[Archived] Prenatal/Postnatal Home Visiting Programs and Their Impact on Young Children’s Psychosocial Development (0-5): Commentary on Olds, Kitzman, Zercher and Spiker

Introduction

Home visitation has been cited by several policy analysts and advocates in the U.S. as offering a particularly promising service delivery approach for educating parents and reducing abuse potential.^1,2,3 This is particularly true if services are offered early in a child’s development. Initiation of services during pregnancy or at birth facilitates the development of a secure, positive attachment between the parent and child and establishes a cornerstone for later development.⁴ Offering such services in a parent’s home has a number of added advantages.  Such services offer the provider an excellent opportunity to assess the safety of the child’s living environment and to work individually with the parent to improve parent-child interactions. The method also affords the participant a degree of privacy and the practitioner a degree of flexibility that is difficult to achieve in group-based programs.

Despite the strategy’s theoretical and popular appeal, rigorous evaluations of prenatal/postnatal home visitation programs confirm mixed performance levels, as noted in each of the three CEECD papers submitted on this topic.  Zercher and Spiker consider the empirical evidence in light of the broadest array of research questions, looking for empirical support for the method’s efficacy and effectiveness.  By contrast, Kitzman focuses on the ability of home visitation programs to reach socially disadvantaged families effectively and pays particular attention to how different program structures or elements might influence enrolment rates, as well as individual outcomes.  Olds examines the evidence that these types of interventions can address three core predictors of social and emotional problems for children (e.g. mothers’ prenatal health, parents’ caregiving and maternal life course). All three papers note the wide variability among programs grouped under the broad heading of prenatal/postnatal home visitation and the limited number of what might be considered “high-quality” evaluation studies (i.e. randomized clinical trials).

Research and Conclusions

Despite the innovation’s popularity, evaluative data on home visitation programs reviewed by all three authors indicate that positive outcomes are neither universal for all models nor consistent across all populations. All three of the papers agree that large randomized trials generally conclude that home visitation services produce “a limited range of significant effects and that the effects produced are often small.” All three also agree that effects are more likely to occur among the most disadvantaged populations.  Overall, Kitzman and Olds, drawing largely on their own work, are slightly less dismissive of the intervention than Zercher and Spiker, noting that significant and positive impacts have been observed in pre-natal health behaviour in mothers, child abuse and neglect, and mother-infant relationships, and that positive impacts can be sustained and improved over time. At least one longitudinal study cited in all three papers demonstrated a reduction in welfare dependency and criminal behaviour among the treatment group compared to the controls.⁵

In drawing their conclusions, Zercher and Spiker rely almost exclusively on one primary source for their evaluative data, a summary document produced by the Packard Foundation on data gathered over a decade ago.⁶ Kitzman and Olds heavily reference their own work.  To be fair, the Kitzman and Olds research constitutes an impressive package of studies.  The development of their Nurse Family Partnership (NFP) program and its consistent evaluation through a series of carefully designed randomized trials and longitudinal research are unprecedented in the field of social-service planning.  NFP remains one of the most highly regarded and consistently implemented home visitation programs in the US.   

Since the publication of the Packard Report, however, the research base on prenatal/postnatal home visitation programs has become broader and more nuanced. Meta-analyses of this expanded research base confirm the model’s impacts on a range of risk and protective factors associated with child maltreatment.^7,8,9 In addition, all of the major home visitation models in the U.S. are currently engaged in a variety of research activities, many of which are resulting in better defined models and more rigorous attention to the key issue of participant enrolment and retention, staff training and quality assurance standards.¹⁰  For example, recent findings emerging from the initial two-year follow-up of the Early Head Start National Demonstration Project confirm the efficacy of home visitation programs with new parents.  Specifically, Early Head Start mothers were more supportive, more sensitive, less detached and more likely to extend play to stimulate cognitive development, language and literacy than mothers assigned to the control group in this large randomized trial.  Early Head Start mothers also reported less frequent use of spanking and, in general, described using milder forms of discipline in managing their two-year-olds.¹¹  These impacts were more likely to occur among those Early Head Start recipients who enrolled in the programs implementing home visitation programs than among those enrolled in programs relying exclusively on centre-based services, although the strongest gains were achieved by programs that offered a combination of home- and centre-based services.

Rather than view the lack of consistent findings as an indication of program failure, another interpretation of these patterns is that they underscore the inevitable limitation of any single intervention, no matter how well designed and delivered.¹² Improving child outcomes and parental capacity requires not simply a strong program but also high- quality systems of care.  Indeed, more recent research suggests that partnering these types of intensive home-based interventions with a group- or community-based service program can dramatically increase the proportion of new parents who will use prevention services.^13,14,15 Additional research is needed along these lines to identify any unique role home visitation may play within the context of a broad, diversified system of parent education and support. 

Implications for Policy Development

All three papers offer differing perspectives on the utility of expanding home visitation services. Kitzman suggests that strengthening the knowledge base will require that home visitation programs retain integrity and commitment to a given model to determine overall efficacy as well as the specific utility of various structural elements. Zercher and Spiker argue that the intervention should be adopted only as a secondary prevention strategy, noting that no empirical evidence exists to support a universal service delivery strategy.  Olds cautions that any application of the model to a new culture or population should be done only after an investment is made in randomized clinical trials.

