Home Visitation: The Cornerstone for Effective Early Intervention Deborah Daro Ph.D

1
Home VisitationThe Cornerstone for
EffectiveEarly Intervention Deborah Daro Ph.D
2
Key concepts

• Review current thinking regarding the child abuse
  prevention framework
• Place home visitation within the context of early
  intervention
• Review lessons emerging from research on home
  visitation programs
• The Managing Expectations Dilemma

3
Evolution of CAN Prevention Framework

• Vertical Image
• Birth to Five
• Replicating Best Practices
• Alter Participants AND Context
• Universal AND Targeted

• Horizontal Image
• Multiple age cohorts
• Replicating Models
• Alter Participants
• Universal OR Targeted

4
Factors Contributing To New Paradigm

• Early Intervention
• Early brain research and its accessibility to the
  general public
• Political support for early intervention
• Emphasis on Primary Prevention
• Need to broaden public engagement in this issue
• Limits of prediction models to appropriately
  target at-risk
• Evidence-informed practice
• Concerns with accountability
• Improve the quality of the program/policy
  planning process

5
Why home visitation programs?

• Recommendation from the U.S. Advisory Board on
  Child Abuse and Neglect
• Success of the Nurse Family Partnership and other
  home visitation efforts in achieving positive
  outcomes
• Hawaiis statewide expansion of Healthy Start
• Established a promising pathway for reaching the
  most challenged families

6
How valuable is home visitation in short-run?

• New Parents
• Better birth outcomes
• Enhanced parent-child interactions
• More efficient use of health care services
• Enhanced child development and early detection of
  developmental delays
• Toddlers
• Early literacy skills
• Social competence
• Parent involvement in learning

7
How valuable is home visitation in long-run?

• New Parents
• Reduced welfare dependency
• Higher school completion and job retention
• Reduction in the frequency and severity of
  maltreatment
• Toddlers
• Stronger school performance
• Fewer behavior problems
• Higher high school graduation rates

8
Promising service characteristics

• Solid internal consistency linking program
  elements to desired outcomes
• Begin at birth or sooner (for CAN outcome)
• Engage families in services and sustain
  involvement long enough to achieve outcomes
• Provide direct assessment and services to
  children as well as parents
• Solid organizational capacity
• Build strong linkages among local providers

9
Promising staffing patterns

• Prevention is about building relationships not
  delivering a product hire relationship builders
• For the most intensive services, maintain low
  caseloads (15 per worker)
• Provide staff comprehensive initial and
  in-service training opportunities
• Provide staff multiple opportunities for
  individual and group supervision

10
What elements remain unclear?

• The appropriate target population
• The importance of curriculum consistency
• The optimal service duration and intensity
• The critical qualifications for home visitors
• The appropriate locus of administrative control

11
Are we getting better

• in using data to improve outcomes?
• in working collaboratively across models?
• in setting appropriate expectations for home
  visitation services?

12
Progress in using data

• Major models operate management information and
  quality assurance systems
• More honest reflection on identifying program
  shortcomings and adjusting the models as
  necessary
• Expanded research base, including more rigorous
  assessments utilizing stronger evaluation
  designs, larger samples and more reliable
  measures

13
Progress in fostering collaboration

• Participation in a Home Visit Forum to
• Strengthen empirical and clinical capacity to
  assess and improve service
• Develop multi-model research inquiries and link
  findings to practice
• Create and support efforts to better place home
  visitation within a broader system of early
  intervention

14
Home Visit Forum members

• Early Head Start (EHS)
• Healthy Families America (HFA)
• HIPPY
• Nurse Family Partnership (NFP)
• Parent Child Home Center
• Parents As Teachers (PAT)

15
Forum products and outcomes

• Revision of each models theory of change and
  identification of common as well as unique goals
  across models
• Identification of a shared set of lessons
  regarding supervision
• Joint advocacy efforts to expand Federal and
  state support for home visitation

16
Progress on managing expectations

• Conducting more critical assessments of the
  available research
• Drawing lessons from implementation studies as
  well as outcome studies
• Establishing stronger conceptual models that
  better articulate proximate and intermediate
  outcomes

17
Key Pitfall to Avoid In Moving Forward

• Debating the quality of a model (technical
  solutions) without paying comparable attention to
  the types of contextual changes needed to
  maximize impacts (adaptive challenges).

18
Home Visitation As Leverage Not Solution

• Technical solutions
• Creating programs and supportive services for new
  parents
• Adaptive challenges
• Creating a culture which validates seeking help
  and giving help
• Altering institutional structures and openness to
  collaboration and shared responsibly for common
  objectives
• Altering the political process to embrace
  investment in young children

19
Use of Evidence-Based Decision Making

• Carefully review research findings in light of
  your theoretical assumptions and participant
  needs
• Value both implementation and outcome research
• Seek programs that recognize the need for
  continuous self-assessment and adaptation
• Be as critical of potentially positive findings
  as you are of negative findings
• Accept the fact that not all things can be
  proven

20
Data Sources for Assessing Effectiveness

• Basic research on human physical and
  social-emotional development
• Randomized clinical trials on highly specified
  interventions
• Administrative data on incidence and service
  levels
• Descriptive studies on service implementation and
  the public policy response

21
Strategies for Managing Expectations

• Better methods
• Utilize a diverse array of evaluation designs
• Craft implementation as well as outcome studies
• Better theory
• Link program efforts to realistic outcomes
• Articulate models linking proximate and distal
  outcomes
• Better synthesis
• Meta-analytic techniques
• More critical assessments of the available
  research
• Draw on findings from other disciplines

22
Staying the Course

• The Great Society asks not how much, but how
  good not only how to create wealth but how to
  use it not only how fast we are going, but where
  we are headed.
• It proposes as the first test for a nation the
  quality of its people.
• This kind of society will not flower
  spontaneously from swelling riches and surging
  power.
• It will not be the gift of government or the
  creation of presidents. It will require of every
  American, for many generations, both faith in the
  destination and the fortitude to make the
  journey.
• And like freedom itself, it will always be
  challenge and not fulfillment.
• LBJ (1965)