Home Visiting Programs
National Physicians Center for Family Resources
INTRODUCTION: In response to recent presidential commissions and recently introduced federal legislation promoting the expansion of infant and toddler home visiting programs, the National Physicians Center is calling for review of these programs with regard to scientific validity and effectiveness, potential side effects, cost, and issues of family autonomy and scope of government.
- Social and Emotional Assessment and Monitoring in Infants and Young Children: Home visiting programs in general and the NFP program specifically are being held up as model programs as a way to improve infant and early childhood social and emotional development (mental health) and behavior. For example, the 2004 New Freedom Commission Report mentioned NFP, saying:
" Early detection and treatment of mental disorders can result in a substantially shorter and less disabling course of illness.144; 145 As the mental health field becomes increasingly able to identify the early antecedents of mental illnesses at any age, interventions must be implemented, provided in multiple settings, and connected to treatment and supports."
" Early interventions, such as the Nurse-Family Partnership (See Figure 4.1.), and educational efforts can help a greater number of parents, the public, and providers learn about the importance of the first years of a child’s life and how to establish a foundation for healthy social and emotional development."
However, as the following quotes demonstrate, there is no evidence for understanding the cause of mental illness, much less the early antecedents. Nor, is there any real agreement on diagnostic criteria, especially in young children; evidence for interventions; or outcome measures.
- “The diagnosis of mental disorders is often believed to be more difficult than diagnosis of somatic or general medical disorders since there is no definitive lesion, laboratory test or abnormality in brain tissue that can identify the illness.” (Surgeon General 1999)
- “Childhood and adolescence being developmental phases, it is difficult to draw clear boundaries between phenomena that are part of normal development and others that are abnormal.” (World Health Organization, World Health Report, 2001)
- Dr. Benedetto Vitiello, director of Child and Adolescent Treatment and Preventive Interventions Research Branch for the National Institutes of Mental Health, acknowledged (2001) “the diagnostic uncertainty surrounding most manifestations of psychopathology in early childhood.”
- A 2005 National Center for Infant and Early Childhood Health Policy report on infant mental health admitted the following barriers to implementing the planned infant mental health system, which would also apply directly to carrying out the proposed legislative language listing state activities, such as “adopt a clear, consistent model that is grounded in empirically-based knowledge related to home visiting and linked to program determined outcomes;” or providing parents with “knowledge of age appropriate child development in cognitive, language, social emotional, and motor domains;” or “provide referrals for eligible families, as needed, to additional resources available in the community, such as center-based early education programs…mental health services…social services…”
- “Diagnostic classifications for infancy are still being developed and validated…”
- “Lack of longitudinal outcome studies”
- “There is neither a systematic data base, clear criteria for [medication] treatment or dosage recommendations that have been identified or standardized for pediatric use (Greenhill et al. 2003).”
- “Broad parameters for determining socioemotional outcomes are not clearly defined”
- “Little research has been conducted to study the effectiveness of psychosocial interventions in young children, and the long-term risk-benefit ratio of psychosocial and pharmacologic treatments is basically unknown.” (Vitiello, 2001)
- Effect of Home Visiting Programs on Socioemotional Development and Behavior:
- While the Nurse Family Partnership (NFP) programs had some statistically significant effects on subsequent maternal behavior, contrary to what was stated on the NFP website, analysis of the studies showed that there were few, if any, statistically significant effects on child socioemotional development and behavior:
- “It is important to note, however, that the reduction in total behavioral problems on the CBCL [Child Behavior Checklist completed by the mothers] was not corroborated by teachers' reports of child behavior.” (Olds and Kitzman, 2004)
- “There were no program effects on …mental development, or behavioral problems...” (Kitzman and Olds, 1997)
- “There were no statistically significant program effects for the nurses on… their children's temperament or behavior problems.” (Olds and Robinson, 2002)
- “There were no statistically significant nurse effects on sensitive-responsive mother-child interaction, children's emotional regulation, or externalizing behavior problems [nurse visited].” (Olds and Robinson, 2004)
- Effect of Home Visiting Programs on Child Abuse Rates:
- There have been two studies where home visiting programs were not effective as admitted by proponents of these programs. (Chaffin,2004; Gomby, 2005).
