House Calls

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Amid the rush to establish home-visiting programs for at-risk children, researchers are beginning to explore which techniques work best.

Two years ago, Ohio launched Early Start, a program that sends trained caseworkers into the homes of infants and toddlers considered at risk of abuse, neglect, or developmental problems.

In an effort to encourage initiative and creativity, the state gave the 30 participating counties freedom to run the program as they wished. But the result, state officials found, was a tremendous variation in the return Ohio received on its $1,200-per-family investment.

In one county, a home visitor had an unmanageable caseload of 100 families. In another, the average visit lasted only 30 minutes.

So, state officials in Columbus have returned to the drawing board. This time, they plan to retool the program based on a small but growing body of research that suggests what does and doesn't work in home-visiting programs.

Such programs have flourished in recent years as states and communities increasingly focus attention and resources on young children and school readiness. Home visiting is seen as a way to give the most vulnerable children, especially those born to teenage mothers on welfare, a better start in life.

But many programs have been based more on good intentions than sound policy, and hard lessons have emerged from both the successes and the failures.

"People are still looking for silver bullets, and some people believe home visiting is the silver bullet," says Linda McCart, the executive director of Ohio Gov. George V. Voinovich's Family and Children First project, which oversees Early Start. But, she adds, "it's like teen-pregnancy prevention--there's no one way that it works."

Much of the research on home visiting has not been scientific, and critical questions remain unanswered, most notably whether home visits bring about improved performance in school.

But research on a few programs has found promising results and provided some guidance for both policymakers trying to design programs and for the caseworkers who will be knocking on doors.

  • From 1982 to 1985, two Yale University researchers conducted a small study of the Yale Child Welfare Project. Researchers Victoria Seitz and Nancy H. Apfel found that the "parent-focused intervention" program for poor, first-time mothers in New Haven, Conn., which included home visits, helped the firstborn children adjust well to school. They were less likely to be held back a grade, less likely to need special education, and had better attendance than children in a comparison group.

'Powerful Information'

But the program also had similar benefits for the women's other children--even after the intervention had ended.

"For a policymaker, that's powerful information because you're affecting the later siblings," says Douglas R. Powell, the head of the department of child development and family studies at Purdue University in West Lafayette, Ind.

In an April 1994 article in the journal Child Development, Ms. Seitz and Ms. Apfel concluded that through the program, the mothers "learned a more effective parenting style that they then used with all their children."

  • Researchers from the University of Arkansas at Little Rock found that children who participated in the Home Instruction Program for Preschool Youngsters, or HIPPY, had better grades, higher math scores, and displayed more "age-appropriate behavior" at the end of 2nd grade than children who had no formal preschool experience.

HIPPY, which began in Israel, uses paraprofessionals to bring weekly educational activities into the homes of 3- to 5-year-olds.

"Paraprofessionals" basically means workers without a college degree. In practice, that can be anyone from a welfare recipient who has never had a job to someone with years of experience either in volunteer work or working with families.

There are now nearly 130 HIPPY programs in 28 states, serving about 15,000 families. Nationally, the program is administered through HIPPY USA in New York City. At the local level, programs are run by a variety of agencies, including schools and human-services departments.

  • A 1995 study of the U.S. Department of Education's Even Start family-literacy program, which includes home visits, showed that children in the program learned school readiness skills, such as colors and shapes, at a faster rate than a control group.

The federally funded evaluation, however, also noted that once the control-group children entered preschool, they caught up with the Even Start group. The researchers concluded that not enough is known about the long-term effects of an "early boost in learning."

School Involvement

While most home-visiting programs are conducted long before children enter school, research suggests that these programs can have far-reaching implications for educators.

On a practical level, schools might be more likely to get involved in home visiting, as opposed to other early-childhood programs, simply because they don't have to give up a lot of classroom space in order to do it. "One of the appeals for home visiting is that you don't have to have bricks and mortar," Mr. Powell says.

While most home-visiting programs are conducted long before children enter school, research suggests that these programs greatly affect their education.

But most educators who care about improving the home environments of young children do so for more philosophical reasons.

"If you are truly concerned about children being ready for school, a school district has no choice but to be involved in early childhood," argues Betty Hutchins, the director of federal programs for the Rutherford County schools, a rural, 10,000-student district in western North Carolina. The district has been involved in the St. Louis-based Parents as Teachers program for 10 years and is now serving about 400 families.

