Excerpted from Chapter 1 of Your Guide to Nurturing Parent-Child Relationships: Positive Parenting Activities for Home Visitors, by Nadia Hall, M.Ed., Dip, C.S., M.A., Chaya Kulkarni, Ed.D., M.Ed.,and Shauna Seneca, B.S.W.
Copyright © 2008 by Paul H. Brookes Publishing Co. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Many families struggle with limited resources and supports, low self-confidence, and poor understanding of child development. The great diversity of home visiting programs across North America bears witness to home visitation as a powerful and effective way to support families through voluntary, long-term relationships. The variety in programs is seen in the range of purposes and intended outcomes, target populations, and types of interventions.
Prevention and early intervention programs also vary with regard to staff background. The roles assumed by many home visitors—educator, nurturer, advocate, collaborator, coordinator, and counselor, to name a few—are shouldered by staff from the fields of nursing, social work, early childhood development, and mental health. However, research has shown that no conclusions can be drawn at this time with regard to individuals from a particular professional or educational discipline being better home visitors than others (Gomby, Culross, & Behrman, 1999). The range in home visitors' knowledge, skill sets, attitudes, and supervisor support all factor into the complex art of working in partnership with families to optimize children's development.
FAMILIES WHO BENEFIT FROM HOME VISITING
A child's developmental path is influenced by a complex and continuous interplay of biology and experience. Both genetic and environmental factors can either buffer or buffet family functioning and thus have a profound effect on a child's growth. As desirable as it might be to predict a child's developmental path based on a vulnerability and resiliency factor formula, research has shown this to be impossible (Invest in Kids, 2004a). What is known from the work of Werner (1995) and Rutter (2000) is that interactions among risk and protective variables are complex and change over time; knowing the factors that create burdens does not inform one about the mechanisms or processes by which such factors operate. The somewhat daunting task for home visitation programs, therefore, is to decide who will benefit the most from this intervention.
In its literature review (Infant Mental Health Promotion Project, 1996), the Ontario Task Force on Home Visiting concluded that home visitation is an effective intervention approach for pregnant women and families with young children when there is
- High risk of suboptimal pregnancy outcomes due to multiple risk factors
- High risk of ineffective parenting (including abuse and/or neglect) due to characteristics of parents, child, or social situation
- Difficulty establishing the breastfeeding relationship
- Resistance, suspicion, and/or mistrust of support or services
- Social isolation or immobility
- Poor access to community and health care resources
- High level of stress and potential mental health problems
- High risk of compromised infant development
Components of Effective Home Visits
Just as a vulnerability and resiliency factor formula does not exist, neither does a system that could be used to determine which configuration of components in a home visiting program would be most effective for improving child outcomes in each family. The research, however, does offer compelling arguments for the effectiveness of home visiting. As a prevention and intervention strategy, home visiting is successful when (Cliska et al., 1999; Gomby et al., 1999; Invest in Kids, 2003a; Shonkoff & Phillips, 2000; Wade et al., 1999)
- It is part of a comprehensive program that targets a variety of goals and outcomes. Programs that focus on only one area, such as discipline or feeding issues, usually do not have robust or lasting effects.
- It is provided by professionals or highly trained and well-supported paraprofessionals. Home-visiting nurses may be particularly important during pregnancy and the immediate postpartum period to help with health-related issues.
- It is one of a range of intervention strategies or is part of a continuum of services used either within the program or through a well-established system of referral or linkages with other community services and resources
- It is provided to overburdened families. Families who are self-sufficient or have sufficient support from those they know usually experience fewer benefits from home visit programs, whereas families at higher risk will suffer most without services and hence, are likely to show more improvement than low-risk families who do not receive services.
- It is regular and frequent (intensity), begins if possible in the prenatal period, and continues for 2 or 3 years after a child's birth (duration)
- It involves an infant mental health approach in which relationships between the mother and her infant/child and between the mother and the home visitor are the center of intervention
- Its content is flexible, responsive, and constantly reviewed for each family
- It is accompanied by regular supervision and case coordination Further research by Shonkoff and Phillips (2000) has identified a core set of essential features for state-of-the-art early intervention programs:
- Individualization of service delivery "that matches well-defined goals to the specific needs and resources of the children and families who are to be served" (Shonkoff, Phillips, & Keilty, 2000)
- High-quality program implementation, including close supervision, well-trained staff, high level of funding, and supportive policies
- Family-centered, community-based, and coordinated orientation
- Strong provider knowledge, skills, and relationships with families
- Appropriate timing, intensity, and duration of services
Evaluation of the field's efforts still leaves much room for discussion about which intervention works in which ways for which children at which time. Thus, the home visitor must use whatever skills, commitment, knowledge, and support are at his or her disposal to meet the needs of individual families.
THEORETICAL MODELS FOR PRACTICE Practice is informed by theoretical models, research and program evaluation, and professional experience (Shonkoff & Phillips, 2000). Theoretical models provide a framework for organizing what is known and opportunities to test out promising practices that reflect the appropriate theoretical perspective. The development of Your Guide to Nurturing Parent- Child Relationships: Positive Parenting Activities for Home Visitors was shaped by the following theories of human ecology, family empowerment, and transactional dynamics (Invest in Kids, 2004a):
- Bronfenbrenner's ecological model (1979) provided a framework for understanding a child's development within the context of circles of social influence—in other words—the child in the context of the family, the family in the context of the community, and the community in the context of the larger political environment.
- Dunst's family empowerment model (1988) showed the importance of building on the inherent strengths of families and communities to improve the mental health of children and their families.
- Sameroff and Chandler's transactional model (1975) "views the development of the child as a product of the continuous, dynamic interactions between the child and the experience provided by his or her family and social context" (Sameroff & MacKenzie, 2003, p. 17). This bidirectional exchange means that the child influences his or her environment and the environment influences the child continuously, over a long period of time. Program protocols and home visit procedures reflect the translation of these theoretical positions into applied practice. The material in this guide offers ways in which home visitors can, through modeling, teaching, coaching, and providing feedback, help parents
- Strengthen their parenting competencies
- Interact with their children to promote a nurturing parent-child relationship
- Discover how to enhance personal skills and adaptive behaviors
- Use the community network of resources
- Focus on solutions rather than deficits
- Experience confidence and success in parenting and other aspects of life