- A national review of 6 Healthy Families America home visiting programs revealed the following: “Six control-group studies have been conducted on individual HFA programs currently in operation. Five of the six studies failed to show conclusively that the program had a significant impact on child abuse rates or measures of child abuse potential among first-time mothers enrolled in the program. The sixth study used a method of calculating child abuse rates that makes its findings ultimately inconclusive. No well-constructed control-group study of an HFA program has shown clear success in reducing child abuse rates or measures of child abuse potential in a given target population.” (Lightfoot and Watson, 1999)
- The programs Parents as Teachers was described in a recent Congressional hearing by proponents as resulting in “prevention of child abuse and neglect,” yet no research or data to substantiate that claim was provided.
- Effect of Home Visiting on School Readiness and School Performance
- Proponents of these programs have mentioned improved scores on cognitive measures and test scores, including kindergarten readiness assessments and early elementary standardized tests. It is not clear if these effects are from the visits or preschool attendance. However, research about preschool and comprehensive intervention programs like Head Start continues to show that improvements in academic performance are not sustained much beyond the third or fourth grade:
- Former preschoolers and children who did not attend preschool ended up on nearly equal footing in cognitive and social development, regardless of their mother tongue by the end of third grade. (Rumberger 2006)
- “It's also in the early years when American students are most competitive internationally. Consider France, England, Denmark, Spain and Belgium where more than 90 percent of 4-year-olds attend public preschools. International tests show that by age 9, when the benefits of preschool should be most apparent, American children outscore nearly all of their universally preschooled peers on tests of reading, math, and science.” (NCES, 2000)
- “‘Fade out’ is important to any discussion of universal preschool because it means that early intervention may be virtually irrelevant to how a child turns out in adolescence or early adulthood.” (Olsen, 1999)
- “In the Abecedarian Project, children in the preschool program had IQs 4 to 5 points higher than the children in the control group at ages 12 to 15. Nonetheless, the early enrichment did not result in these children reaching IQ levels comparable to middle-class children in the community, nor did they reach the national average IQ of 100.” (Bruer, 1999)
- “In the long run, cognitive and socioemotional test scores of former Head Start students do not remain superior to those of disadvantaged children who did not attend Head Start.” (McKey et al., 1985)
- Brain Research: Proponents speak of brain research as the foundation for home visiting, early childhood programs and other interventions. The following quotes are indicative of the tendency of proponents of certain policies to over extol the benefits or potential benefits of programs based on basic science research about which there is little expert agreement regarding clinical, policy, and practical classroom application:
- “Assertions that the die has been cast by the time the child enters school are not supported by neuroscience evidence and can create unwarranted pessimism about the potential efficacy of interventions that are initiated after the preschool years.” ( Jack Schonkoff and Deborah Phillips, 2000)
- “For the most part, brain research does not offer clear evidence about the right time to begin programmatic interventions in young children’s lives or the types of care and instruction that should be provided.” (Alter, Randall, and Goldstein, 2001)
SIDE EFFECTS: Two recent studies, as well as much older research highlights the negative effects of out of home child care and preschool programs that are almost universally promoted by these home visiting programs, as well as introduced federal legislation:
- A 2002 study NICHD followed a group of more than 1,300 children in 10 different states through their first seven years of life and found that children who spend more hours per week in non-parental childcare have more behavior problems, including aggressive, defiant and disobedient behavior in kindergarten.
- “Attendance in preschool centers, even for short periods of time each week, hinders the rate at which young children develop social skills and display the motivation to engage classroom tasks, as reported by their kindergarten teachers...Our findings are consistent with the negative effect of non-parental care on the single dimension of social development first detected by the NICHD research team [in 2002].” (Fuller, et. al., 2005)
- Research summarized by Moore from as far back as the 1950’s and 1960’s demonstrates that early kindergarten entrants have more difficulty with speech defects, nervous indications, personal and social maladjustment, lack of leadership skills, poor grades, poor reading ability and a poor attitude towards school. If this is the case with early kindergarten entry, one can only imagine what potential problems may manifest themselves with infant and early childhood intervention and preschool programs.
