Home Visiting Challenges

The majority of home visiting programs that exist in the United States target highly vulnerable, at-risk families living in fragile situations. Jones (1997) describes these “psychologically vulnerable” families as individuals who are “experiencing pervasive stress on a daily basis over time and who typically experience more than their share of devastating episodic crises.”  Because of the high needs and intensity of service delivery required by families with such vulnerabilities, it is important for home visiting programs to provide an intensive, well coordinated and highly specialized range of services. Such an individualized and intensive approach can be extremely challenging for service providers, program administrators, and researchers trying to deliver the services and to document outcomes.

Most home visiting programs have developed approaches that are relationship-based and rely upon a type of “kitchen therapy” pioneered by Selma Fraiberg (Fraiberg, 1987; Jones Harden & Lythcott, 2005) that was designed to deliver infant mental health interventions in order to effect changes in parent-child relationships.  Strong interpersonal relationships are a key component of home visiting programs that are “relationship-based.”  Research conducted by Heinicke and his colleagues (Heinicke & Ponce, 1999; Heinicke et al., 2001) has demonstrated that the quality of the relationship between the home visitor and the caregiver has a significant impact upon the efficacy of home visiting.  High risk parents may have a need for positive emotional experiences as their past experiences with relationships have often been negative and difficult. Consequently, they may view professionals as unpredictable and untrustworthy, mirroring their previous experiences with other relationships.  Overcoming such beliefs by demonstrating that they are nonjudgmental, flexible, consistent, and nurturing while setting appropriate limits in the relationship is a challenge that every home visitor faces.

Families living in high risk communities often have significant needs for concrete assistance and access to resources.  Maslow’s hierarchy of needs (Maslow, 1943) tells us the value of building from the basics—few of us can respond to complex developmental and psychological interventions if we do not have food or a place to sleep, yet there is often an expectation for families who have experienced job losses, whose cupboards are bare and who are facing eviction to meet with the home visitor and talk about their young child’s health and development without attention to the elephant in the room. Home visiting staff must be assisted in developing an appropriate array of concrete resources that they can tap when needed, and must be assisted in understanding how to help families to access such resources without assistance.  Program staff must also be supported in using their judgment when determining that it may be necessary to say “no” to ongoing requests that reflect dependency or lack of effort in order to build a family’s own skills. Providing support while simultaneously developing family empowerment requires some agility, practice and mentoring.

The extremely high risk communities in which many families live creates significant safety concerns for both the families and for home visiting program staff.  Safety issues may include domestic violence in the family, psychologically impaired family members or caregivers, community violence and crime, and family or community crises. Programs must create clear protocols for dealing with staff safety while in the field and for handling emergencies.  Administrators must be realistic about the environments in which home visitors are immersed and must offer support and encouragement for staff to make difficult decisions about when risks may be too great to continue to provide home based services. In addition, the overwhelming mental health needs seen in families served creates an additional layer of service needs that are rarely included in the design of home visiting programs and adds to the burden of individual home visitors.

Accommodations may need to be made in home visiting “curriculums” or schedules in order to work most effectively with family crises, concrete needs, and looming family concerns. Further, immersion in the realities of the challenges of family living situations can create significant psychological burden on the home visiting professional.  The stressors of the job go well beyond long drives, heavy traffic, failed appointments, unsafe homes and neighborhoods, and the isolation of field based work.  Significant challenges also exist in dealing with caregivers’ fantasies and wishes about their babies, their personal histories of how they were parented, their coping styles, their buried feelings of loss regarding past relationships and/or previous children, and their anger towards professionals who may have failed them repeatedly in the past.  High quality and responsive reflective supervision is essential to help home visitors think about these issues outside of the home environment in order to best serve families, avoid burnout, and cope with the stresses of their roles.

In addition, many new parents do not have experience with young children and may have inappropriate ideas about development, parenting, discipline, and expectations. They may never have experienced nurturing and may consequently have difficulty demonstrating nurturance with their infants and young children.  “Teaching” in a didactic style does not work for many high risk families who have spent their lives being criticized and told what to do by others. Because of their histories, they may have particular sensitivities around how information is delivered and how suggestions are made for intervention. Gomby and her colleagues (1999) also point out the difficulty of trying to change child and family behaviors that caregivers may not believe need to be changed.  The inherent challenges to the home visitor are clear.

