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

 

References

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.

A Brief History of Home Visiting in the United States

In the United States, the origins of home visiting can be traced to several developments in the 1800’s, including the kindergarten, public health nursing and settlement house movements.   Although there were some broad similarities between the three movements, each had a slightly different focus and used different kinds of individuals to deliver services. Original funding sources were primarily philanthropic, with government funding coming later as programs demonstrated efficacy and grew in size and scope.  Because of the philanthropic sources of funding, a great deal of advocacy to improve the health, education, and environmental conditions of individuals within poverty communities was carried out by the programs. Today’s home visiting programs reflect the important influence and emphases of the pioneering work in the 1800’s. The roots of advocacy and interagency collaboration can also be seen in these early programs.

The early kindergarten movement in the United States, begun in the mid-1800’s, was modeled on the play-based early education programs originated by Friedrich Froebel in Germany in 1837.  In the United States, kindergarten programs were typically focused on immigrant populations living in poverty in large cities (Bhavnagri & Krolikowski, 2000). These kindergartens were funded by philanthropic groups and had teachers who taught young children in the mornings and did home visiting in neighborhoods in the afternoons. Home visiting was designed to teach families about child rearing and how to use toys to stimulate learning, and to build community and family relationships. Teachers acted as family advocates with landlords, local stores, and the government. By the 1930’s, demand increased for kindergartens and there was a shift to morning and afternoon kindergarten sessions and the elimination of the home visiting component.

Another early model of home visiting can be found in the origins of public health nursing in America.  Public health nursing was modeled after nurse home visiting programs in England where trained nurses provided health care and social support in specific geographic regions. Florence Nightingale is generally credited as the first person to use the term “health nursing” and to develop and promote training for regional nurses in England (Georgia Dept of Human Resources).  In the United States, community nursing began in the 1870’s with a handful of nurses relying on funding from philanthropies.   Lillian Wald coined the term “public health nurse” and is credited with pioneering public health nursing in the lower east side of Manhattan in the 1890’s (Bekemeier, 2008; Buhler-Wilkerson,1993).  The work was similar to Settlement House efforts and included community activism to address social conditions in impoverished communities.  The public health nursing approach included preventative care and family education until funding shifted from a philanthropic to government base.  Following the funding shift, the philosophical approach changed to that of a medical model focused on obstetrics, well baby care, and health education. For many years, the focus remained on health care with little attention to the social support that is generally included in nurse home visiting programs in Europe. Government funding contributed to a rapid expansion of the public health nursing workforce in the U.S. from the early 1900’s to the 2000’s.

The Settlement House movement began in American in the 1880’s (Adams, 1910; Weiss, 2006). Through this movement, upper class reformers tried to improve the living conditions of the immigrant poor through a broad reach across social and education programs. They attempted to influence the early education of young children, to provide support for families dealing with health and social crises, and to force improvements in environmental conditions such as housing, parks and playgrounds, and trash collection through legislative advocacy and direct service. Settlement House reformers lived and worked in the poverty communities to both better understand the families being served and to model the behaviors and skills that they believed all individuals should possess.  Wealthy women who were part of the Settlement House movement raised funds for day nurseries, advocated for the development of branch libraries, kindergartens, and night classes, taught homemaking and child care skills, provided homeless shelters, and taught English to new immigrants in urban communities.

The Great Depression in the 1930’s had a huge impact on philanthropic organizations, with more than one in three shutting down between 1929 and 1932. The federal government developed a variety of initiatives to assist the millions of citizens who lost their jobs and their homes (Trattner, 1999).  A prosperous period following World War II led to a decline in interest in funding social initiatives, but there was a resurgence in the 1960’s with the federal “War on Poverty” and initiatives such as Head Start and Home Start.  Home visiting programs were funded with a focus on social issues such as poverty and teen parenting, and health issues including the increasing rates of very low birthweight babies due to technological advances in medicine.  Home visiting programs in the 1960’s were often focused on “infant stimulation” intended to reduce intellectual deficits, improve a range of developmental outcomes, and prepare young children for school success.  Many home visiting programs in the 1970’s shifted their focus to include family support with a broader reach towards prevention services aimed at the whole family, harkening back to the days of the Settlement House movement.  These models included attention to access to support services along with promotion of developmentally appropriate parenting practices and parent self-efficacy.