FAMILY AUTONOMY/SCOPE OF GOVERNMENT/PRIVACY: The Lightfoot and Watson study revealed numerous concerns along this line, which will be outlined below. Of particular concern is the federal government promoting through taxpayer funds and even enforcing via potential child abuse and neglect reporting mechanisms one particular view and philosophy of parenting and norms for socioemotional health. In addition, the bill demotes parents to mere partners with government in the raising and education of children when settled case law such as Pierce vs. Society of Sisters (1925), Meyers vs. Nebraska (1923), Wisconsin vs. Yoder (1972) and Troxel vs. Granville (2000), as well as hundreds of years of history and legal tradition have clearly delineated the parents alone as the sole determiner of these decisions and philosophies. It is also quite concerning to proponents of these programs describe the infants of our nation as mere “human capital” in which to be invested by government and business, instead of unique individuals “endowed by their Creator with certain unalienable rights including life, liberty, and the pursuit of happiness” free from government interference in their emotional and family lives.
- Privacy and Data Issues - It is unclear whether proper safeguards are in place to ensure the privacy of families and the confidentiality of medical records are properly protected in these programs. Mothers targeted by the program may not be fully informed about how the personal data collected may be used by HFA programs. Questions also arise about whether full consent is obtained before this data is transferred to other persons or entities.
- Voluntary and Informed Consent - Mothers targeted by the program may not be given complete information concerning the program, or an appropriate opportunity to consider the offer of enrollment before accepting. Recruitment often happens when the mother is physically and emotionally drained after childbirth, bribes happen in the form of baby necessities and “creative outreach may continue for up to four months after an initial refusal.
- The Nature of the Teaching – Prevent Child Abuse America’s philosophy of parenting is not shared by all Americans. There are legitimate concerns about the government officially endorsing PCAA’s philosophy of parenting (or any one philosophy of parenting) as one that should be taught to all new parents. This applies to all of the other programs discussed in this hearing and promoted in the legislation.
- The Duplicitous Role of the Home Visitor - The home visitor is presented as a “helper” but is also responsible for “determining the safety of the home” and making reports to authorities if “abuse or neglect or imminent harm are suspected.” Constitutional concerns arise when government sponsored workers are, in effect, engaging in a “search” of a private home under false pretenses and without probable cause.
COST: If the figures in recent hearings of between 400-500,000 children being involved in home visiting programs are true, then a great deal of taxpayer funds is already going into these programs. Given the concerns raised here, before another $400 million more in federal funds are spent as proposed, the conclusions and recommendations listed below should be considered.
CONCLUSIONS AND RECOMMENDATIONS: While home visiting programs are well intentioned and have had some positive effects in several areas of child welfare and development, there are also several concerns from a scientific validity, efficacy, privacy, and parental autonomy point of view that call the entire effort and the proposed legislation into serious question. If however action is taken on legislation, the following items are strongly recommended before further action is taken to expand these programs:
Karen R. Effrem, MD
- Any home visiting program should be limited to families that are at very high risk of child abuse or developmental delay by strict and well-defined criteria.
- Given the lack of scientific validity of screening instruments and diagnostic instruments, safe treatment options, long term assessment, and agreed upon outcomes, screening and intervention in the mental health of infants and young children should not be a part of any of these programs.
- Protections should be immediately put in place regarding:
- The confidentiality of medical records and privacy rights of targeted mothers
- Truly informed and voluntary consent for participation in the program
- The prohibition of home visitors from presenting information that is not scientifically supportable or violates the government’s duty to maintain neutrality regarding deeply held personal beliefs
- Insuring that home visitors make their investigative role clear to parents and obtain informed consent to the “search” of the home that is implicit in the home visitation concept
- Insuring that home visitors use legal definitions of child abuse and neglect as the standard for making reports to Child Protective Services as opposed to personal opinions about the propriety of spanking as a form of child discipline or other issues in the realm of parenting philosophy
- Insuring informed and voluntary consent is obtained before personal information is entered into a database, and that sufficient safeguards are placed on the use of this data and its ability to be accessed by other individuals and government agencies
- Considering other alternatives to the home visiting model, such as:
- Promotion of marriage and stable two-parent families
- Making child safety a top priority by limiting “family preservation” efforts, as well as limiting time in foster care and promoting permanency through adoption and private group homes / orphanages
- Prevention efforts, such as voluntary family education and support classes and community-based respite care centers