"We looked at the condition of children as they entered kindergarten, and we were seeing a rapid decline," Ms. Hutchins says. "We want parents to think very early that their kid is going to be in school someday."

'Like an Appointment'

PAT is run by school districts in 48 states and serves roughly 500,000 families, of all income levels. But the program, which was designed by Mildred Winter--who still serves as the executive director of the PAT National Center in St. Louis--started as a pilot program with 380 families in 1981.

Janice Benjamin already had two school-age sons when she became part of PAT. But this Middle River, Md., parent, who tends bar at night and attends nearby Towson State University during the day, felt as though she never took the time to watch her children's development.

But she's trying to change all that with her 14-month-old daughter, Kyra Compton.

"I find myself a lot more patient now that I'm learning more about letting her express herself," Ms. Benjamin says as her barefoot daughter climbs into a dishpan-sized plastic container full of uncooked popcorn.

On a cold and rainy Thursday, Nancy Gardner, a home visitor from Martin Boulevard Elementary School in the Baltimore County district, has brought materials designed to bring "outside play" indoors. Research suggests it is helpful for home visitors to bring books or activities with them to help spur conversation.

Ms. Gardner drops the popcorn through a funnel into Kyra's hand. "She has an amazing attention span," she tells Ms. Benjamin.

Kyra picks up handfuls of the kernels and shrieks playfully as she scatters them onto a plastic sheet Ms. Gardner has placed on the living room floor of the two-story townhouse. Then Ms. Benjamin sits her daughter on her lap to read a story about children playing at the beach.

"These visits are like an appointment," Ms. Benjamin says. "You keep it because it's important for your child and for you."

Ms. Gardner, who also supervises other home visitors in the 105,000-student district, walks the few blocks back to the school, where she'll write up a report about her visit. She has found, though, that her staff's work is, in many ways, invisible to other members of the faculty because it doesn't happen inside the school. And sometimes, even teachers don't see the link between early education and future success in school.

"They'll say, 'What can you teach a baby?'" says Cheryl Hedrick, another of Baltimore County's 25 home visitors. "You'd be surprised what you can teach a baby."

Spreading the Success

Another challenge facing both researchers and members of the home-visiting field is to determine whether the impressive results of small, closely controlled pilot programs can be reproduced on a much larger scale.

In fact, it was exactly that concern that for several years kept David L. Olds, a professor of pediatrics at the University of Colorado, from allowing a demonstration project he designed for poor, unwed, first-time mothers to expand nationally.

Home-visiting programs are run by a variety of human-services agencies and serve a variety of different goals.

The program began in 1977 with 400 women in Elmira, N.Y., and has since expanded to Memphis, Tenn., and Denver.

The most recent research on the program showed that, after being visited frequently by a nurse during their child's first two years of life, the mothers were less likely to abuse or neglect their children, have another child, and abuse drugs or alcohol than mothers who did not receive home visits. The program, tested with mostly white mothers in semirural Elmira and in Memphis with African-American mothers, also successfully reduced the length of time the mothers spent on welfare.

But it was also expensive. Mr. Olds estimates the costs at roughly $7,000 per family a year.

Even though his work is considered by many to be the best in the field, he and his team of researchers held off on disseminating the model until 1995, when the U.S. Department of Justice offered to develop the prenatal and infancy home-visitation program as a pilot in six communities.

Professionals or Not?

Colorado and a few other states have begun efforts to combine both state and federal money to establish versions of the program. But Mr. Olds still maintains that it cannot be duplicated on a large scale in a short time without being watered down. "If we are not careful, we will squander both money and hope on programs that don't work," he says.

He is also concerned that because of the growing popularity of home visiting, some organizations are using his research to promote other, less intensive visitation models.

Home-visiting programs are run by a variety of human-services agencies and serve a variety of different goals, from ensuring that children have proper nutrition to providing new mothers information on breast-feeding or preventing child abuse. One of the goals of future research will be to identify which programs best meet differing needs.

And experts point out that although some programs may not be designed specifically to bring about future school success, that doesn't mean educators should ignore them. Programs that focus more on moving families off welfare or improving a mother's parenting skills can have less obvious but still important benefits for schools.

A study under way in Hawaii is exploring that question by looking at the extent to which Hawaii Healthy Start, a home-visiting program designed to prevent child abuse, is helping children in other ways.

Researchers at Johns Hopkins University in Baltimore are following 684 families for three years to determine whether Hawaii's well-regarded program also enhances children's development and better prepares them for school.

