the Joining Forces project sponsored by the Council of Chief State School Officers and the American Public Welfare Association, urged that those considering home-visiting programs “contact their counterpart in the other systems” at the outset.
Most agree that the success of a home-visiting program depends on how well-defined its goals are.
“Home visiting is a tool as opposed to an end in itself,” said Emily Fenichel, associate director of the National Center for Clinical Infant Programs.
Conceding that home visiting “will not by itself eliminate child abuse and neglect or even cut it in half,” Mr. Davidson of the child abuse panel said, nonetheless, that “we believe a substantial impact can be made.”
