Over the last five years, sending people into the homes of struggling families to help improve their children’s lives and prevent abuse has been the strategy held out as society’s best hope.
Yet amid the fallout of a major report saying such home visitation programs have not achieved their goals, experts are struggling with a fundamental question: How much is it possible to change people’s lives?
The report’s editors say the results do not suggest that home visitation should be abandoned, but they call for new efforts to determine which techniques work and which don’t, as well as a lowering of expectations.
“These programs are one of the things we can use to change families’ lives, but they are not the only thing,” said Deanna Gomby, co-editor of the spring/summer issue of “The Future of Children,” a publication of the California-based David and Lucile Packard Foundation. “And when we do them, we should make sure they are as good as we can make them.”
In the first broad analysis of research on six of the country’s best-known home visiting programs, including one model that operates in Illinois, the Packard Foundation report found that the programs had no large or consistent impact on how children developed intellectually or what kind of health care they received. And although some positive changes did occur in the areas of child-abuse prevention and parenting skills, the report states, they were often quite small, despite the millions of dollars in public and private funds invested in the effort.
These findings have created a stir among child-abuse prevention advocates, who fear the news may derail support for these programs– most of which are fairly new– before they have a chance to succeed, a fate some compare to shutting down the space program just because the first few rockets didn’t reach the moon.
Some experts dispute the report’s significance, arguing that it draws an overly negative interpretation of the research and fails to recognize that the statistics don’t differ much from those of other programs that target low-income groups.
But almost everyone agrees that home visiting, which has drawn such heady praise as an American Academy of Pediatrics endorsement that called one program the “most hopeful and promising development . . . within the memory of anyone working in the field of child maltreatment,” cannot by itself bear the weight of such high expectations.
What distinguishes the Packard Foundation analysis from most other research findings beginning to trickle out about home visiting programs is that it relies upon studies that compare families who participated in these programs with similar families who did not, which is considered one of the most reliable research methods.
Among the programs discussed is Healthy Families America, a project of Prevent Child Abuse America, the Chicago-based organization formerly known as the National Committee to Prevent Child Abuse, and a model that now operates in 330 sites across the country, including 28 in Illinois.
This year, the General Assembly increased funding for the state-wide effort to $8 million from $3.5 million.
In its analysis of the studies, the report states: “These findings are sobering. In most of the studies described, programs struggled to enroll, engage and retain families. When program benefits were demonstrated, they usually accrued only to a subset of the families originally enrolled in the programs, they rarely occurred for all of a program’s goals, and the benefits were often quite modest in magnitude.”
The problem is that, as the report makes clear, no one is sure yet who gets the most benefit from home visiting and what is the best way to do it.
Most programs are voluntary and focus on families who are poor, but otherwise, they share little except a label.
Home visits might be made by a nurse or a neighbor. A visit might involve conducting a primer on a toddler’s language development skills or comforting a teenage mother whose boyfriend just walked out– or both. And these issues may vary, not only from program to program, but from family to family and visit to visit, making it extremely difficult to identify what works and what doesn’t.
All the programs experienced fairly high dropout rates, ranging from 20 percent to 67 percent, and none demonstrated a strong ability to influence children’s cognitive development. But while several programs seemed to have the greatest effect upon poor, young, unmarried first-time mothers, other programs, including Healthy Families America, could not identify with any consistency who was the best target for their services.
“I think we need to study the process of home visiting,” said Barbara Hanna Wasik, director of the University of North Carolina Center for Home Visiting and the author of a book about home visiting programs.
“We need to know what is actually going on during the home visit. The more knowledge we have about that relationship, the more effective we can be in designing programs that would reach our goals.”
One of the primary goals of most home visiting programs, and the one largely responsible for their increased popularity, is the prevention of child abuse and neglect. But the report and other research indicates that that may be the most elusive effect to measure.
The strongest evidence comes from studies that University of Colorado pediatrics professor David Olds conducted in Elmira, N.Y. Poor, unmarried, teenage mothers enrolled in the Nurse Home Visitation Program there had 80 percent fewer verified reports of child abuse and neglect during their children’s first two years of life than their counterparts who didn’t take part in the program. After 15 years, the gap still persisted, although it dropped to 50 percent.
Olds himself, however, cautions that these findings may be unique to Elmira, which not only had the state’s highest rate of child abuse but an extremely efficient system for reporting it. Other studies looking at child abuse prevention have turned up much more mixed results.
There is also the complication that families involved in home visiting programs may actually be more likely to be reported for abuse and neglect because their children are regularly seen by outsiders.
“Most of these studies will have a hard time detecting an impact on child maltreatment even if there is an effect,” Olds said.
Like a number of other experts, Olds thinks that home visiting programs have been “oversold” in recent years, raising hopes for far more dramatic results than can be expected for any effort that attempts to reach the country’s neediest families.
“Did our rhetoric get ahead of our data?” asked Deborah Daro, a research fellow at the Chapin Hall Center for Children at the University of Chicago, whose evaluation of Healthy Families America appears in the Packard report. “Absolutely.”
But Daro believes that home visiting programs do make a difference, albeit one that doesn’t necessarily translate into percentages.
“Statistical significance is important, but so are the countless stories that people tell us,” she said.
Ryan Gregory, who became a mother at 17, volunteered to participate in the Healthy Families America program after learning about it from a friend.
Her family support worker, Kathy Burkhart, brings her handouts on parenting and child development, outlet covers and– this week–a small birthday present for her son, 1-year-old Nicholas de la Cruz. But what is most important about the program, Gregory says, is something altogether different.
“It’s helped me out when I’ve needed somebody to talk to about stuff,” she says simply.
“It was tough in the beginning when nobody wanted him but me.”
