Children's Voice Jan/Feb 2007

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Change Agents

Home visitation programs are expanding nationally to help parents play greater roles during their children's earliest years.

By Jennifer Michael

As soon as Adriana Ramos Bock (below left) walks in the door to the tiny but tidy condominium where 3-year-old Jessica Ortega lives, the little girl is right there to greet her with a nonstop stream of Spanish. Dressed in a pink T-shirt, denim skirt, and matching pink flip flops, Jessica points to the clock and tells Ramos Bock she is 10 minutes late. The girl's mother, Guadalupe Sixtos, chuckles.

Sixtos's daughters, Adriana, 7, and Jessica (pictured below right) have many reasons to count down the minutes to Ramos Bock's regular visits. They spend long hours inside their Maryland condo, especially in the summer, while their father Javier Sixtos works for a landscaping company. As immigrants from Mexico, their English is limited. Guadalupe cannot speak English at all.

Ramos Bock is a home visitor--or parent educator--for Parents as Teachers (PAT), a Missouri-based home visitation program with thousands of sites across the United States. Ramos Bock's role as a parent educator is to coach parents with children age 5 or younger on how to interact with and promote their children's development so their children are better prepared for school and for life. Originally from Mexico herself, Ramos Bock is bilingual, and most of the parents she visits are among the growing Hispanic community in Columbia, Maryland, a suburb between Baltimore and Washington.

Guadalupe enrolled in PAT--a voluntary, free program for parents--on the recommendation of Adriana's teachers. Adriana has struggled in school, and Sixtos wanted to make sure Jessica got off to a better start. When Ramos Bock first met Jessica, she sucked on a bottle all day and watched television. The toddler couldn't speak because she was rarely spoken to.

Now, a year later, Jessica is a chatterbox in Spanish and is beginning to pick up words and numbers in English. On the day Ramos Bock arrives a few minutes late, she spreads out a plastic mat on Guadalupe's green living room rug, next to a big screen TV and a coffee table covered with framed pictures of the children. Jessica and Adriana gather around her, while their mother sits off to the side and observes as Ramos Bock shows the girls how to string ribbon through holes punched around a paper plate. In the middle of the plate, the girls glue pictures of their cousin Jacqueline, who used to live with them but recently moved to another state.

"Jessica has gotten very good with her fingers," Ramos Bock says in Spanish to the girl's mother, who nods and smiles proudly. Big sister Adriana is still slowly stringing her ribbon when Jessica finishes hers and is ready for the next activity of matching colorful laminated shapes of circles, stars, and hearts and saying their names in Spanish and English.

Although Ramos Bock is there for Jessica, she gives Sixtos advice about helping Adriana with her schoolwork. From her bag she pulls a game she fashioned out of plastic bags and colorful chips and hands it to Sixtos. Ramos Bock tells her to use it with Adriana to improve her counting skills.

Jessica, at age 3, is already enthusiastically working on her math skills, pointing with her little fingers to the pictures of cows, horses, and ducks on the cards that Ramos Bock brought, and counting, "one, two, four, five..."

Under the PAT program, Ramos Bock could continue to see Jessica until age 5, but she says she will soon stop her visits. She has an extensive waiting list of other local immigrants who want her assistance with their little ones. Ramos Bock notes that Jessica's development is now on track with other children her age, and she will enroll in preschool in the fall, thanks to Ramos Bock's work in researching available local programs for the girl and helping Sixtos complete the paperwork.

Lessons in the Living Room

Home visitation programs aren't meant to be intrusive. They don't reprimand parents for raising their children incorrectly, or instigate rules and regulations. Rather, a home visitor is a parent confidant and guide, helping moms and dads learn how to play a pivotal role in their children's early development. Today, an estimated half million children nationwide benefit from such programs during the critical development period from before birth to approximately age 5.

Sitting down in a living room on a weekly or monthly basis, face-to-face with a mother and child, the home visitor can discuss how to get a baby to sleep through the night and begin eating solid foods; she can demonstrate how to interact with a toddler, read books to the child, help him vocalize his first words, and react to his misbehavior.

Home visitors can also be the critical link between parents and community resources that can benefit their children, such as free clinics offering immunizations and health screenings, preschool programs, day care services, and educational and recreational programs at local libraries and parks.