Although the home visitor is working with the entire family, it is easy to become too infant-centered or too parent-centered. Undiagnosed cognitive delays, medical issues, and mental health issues exist in many family members. A program that reflects a “system of care” philosophy must develop mechanisms to deal with all of these issues in providing services beyond the “targeted client.” It is important to be responsible to all family members and to understand where both child and parent “are” in order to work in a truly collaborative and meaningful way in the home. Stepping back and thinking reflectively about the individual family dynamics and child and family needs, and discussing this during reflective facilitation sessions with a well trained and thoughtful mentor is essential in order to keep perspective and to avoid burnout.

And what about “outcomes” selected to measure the success (or implied failure) of home visiting programs?  Outcomes selected may have little to do with the type of work being conducted by the home visitor or may be extremely unrealistic for the population being served.  For example, a program focused on providing family support to insure that very small preemies get the specialized follow-up care they need, that the family understands the complex neurological and medical issues that the child has, that the family is connected to appropriate resources to help them deal with devastating diagnoses, and that a caregiver is helped in dealing with depression due to the overwhelming health care needs of her infant should be relying upon different outcome measures than a program focused on healthy babies.  To date, the greatest successes in documenting positive outcomes have been related to factors including decreased social isolation in caregivers, improved parenting skills, safer home environments, improved maternal mental health (particularly increased self esteem and self efficacy and decreased depression), and more positive attitudes towards parenting (Egeland & Erickson, 1993; Henicke & Ponce, 1999). Unfortunately, these outcomes are often unmeasured in programs.

What is needed for all home visitors?

  • Regular reflective practice facilitation from an experienced and well seasoned supervisor
  • Informal support from peers & colleagues
  • On-going assistance with professional boundaries
  • On-going training and opportunities for scenario-based learning
  • Interdisciplinary case conferencing
  • Accessible mental health consultation
  • Safety protocols for both crises and day-to-day situations
  • Help with managing an appropriate ratio of extremely intense and high needs cases along with low intensity “easy” cases
  • Appropriate breaks, timeouts, retreats, opportunities for celebrating their hard work
  • Peer and supervisor support—a place to calm down at the end of the day and to “vent” with trusted colleagues about the day’s stressors can be crucial in staff retention and is an important part of organizational support that is generally overlooked

Despite its challenges, home visiting targeting new parents  provides a critical opportunity for intervention as the family is often most open to change and to services on behalf of the baby. This offers a “foot in the door” for the home visitor that might not otherwise exist. High quality home visiting programs can be the key to creating the positive changes in families needed to optimize child and family health and well being and can have an impact across the lifespan.  Although the work can be lonely and difficult, most home visitors do an amazing job and remain focused on the important long term value of the development of trusting and caring relationships that create ripples in family lives.  Perhaps most important to keep in mind when facing what sometimes appear to be insurmountable odds is Jeree Pawl’s wise adage that “how you are is as important as what you do” in working with families (Pawl & St. John, 1998).

Karen Moran Finello photo

Karen Moran Finello, PhD
WestEd Center for Prevention & Early Intervention
Principal Investigator, California MIECHV External Evaluation
Associate Professor, Emeriti Center, University of Southern California



Egeland, B. & Erickson, M. (1993).  Attachment theory and findings:  Implications for prevention and intervention.  In S. Kramer & H. Parens (Eds.), Prevention in mental health: Now, tomorrow, ever?  Northvale NJ:  Jason Aronson, Inc.

Fraiberg, S. (1987).  Ghosts in the nursery:  A psychoanalytic approach to the problems of impaired infant-mother relationships.  In L. Fraiberg (Ed.), Selected writings of Selma Fraiberg.  Columbus:  Ohio State University Press.

Gomby, D.S., Culross, P.L. & Behrman, R.E. (1999).  Home visiting: Recent program evaluations–Analysis and recommendations.  Future of Children, 9(1), 4-26.

