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September/October 2015 Issue

Children and Families Forum: Home Visiting Programs
By Christina Grange, PhD; Darcey Terris, PhD; Anita Brown, PhD; and Carole Steele, AM
Social Work Today
Vol. 15 No. 5 P. 37

Helping an expectant mother transition to life with a new baby, and encouraging maternal support of a child's progress toward key developmental milestones is important, because the early years are a critical foundation for the rest of her child's development. In these early years, parents perform a vital role in monitoring and strengthening a child's social, emotional, language, cognitive, and physical development (CDC, 2015). The critical nature of this period is due, in part, to the dramatic brain development that occurs from birth to 3 years of age, affecting babies' ability to think, speak, learn, and reason (Shonkoff & Phillips, 2000).

In a recent series published in Pediatrics (2013), Terry Adirim, MD, MPH, and Lauren Supplee, PhD, of the U.S. Department of Health and Human Services highlighted a growing body of research supporting the link between babies' and young children's early life experiences and the effects of these experiences on body and brain development. These early effects can last a lifetime. When family stress is present or when caregivers struggle to manage their responses to stress, child development can be negatively impacted (Vaughan, Fienn, Bernard, Brereton, & Kaufman, 2013).

Home visiting programs provide one approach to supporting mothers by specifically addressing family context and other risk factors associated with a high risk of child maltreatment. The programs build upon families' existing strengths and resiliency, addressing issues related to maternal and child health, positive parenting practices, safe home environments, and access to health and social services. In 2010, the Health Resources and Services Administration funded the Maternal, Infant and Early Childhood Home Visiting (MIECHV) initiative to support the expansion and strengthening of home visiting programs across state, territorial, and Indian health services within a maternal and early childhood systems framework. A stated aim of MIECHV is to strengthen the evidence base around home visiting outcomes in addition to funding quality improvement projects and capacity building for participating community-based home visiting organizations.

What is Home Visiting?
The goal of home visiting programs is to support parents in the earliest years of a child's development. Home visiting programs typically serve expectant mothers and families with newborn children to 5 years old. There's a variety of home visiting program models (see http://mchb.hrsa.gov/programs/homevisiting/models.html), all implemented by trained home visiting program staff (hereafter collectively referred to as home visitors). Home visitors are certified in program processes and curricula, receive regularly scheduled ongoing reflective supervision, and participate in continuing education. The home visitors facilitate program sessions, with the majority of sessions occurring one-on-one with families in their home.
Program sessions focus on the mother and child relationship, while parenting partners and involved family members are encouraged to also attend and participate. The sessions generally follow a strength and evidence-based program model with a set format for the frequency and content of sessions. Home visitors are able to tailor sessions to mothers' identified priorities or issues raised in screenings for developmental and social delays, maternal depression, and domestic violence. Home visitors provide mothers with information about what to expect from their newborns and young children, offer emotional support, promote access to additional community services, and gently guide and reinforce constructive parenting practices.

Notable benefits attributed to home visiting include improvement in maternal life course and adaptive parenting behaviors, increased cognitive outcomes for children and overall child health, and a decrease in child maltreatment (Filene, Kaminski, Valle, & Cachat, 2013). In a meta-analysis conducted by Sweet and Appelbaum (2004), children enrolled in home visiting programs were observed to generally fare better on developmental indicators as compared to control groups. Specifically, children who participated in home visiting programs were found to have higher intellectual performance and express less aggression (Olds et al., 2004). Home visiting outcomes are influenced by the context and setting in which the family lives and vary by program focus, visit completion rate, and length of retention.

However, potential benefits are only possible if a referred family agrees to enroll in a home visiting program. Most families will say that they want support in raising the strongest, brightest, healthiest child possible. But families most at risk—those most likely to be referred to a home visiting program—typically face multiple simultaneous life stressors (e.g., residential and financial uncertainty) and emotional health challenges (e.g., postpartum depression) that construct barriers to participation. Concerns about the privacy of information shared in home visiting sessions may also lead to distrust and opposition. Finally, families may be uncomfortable having an outsider in their home or assume home visiting comes with the stigma of being a bad mother.

As a result, home visitors are challenged to make participation in a home visiting program feel safe and comfortable for the families they serve. Home visiting curriculum and protocol knowledge is complemented with offers of flexible scheduling, stress management, and links to additional community resources—all to promote an understanding that the family is the priority and the home visitor will support the mother's goals for her child.

Knocking Down Home Visiting Barriers
As an expansion on Georgia's MIECHV program, researchers and evaluators at the Center for Family Research at the University of Georgia partnered with the Governor's Office for Children and Families (the initial MIECHV lead agency in Georgia) to pilot test a protocol designed to increase the likelihood of families' enrollment and continued participation in one of two home visiting programs. The programs were based on the Health Families America or Parents as Teachers model. The enhanced engagement protocol was tested over a 12-month period in six Georgia communities.

The enhanced engagement protocol was based on the model of peer counseling. Since the 1950s, peer counseling models have been successfully used to promote engagement in services focused on positive behavior change (Bronner, Barber, & Miele, 2001). In recent years, the Women, Infants, and Children Food and Nutrition Service program adopted the use of peer counselors to promote breastfeeding among new mothers. In Georgia, the peer-counseling model was adapted so that mothers who previously graduated from a home visiting program were recruited to serve as Community Peer Liaisons (CPLs). In this capacity, the CPL helped potential participants better understand the benefits of home visiting by referring to their own experiences in the program. CPLs also addressed initial questions about how sessions and the relationship with a home visitor would be conducted. Beyond initial enrollment, CPLs were called upon to support home visitors in their efforts to address issues that appeared to be limiting a family's involvement in or commitment to the home visiting program.