The program's administrators "started to realize that they weren't just preventing child abuse and neglect, but improving parenting along the whole continuum," says Anne K. Duggan, an associate professor of pediatrics at Johns Hopkins who is the study's principal investigator.

The issue of exactly who should be making home visits is another priority for research. Several researchers are exploring whether nurses or nonprofessionals, for example, make the best home visitors.

Common sense may suggest that nurses or social workers are best equipped to respond to the complex and deep-seated problems of poor mothers.

But others argue that paraprofessionals--especially those who come from the same communities as the families they are serving--can relate more effectively because they might share the same values and, ideally, have overcome some of the same problems.

'Wonderful Mentoring'

HIPPY, for example, relies on paraprofessionals. "Our philosophy is that the families that we are dealing with have so many obstacles to overcome and have so many negative experiences with professionals," says Miriam Westheimer, the president of HIPPY USA.

The federal government recently declared that working as a home visitor for HIPPY fulfills the work requirements of the 1996 welfare-reform law.

Another advantage of paraprofessionals is that they cost less. But Ms. Westheimer and others strongly emphasize that when paraprofessionals are used, they must have extensive training not only in the program they are using, but also on how to avoid becoming so personally involved with families that they lose their ability to help.

"It's really tough for home visitors to draw those boundaries," says Rebecca Maynard, a professor of education and social policy at the University of Pennsylvania. Ms. Maynard is involved in an evaluation of the Home Visiting Services Demonstration, a program that uses paraprofessionals, many of whom are former welfare recipients.

There is a growing consensus in the field that both nurses and nonprofessionals are appropriate home visitors at different times in a child's life.

The program, a joint project of the Henry J. Kaiser Family Foundation and the federal government, serves about 2,400 families in Chicago; Dayton, Ohio; and Portland, Ore. Results of the study are expected this summer.

In Denver, Mr. Olds is also exploring whether, in his model, well-trained paraprofessionals can be as effective as nurses. The first results are due later this year.

While it's clear that further research is needed, there is a growing consensus in the field that both nurses and nonprofessionals are appropriate home visitors at different times in a child's life.

In programs that serve infants, researchers say, it's more desirable to have a nurse or other professional because the mother is more likely to have questions about her child's general health and development. But in programs that serve older children, many experts agree that paraprofessionals can be very effective at sharing lessons with parents that prepare children for school.

Link to Other Services

A program for 3-year-olds in the northern Kentucky city of Covington has found a way to use both teachers and noncertified assistants for every visit. For the assistants, who often come from the community they are visiting, it's a "wonderful mentoring experience," says Diane Roketenetz, the director of the James E. Biggs Early Childhood Education Center in the 4,950-student Covington district.

For families with more-critical needs, it is the length and frequency of the visits that matter--not whether the visitor has a college degree, says Ms. Winter of PAT.

The services home-visiting programs provide don't always occur just in the home. Several models also include regular group meetings for the parents and center-based activities for the children. And there is widespread agreement that home visitors must be knowledgeable about other services families might need, such as health care, job training, transportation, or Head Start.

Heather B. Weiss, the director of the Family Research Project at Harvard University, wrote in a 1993 article that home visiting by itself is not sufficient to meet the needs of families in poverty, but should be part of a comprehensive approach to family support.

Often, families are struggling to meet their most basic needs for food, clothing, shelter, or heat, and experts note that home visitors must be able to respond to a crisis before trying to proceed with that week's parenting lesson.

"We can't meet all the needs of the family because that's not our goal, but we can't ignore them either," Ms. Winter says.

Most home-visiting programs target poor or other at-risk families, but PAT is unique because it is a universal program, open to anyone who wants it. Because of that, some observers question the model's success.

A study being conducted by SRI International, a nonprofit research organization in Menlo Park, Calif., will investigate the effects of the program on low-income and minority families in four cities--Wichita, Kan.; Fort Worth, Texas; Newark, Del.; and Winston-Salem, N.C. The study is supported by the U.S. Department of Education's office of educational research and improvement.

"We have confidence that the program meets the needs of high-risk families, because we certainly have many of them in our state," Ms. Winter says.

When recruiting new families, PAT seeks out teenage mothers, single parents, and others who have a greater need. But Ms. Winter still believes the strength of the program is its take-all approach: "Every family is entitled to access this kind of support."

Vol. 17, Issue 22, Page 27-29

Published in Print: February 11, 1998, as House Calls
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