While individual home visitation programs are increasingly well defined and carefully implemented, the best method for rigorously evaluating their effectiveness is less clear.  The diversity of family needs and pathways to improving child development suggests that the most effective home visitation programs will be those that are not only well implemented but also well informed of the unique challenges and strengths of their local communities.¹⁶ Fully understanding the impacts of home visitation programs, therefore, requires diverse assessment methods.  The best policies and programs may emerge when we consider the collective lessons from a wide body of research, utilizing diverse theoretical models and methodologies.¹⁷ 

Reference 

1. U.S. Government Accounting Office (GAO). Home visiting: A promising early intervention strategy for at-risk families. Washington, DC: U.S. Government Printing Office; 1990. GAO/HRD-90-83.
2. U.S. Department of Health and Human Services, U.S. Advisory Board on Child Abuse and Neglect. Creating caring communities: Blueprint for an effective federal policy for child abuse and neglect. Washington, DC: U.S. Government Printing Office; 1991.
3. Hahn RA, Bilukha OO, Crosby A, Fullilove MT, Liberman A, Moscicki EK, Snyder S, Tuma F, Schofield A, Corso PS, Briss P. First reports evaluating the effectiveness of strategies for preventing violence: Early childhood home visitation. Findings from the Task Force on Community Preventive Services. Morbidity and Mortality Weekly Report 2003;52(RR-14):1-9.
4. Carnegie Task Force on Meeting the Needs of Young Children. Starting points: Meeting the needs of our youngest children. New York, NY: Carnegie Corporation of New York; 1994. Abridged version available at: http://www.carnegie.org/starting_points/. Accessed February 12, 2007. 
5. Olds D, Henderson CR Jr, Cole R, Eckenrode J, Kitzman H, Luckey D, Pettitt L, Sidora K, Morris P, Powers J. Long-term effects of nurse home visitation on children’s criminal and antisocial behavior: 15-year follow-up of a randomized controlled trial. JAMA - Journal of the American Medical Association 1998;280(14):1238-1244.
6. Gomby DS, Culross PL, Behrman RE. Home visiting: Recent program evaluations - Analysis and recommendations. The Future of Children 999;9(1):4-26.
7. Bakermans-Kranenburg MJ, van IJzendoorn MH, Juffer F. Less is more: Meta-analyses of sensitivity and attachment interventions in early childhood. Psychological Bulletin 2003;129(2):195-215.
8. Geeraert L, Van den Noortgate W, Grietens H, Onghena P. The effects of early prevention programs for families with young children at risk for physical child abuse and neglect: A meta-analysis. Child Maltreatment 2004;9(3):277-291.
9. Sweet MA, Appelbaum MI. Is home visiting an effective strategy? A meta-analytic review of home visiting programs for families with young children. Child Development 2004;75(5):1435-1456.
10. Daro D. Home Visitation: Assessing Progress, Managing Expectations. Chicago, Ill: Chapin Hall Center for Children. Available at: http://www.chapinhall.org. Accessed February 12, 2007. 
11. U.S. Department of Health and Human Services. Building Their Futures: How Early Head Start Program are Enhancing the Lives of Infants and Toddlers in Low Income Families. Summary Report. Washington D.C.: Commissioner’s Office of Research and Evaluation, Head Start Bureau; 2001. Available at: http://www.mathematica-mpr.com/publications/PDFs/buildsumm.pdf. Accessed February 12, 2007. 12.Weiss HB. Home visits: necessary but not sufficient. The Future of Children1993;3(3):113-128.
12. Anisfeld E, Sandy J, Guterman NB. Best Beginnings: A Randomized Controlled Trial of a Paraprofessional Home Visiting Program. New York, NY: Columbia University School of Social Work; 2004. Available at: http://www.healthyfamiliesamerica.org/downloads/eval_NY_bb_2004.pdf. Accessed February 12, 2007.
13. Constantino JN, Hasemi, N, Solis E, Alon T, Haley S, McClure S, Nordlicht N, Constantino MA, Elmen J, Carlson VK. Supplementation of urban home visitation with a series of group meetings for parents and infants: results of a “real world” randomized, controlled trial. Child Abuse and Neglect 2001;25(12):1571-1581.
14. Klagholz D. Starting Early Starting Smart: Final Report. Great Falls, Mont: Donna D. Klagholz & Associates, LLC; 2005. Available at: http://www.healthyfamiliesamerica.org/research/index.shtml. Accessed February 12, 2007.
15. Daro D, Cohn-Donnelly A. Child abuse prevention: Accomplishments and challenges. In: Myers JEB, Berliner L, Briere J, Hendrix T, Jenny C, Reid T, eds. The APSAC handbook on child maltreatment. 2^nd ed. Thousand Oaks, Calif: Sage Publications; 2002:431-448.
16. McCall RB, Green BL. Beyond the methodological gold standards of behavioral research: Considerations for practice and policy. Social Policy Report 2004;18(2):3-19. Available at: http://www.srcd.org/Documents/Publications/SPR/spr18-2.pdf. Accessed February 12, 2007.