Jones, B. (1997).  You can’t do it alone: Home visitation with psychologically vulnerable families. Zero to Three, 17(4), 10-16.

Jones Harden, B. & Lythcott, M. (2005).  Kitchen therapy and beyond:  Mental health services for young children in alternative settings.  In K.M Finello (Ed.), The Handbook of Training & Practice in Infant and Preschool Mental Health. San Francisco:  Jossey Bass.

Heinicke, C.M., Fineman, N.R., Ruth, G., Recchia, S.L., Guthrie, D., (2001),  Relationship-based intervention with at-risk mothers: Outcome in the first year of life. Journal of Infant Mental Health, 2001. 22(4): p. 431-462.

Heinicke, C.M. & Ponce, V.A. (1999).   Relationship-based early family intervention.  In D. Cichetti & S.L. Toth (Eds.), Rochester Symposium on Developmental Psychopathology, V. X: Developmental Approaches to Prevention & Intervention (pp. 153-193). Rochester, NY: Univ of Rochester Press.

Maslow, A.H. (1943).  A theory of human motivationPsychological Review, 50(4), 370-96.

Pawl, J. & St. John, M. (1998). How you are is as important as what you do…in making a positive difference for infants, toddlers and their families.  Washington, DC: Zero to Three.

DSM-5: A Concise Review of the Changes with a Special Focus on Young Children

The first of several surprises: DSM-5 includes only Axis I Disorders. Axes II, III, IV and V are eliminated and replaced by a developmental conceptualization and organization throughout the manual. The diagnostic chapters begin with disorders common in childhood and end with disorders frequently presenting in later life. This new developmental conceptualization incorporates research on the influences of culture and gender, and on genetic and neurodevlopmental differences. DSM-5’s primary goals are to support more accurate and consistent diagnoses based on new research that shows how similarities between disorders inform better treatment.

Another surprise, and most controversial, is the new diagnostic name, Autism Spectrum Disorder (ASD).  The new ASD diagnosis underlines the continuity within the DSM-IV Autism, Asperger’s Disorder, Child Disintegrative Disorder, and Pervasive Developmental Disorder Not Otherwise Specified. However, many clinicians voice concern that lumping these disorders may decrease access to care and public understanding. They emphasize that these limitations may lead to greater stigma and less individualized treatment for children, especially those now diagnosed with Asperger’s Disorder.

A third surprise, Disruptive Mood Dysregulation Disorder (DMDD), a new Depressive Disorder, describes children up to age 18 years with “persistent irritability and extreme behavioral dyscontrol”. This common presentation of chronic irritability and severe behavioral dysregulation in children is often comorbid with various psychiatric diagnoses including Attention-Deficit/Hyperactivity Disorder, Posttraumatic Stress Disorder, Depressive Disorder and Bipolar Disorder. DMDD addresses concerns about potential over-diagnosis of Bipolar disorders, especially in young children.

DSM-5’s new organization includes three sections that facilitate clinical decision-making and research:
• Section 1 introduces the DSM-5 and how to use the new manual.
• Section 2 sequences diagnostic chapters developmentally by age. It also groups similar disorders in new chapters, and similar chapters adjacent to each other.
• Section 3 features conditions that require additional research.

bonnily Section 1 
DSM-5, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, provides an overview of the newly conceptualized developmental frame, based on new science that informs both the organization of the chapters and the diagnostic criteria. Research shaping the new organization integrates the following:
• Influence of culture and gender
• Influence of genetic and neurodevelopmental research
• Symptoms occurring across multiple disorders

DSM-5, in addition, focuses on increasing the congruency between the DSM-5 and the proposed International Classification of Disorders, Eleventh Edition (ICD-11) by the World Health Organization (WHO).