PAT is just one home visitation model. Others include Healthy Families America (HFA), the Nurse Family Partnership (NFP), and the Parent-Child Home Program (PCHP). Each model has a different focus. Whereas PAT is a voluntary program, often coordinated by local school systems and open to any parent who wants the service, HFA specifically targets parents facing multiple challenges, such as parents who are single, low-income, facing substance abuse problems, or victims of abuse or domestic violence. HFA home visitors are often paraprofessionals and work to ensure parents are providing for their children's medical and development needs.

NFP similarly focuses on children's early health and development, but works only with first-time mothers, and all home visitors are registered nurses. PCHP home visitors focus on children's early literacy and school readiness, bringing books and toys along for each visit at a cost of $2,400 per family, per program year, unlike PAT, HFA, and NFP, which are free to parents.

The last decade and a half has seen widespread growth in home visitation programs as new research has emphasized the importance of children's early development on their physical and mental health later in life. PAT programs were first implemented in all Missouri school districts in the mid-1980s under the urging of then-Governor Christopher Bond (R), who had personally participated in a PAT pilot program as a new parent. PAT programs now operate in 3,200 sites nationally and 8 internationally.

Today as U.S. Senator, Bond remains a strong advocate of PAT and other home visitation programs. Along with Representatives Danny Davis (D-IL), Tom Osborne (R-NE), and Todd Russell Platts (R-PA), Bond has introduced legislation that would for the first time provide dedicated federal funding for home visitation programs at the state and local levels. The Education Begins at Home Act would provide $400 million over three years to states to expand home visitation programs, while also reauthorizing Early Head Start. An additional $100 million over three years would fund home visitation services to families with English language learners and families on military bases.

The number of children birth to age 5 residing in a state would determine a state's funding allocation, which would not exceed more than $20 million per year. States would use the funding not only for voluntary early childhood home visits, but also for group meetings to educate parents, for training and technical assistance for visitation staff, and to provide health, vision, hearing, and developmental screening to eligible children.

CWLA is among a large group of child advocacy organizations that have formed a home visiting coalition to actively lobby Capitol Hill in support of the legislation.

PAT President and CEO Sue Stepleton calls the legislation a "pioneer effort."

"The funding is not to supplant any current state efforts," she says, "so it really is intended to bring added resources to all the states."

HFA Director Lisa Schreiber says the legislation establishes a solid plan for program implementation. "It defines quality for the field. It sets up expectations for training and service delivery, and it encourages state planning. But most importantly, it provides an unprecedented opportunity to get home visitation the visibility and funding it deserves."

Continuous Quality Improvement

As home visitation programs have expanded, researchers have taken advantage of emerging data to study how the models can be improved. In general, home visitation programs are found to be particularly effective with hard-to-reach populations, such as single parents and low-income families.

But home visitation programs vary in quality, says Deborah Daro, a research fellow at the University of Chicago's Chapin Hall Center for Children. The ones that work are internally consistent, making repeated visits over many years. To do a good job, home visitation programs need to give home visitors low caseloads, link with other community services, and be clear about who they are giving services to. Ultimately, Daro says, "They need to go forward with a keen eye toward quality."

The Spring/Summer 1999 issue of The Future of Children, a publication of The Woodrow Wilson School of Public and International Affairs at Princeton University and The Brookings Institution, laid out a particularly critical analysis of six home visiting models.

The publication's executive summary noted, "Several home visiting models produced some benefits in parenting or in the prevention of child abuse and neglect on at least some measures," but also pointed out, "no model produced large or consistent benefits in child development or in the rates of health-related behaviors such as acquiring immunizations or well-baby check-ups." The article went on to say, "Most programs struggled both to implement services as intended by their program models, and to engage families."

Many home visitation programs have acknowledged they need to work on how best to serve families. HFA was one program the publication noted did not "demonstrate significant improvements in children's development or maternal social support." Today, HFA operates under "a culture of continuous quality improvement," Schreiber says. Specifically, HFA has developed a research-practice network to continuously explore issues of program implementation.