Data from Georgia's pilot project suggests that CPLs have the potential to positively influence engagement in home visiting, particularly with Hispanic and Latino families. Hispanic and Latino families who were assigned to a CPL during the evaluation period were significantly more likely to stay involved in program services than those who didn't have CPL support.

Supporting Parent Involvement and Positive Outcomes
From the beginning, parents want what's best for their children, but may not know how to move toward achieving this goal. Home visiting programs provide one way to help parents take the important first steps in supporting their child's healthy development. Yet, significant barriers to family involvement remain that must be addressed if home visiting and other family support programs are to have any potential impact. Considerable effort connected to the MIECHV initiative is now taking place at the national, state, and local levels to ensure that high quality, evidence-based home visiting services are available to promote the best outcomes for infants and children today, and the adults they'll become tomorrow.

— Christina Grange, PhD, is an assistant professor of psychology at Clayton State University.

— Darcey Terris, PhD, is the evaluation and quality improvement advisor at the Center for Family Research at the University of Georgia.

— Anita Brown, PhD, is the associate director for the Center for Family Research at the University of Georgia.

— Carole Steele, AM, is the director of the Office of Prevention and Family Support with the Georgia Division of Family and Children Services.

Adirim, T., & Supplee, L. (2013). Overview of the Federal Home Visiting Program. Pediatrics, 132(Suppl. 2), S59-S64.

Bronner, Y., Barber, T., & Miele, L. (2001). Breastfeeding peer counseling: Rationale for the national WIC survey. Journal of Human Lactation, 17(2), 135-139.
Centers for Disease Control and Prevention (2015). Facts about child development. Retrieved July 15, 2015, from http://www.cdc.gov/ncbddd/childdevelopment/facts.html.

Shonkoff, J.P., & Phillips, D.A. (Eds.). (2000). From neurons to neighborhoods: The science of early childhood development. Washington, DC: National Academies Press.
Filene, J. H., Kaminski, J. W., Valle, L. A., & Cachat, P. (2013). Components associated with home visiting program outcomes: A meta-analysis. Pediatrics, 132(Suppl. 2), S100-S109.

Olds, D. L., Kitzman, H., Cole, R., Robinson, J., Sidora, K, Luckey, D. W., et al. (2004). Effects of nurse home-visiting on maternal life course and child development: Age 6 follow-up results of a randomized trial. Pediatrics, 114(6), 1550-1559.
Sweet, M. A., & Appelbaum, M. I. (2004). Is home visiting an effective strategy? A meta-analytic review of home visiting programs for families with young children. Child Development, 75(5), 1435-1456.

Vaughan, E. L., Fienn, R., Bernard, S., Brereton, M., & Kaufman, J. S. (2013). Relationships between child emotional and behavioral symptoms and caregiver strain and parenting stress. Journal of Family Issues, 34(4), 534-556.

Extracurricular Sports Produce Disciplined Preteens
Regular, structured extracurricular sports seem to help kids develop the discipline they need in order to engage effectively in the classroom, according to a new study led by Linda Pagani, PhD, of the University of Montreal and its affiliated CHU Sainte-Justine children's hospital.

"We worked with information provided by parents and teachers to compare kindergarteners' activities with their classroom engagement as they grew up," Pagani says. "By time they reached the fourth grade, kids who played structured sports were identifiably better at following instructions and remaining focused in the classroom. There's something specific to the sporting environment—perhaps the unique sense of belonging to a team in a special group with a common goal—that appears to help kids understand the importance of respecting the rules and honoring responsibilities."

Pagani and her colleagues Geneviève Piché, PhD, and Caroline Fitzpatrick, PhD, came to their conclusions after reviewing the data on 2,694 children who were born in Quebec between 1997 and 1998. The information was retrieved from the Quebec Longitudinal Study on Child Development, a public data set coordinated by the province's statistical institute.

"Our goal was to answer two questions: First, does participation in extracurricular activities in kindergarten predict fourth grade self-discipline, and secondly, do kindergarten self-discipline characteristics predict fourth grade participation in sports?" Pagani says. These characteristics encompass things such as classroom engagement, physical aggression, impulsivity, and emotional distress.

At kindergarten, when most children in the study were 6 years old, teachers filled in questionnaires about their students' behavior and parents were interviewed either by phone or in person about their home life. The exercise was repeated four years later.

The researchers then analyzed the data by eliminating preexisting influences such as child's physical fitness and cognitive abilities, mother's education, and how well the family unit functioned (asking families to rate, for example, how well they communicate) which could have influenced the results.

"Children who were involved in sports at kindergarten, or in fact who were involved in any kind of structured activity, were likely to be involved in teams sports by age 10. However, involvement in unstructured activities at kindergarten had no bearing on the child's future. Across the board, we found that children who had better behavior in kindergarten were more likely to be involved in sport by age 10," Pagani says. "Nonetheless, we found that those children who were specifically involved in team sports at kindergarten scored higher in self-regulation by the time they reached the fourth grade."

The researchers believe that sporting activities and attention skills go hand-in-hand and can be addressed simultaneously in school planning. Their findings could help schools and public health authorities better reach children at risk of insufficient exercise as a way of addressing both the obesity and school dropout crises at the same time.

"Programs to help parents develop their child's self-regulation skills and the availability of extracurricular sports programs as early as kindergarten could help decrease the risk of kids being left behind," Pagani adds. "We also hope policy makers consider our findings in order to improve access to parks and playgrounds, where children and their families can engage in sporting activities, to improve access to K-12 enrichment programs that target self-regulation skills, and to improve the promotion of active schools and communities, generally speaking."