Section 2
DSM-5 diagnostic chapters are organized to reflect differences across the lifespan. Neurodevelopmental Disorders are listed first to support early identification and intervention. Chapters below describe changes most helpful in understanding children’s developmental processes:

Neurodevelopmental Disorders (frequently presenting together)
• Intellectual Disability (Intellectual Developmental Disorder)
• Communication Disorders
• Autistic Spectrum Disorder
• Attention-Deficit/Hyperactivity Disorder
• Specific Learning Disorder
• Motor Disorders

Depressive Disorders
• Disruptive Mood Regulation Disorder (new)
• Bereavement (now included to increase appropriate treatment of chronic symptoms)

Trauma and Stressor-Related Disorders (features separate Posttraumatic Stress Disorder criteria for children 6 years and younger)

Section 3 
DSM-5 supports further diagnostic exploration of conditions that require additional research.  It also includes cultural formulations and a glossary.

DSM-5 integrates new research to advance developmentally informed early identification, age-specific diagnoses and more targeted treatment for children. It also fosters ongoing integrated research to increase understanding of developmental processes and lead to earlier, more accurate and consistent diagnoses and intervention.

For further information, go to:  www.dsm5.org

Submitted by California Center National Advisory Council Member:

Jean Thomas, M.D.
Integrated Therapy Services for Children and Families (ITS)
Clinical Professor, Psychiatry and Behavioral Sciences
George Washington University
Children’s National Medical Center


Meeting the Complexity of Supporting Infants, Toddlers, and Families

This is a time of promise for all of us who work with infants, children and families, as the fields of early intervention (EI) and infant mental health (IMH) have burgeoned over the past several decades. As a clinical psychologist and infant mental health specialist, I feel lucky to work in a wide range of settings with a wide range of individuals. On any given day, you might find me:

  • Attending a transitional IEP meeting at a school or district office
  • Conducting a preschool, day care or home based observation
  • Consulting with regional center staff regarding a referral or children in my caseload
  • Attending  a multidisciplinary team meeting
  • Training clinicians at a public or private agency serving young children
  • Working with parents and families in my office or in the field

I find the field of infant mental health invigorating, as it involves complexity and requires clinical thinking across developmental domains and across disciplines. The ability to properly treat each infant and toddler, dyad and family requires assessment and treatment models as complex the work we do: it involves multi-dimensional thinking and practice. Multi-dimensional thinking is by nature transdisciplinary. My own pathway to transdisciplinary practice was through the DIR® certificate program of the Interdisciplinary Council on Development and Learning (ICDL). Founded by Stanley Greenspan, M.D. and Serena Wieder, Ph.D., the groundbreaking work of the DIR® Institute  brought the wisdom of infant mental health  (harnessing growth through relationships) to all aspects of development while training professionals in allied fields (occupational therapy, speech therapy, physical therapy, education, pediatrics, etc.). The training focus involved looking at many aspects (dimensions) of development and how each caregiver and child’s individual differences impact development and social emotional milestones. By working in small groups during our summer institutes, and through regular reflective supervision, practitioners from different disciplines learned a common language, and way to codify how a child’s individual differences impact the growing relationships and their acquisition of social emotional milestones (described as Axis V of the DC:0-3R).

In practical terms, DIR® training provides important tools for understanding how to support caregivers and help the relationship with their children blossom. A large part of this understanding comes from the knowledge base in the fields of speech and language therapy and occupational therapy. With non verbal communication between parent and infant forming the earliest foundation of joint attention, speech and language therapists help us understand, assess and grow the quality of non-verbal communication in dyads and families. Similarly, when joint attention is not coming online, occupational therapists teach us how subtle differences in sensory processing and integration, vision, and the range of praxis (including the ideation, planning, sequencing, executing and adaptation of motor movements) can impact the critical journey of connection and relatedness.

In summary, development itself is complex, involving interconnected neurological processes influenced by personal biology, relationships, experience and the environment.

As a practitioner working with young children and families, understanding how to support relationships in the context of individual differences creates the dimensional framework necessary to work flexibly with families and support social emotional development. Please check out what is happening on a national level to bring much needed multi-dimensional thinking into our homes, clinics and schools.

For more information visit www.Profectum.org

Mona Delahooke 2013
Mona M. Delahooke, Ph.D.
Licensed Clinical Psychologist
DIR® Certificate: ICDL and Profectum Foundation
Profectum Foundation: Senior Faculty Member
Profectum Mental Health Working Group Co-Chair