"The research has confirmed an issue for us that our program staff have really known for years--that our programs are challenged in serving the highest risk families who deal with such issues as domestic violence, substance abuse, and mental health concerns," Schreiber said during a web conference sponsored by Chapin Hall last year on the subject of home visitation programs. "We have listened to these findings and are assessing what innovations programs have done to grapple with these issues. We know the enhancements to the programs really run the gamut, from improved training [to] adding clinical staff and improving referrals for other critical services for families. We are really trying to learn where it is working well and disseminating that information to the field."

In addition, Schreiber said HFA has recently launched an effort to look closely at the positive outcomes generated by the model and to determine the key practices that led to the outcomes.

HFA is not alone in its continuous self-improvement process. NFP, developed by David Olds, University of Colorado Health Sciences Center, conducted randomized, controlled trials with first-time, low-income mothers participating in the program in New York in 1977, in Tennessee in 1987, and in Colorado in 1994. Study of long-term outcomes for the mothers and their children in all three trials continues today.

Keeping parents enrolled and engaged in home visitation programs is another challenging issue for the visitation models. HFA, for example, retains approximately 66% of the families enrolled in its program after six months, but this number drops to 28% after two years. For NFP, 82% of first-time mothers stick with the program through the delivery of their children, and 51% remain a year and a half later.

An issue brief published by Chapin Hall in September 2005 highlighted a number of strategies for keeping home visits going, including, "more nuanced messages about the benefits of engagement, sustained efforts to address the broad range of needs new parents often express when initially enrolling, more careful assessment of the community context in which services are delivered, attention to the skills needed to build strong relationships between workers and families, and an honest assessment of how racial and cultural factors shape these relationships."

In a letter to the editor published in the journal Child Abuse and Neglect, Daro likens the continuous improvement process for home visitation programs to the continual work necessary to advance public school systems:

In this country we implement public schools based on the value that an educated population is better for a society's successful development than an uneducated one. Every year we send millions of children to schools that are less than perfect, that fail to provide the basic literacy and math skills needed for every day living. However, our response to this failure is to seek ways to improve the system, not stop educating children until we get the data right.

A Complex Job

As home visitation programs continue to grow and expand, they also need to ensure their visitors are supported and qualified for the job, says Martha Staker, a faculty member at the University of Kansas Medical Center, where she directs Project EAGLE, a program offering child development and family support services to area residents.

Staker describes home visiting as a complex job, requiring visitors to be "change agents" in an environment of physical, social, and mental challenges.

In working with her group of low-income parents with limited English language skills, PAT's Ramos Bock admits she must often overcome obstacles before working directly with parents on their children's development.

Ramos Bock has found herself making calls to doctors and trips to pharmacies to help Spanish-speaking parents with pressing medical issues, or to help them get a broken refrigerator or a gas-leaking stove fixed. Providing advice on proper diet is also common. One mother of a 4-year-old, Ramos Bock recalls, wondered why her daughter was suffering from obesity and constipation. When Ramos Bock discovered the woman was feeding her daughter a diet primarily of rice pudding and sugary yogurt, she introduced the mother to different kinds of vegetables to improve the little girl's health. She also saw that the girl visited a doctor for the first time to receive medical care for a lazy eye and poor dental health.

Many of the parents Ramos Bock visits live in older apartment complexes, sometimes two and three families to a one- or two-bedroom apartment. Sometimes, she will make a scheduled visit to a mother and child, only to find a living room full of the mother's relatives and friends and their children who also want Ramos Bock's help. "I call those my Tupperware parties," Ramos Bock says with a laugh.

"I do get overwhelmed, but it's my fault," Ramos Bock says, noting she has elected to work with 25 families at one time, which often requires working more than 40 hours a week. "I believe everybody [including immigrants] should have the same opportunities. The only reason [they] come here is because they want the best for their children."

Amid the challenges, Ramos Bock says her work is satisfying. While researchers often debate the consistent and quantifiable results of home visiting, she sees signs of success every day. Some signs may be small to an outsider, such as a mother taking her children to the library for the first time or enrolling them in a Head Start program, but Ramos Bock sees these kinds of activities as "huge" steps for her immigrant mothers, most of whom only have a sixth grade education.

"One of the things I really emphasize to the families is that they have to be advocates for their children."

Jennifer Michael is Managing Editor of Children's Voice.

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