As home visiting programs demonstrated positive outcomes such as reduction in child abuse, recommendations for universal home visiting programs arose in the 1990’s (Krugman, 1993; U.S. Advisory Board on Child Abuse & Neglect, 1991).  Unfortunately, the federal government did not respond to such recommendations, but a wide range of local foundations and state government programs increased their attention and directed funding towards home visiting in poverty communities.  In addition, some state governments provided categorical funding streams for home visiting services aimed at specific populations, such as teen parents and children and families who were part of health and child welfare systems.

Today’s programs may be funded within the mental health, child welfare, early education, physical health, or developmental disability systems or by private foundation dollars focused on one of these systems.  Although linkages and collaborations are essential for effective service delivery, limitations usually exist in the development of seamless systems of care involving all aspects of health and development (Astuto & Allen, 2009; Finello & Poulsen, 2011).  Despite more than 100 years of home visiting services, most programs find themselves battling the same issues as those seen in the 1800’s.  As Gomby and her colleagues (1999) point out, home visiting programs are being asked to solve broad social problems of enormous magnitude while relying upon individual changes in behavior over short periods of time.  Clearly, we need to be more realistic about goals, outcomes, and what should be considered “success” in the delivery of home visiting services to families over a short period of time.

Click here to read more on the current Home Visiting Program

Coming soon:  “Challenges in Delivering Services through Home Visiting Programs”

 

Submitted by:  Karen Moran Finello, PhD

Karen Moran Finello photo

 

References & Further Reading

Adams, J. (1910).  Twenty years at Hull House. New York:  Macmillan.

Astuto, J. & Allen, L. (2009). Home visitation and young children: An approach worth investing in?  Society for Research in Child Development, Social Policy Report, XXIII(IV), 3-21.

Bekemeier, B. (2008).  Nurses on the frontlines of community health.   Northwest Public Health, Spring/Summer. University of Washington School of Public Health & Community Medicine. www.nwpublichealth.org/docs/nph/s2008/bekemeier_s2008.pdf

Bhavnagri, N.P. & Krolikowski, S. (2000).  Home-community visits during an era of reform (1870-1920).  Early Childhood Research & Practice, 2(1).  http://ecrp.uiuc.edu/v2n1/bhavnagri.html.

Buhler-Wilkerson, K. (1993). Bringing care to the people: Lillian Wald’s legacy to public health nursing. American Journal of Public Health, 83(December), 1778–1786.

Finello, K.M. & Poulsen, M.K. (2011). Unique System of Care Issues & Challenges in Serving Children under Age 3 and their Families.  Special Issue of American Journal of Community Psychology, 2011,  DOI 10.1007/s10464-011-9458-6.

Georgia Dept. of Human Resources, Div. of Public Health.  The history of public health nursing in Georgia (1898-2002).  http://health.state.ga.us/pdfs/nursing/Hist.Pub.Hlth.Nurse.web.pdf

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.

Krugman, R. D. (1993).  Universal home visiting:  A recommendation from the U.S. Advisory Board on Child Abuse & Neglect.  Future of Children, 3(3), 184-191.

Trattner, W.I. (1999). From poor law to welfare state. A history of social welfare in America. (6th Ed.). New York:  Free Press.

U.S. Advisory Board on Child Abuse & Neglect.  U.S. Dept. of Health & Human Services (1991).  Creating caring communities: Blueprint for an effective federal policy for child abuse and neglect.  Washington, DC:  U.S. Gov. Printing Office.

Weiss, H. (1993).  Home visits:  Necessary but not sufficient.  Future of Children, 3(3), 113-128.