National Academies Press: OpenBook

Revisiting Home Visiting: Summary of a Workshop (1999)

Chapter: New Ways of Thinking

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Suggested Citation:"New Ways of Thinking." Institute of Medicine. 1999. Revisiting Home Visiting: Summary of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/9712.

For example, an evaluation of the Nurse Home Visitation Program in Elmira, New York, found that the program did not significantly reduce the reported incidents of child abuse and neglect for families who were also experiencing other forms of domestic violence; however, in families where domestic violence was not a confounding factor, the program was effective at reducing child abuse and neglect. Douglas Teti, of the Department of Psychology at the University of Maryland at Baltimore County, commented in his presentation on maternal depression and mental health on the importance of recognizing the true needs of the parent. He used the example of a parent who possesses very good parenting skills, but whose depression reduces her capacity to use them. Only when the depression is treated can the mother’ s parenting skills be accurately assessed and, if necessary, addressed. This is particularly important because research has shown that the longer and deeper maternal depression becomes, the worse things become for the child. However, it has also been shown that if a mother’ s depression lifts in her child’s early years, negative effects on the child can be mitigated.

Home visitors can play important roles with families in these circumstances. Although it is not an easy task, if they are properly trained and especially if they work as part of a team that includes mental health professionals, home visitors can identify serious problems, break through families’ isolation, provide essential social support, and connect families to appropriate services. Addressing underlying issues is also important for the implementation and evaluation of home visiting programs, since depression, for example, interferes with engagement and motivation to follow up on visits, which makes it more likely that a family will not fully experience the program. Depressed or substance-abusing parents are also poor providers of data about the child. Given the heavy reliance in home visiting on parent report measures, these conditions can compromise the validity of the data used to evaluate effectiveness.

Problems such as depression, substance abuse, and domestic violence often occur along with poverty, compounding the challenges of delivering effective home visiting services. Brooks-Gunn presented evidence from the Infant Health and Development Program that a home visiting and center-based intervention was not effective for poor mothers who were not employed at least part of the time during their children ’s first three years of life. She speculated that this is probably due to the relatively high incidence of maternal depression, substance abuse, and/or domestic violence among poor mothers who are long-term welfare recipients who are not engaged in any work activities (including off-the-book activities). Such mothers probably would benefit from a different mix (or intensity) of services or from more treatment-oriented services, rather than the more child-focused home visiting and center-based services typically offered. Several workshop participants agreed that, among these multirisk families, altering the life trajectories of children by altering parenting is an extremely challenging proposition.


Some new and innovative ways of considering home visitation within an array of available intervention strategies were presented and discussed at the workshop, providing a glimpse of the potential future of home visitation.

Suggested Citation:"New Ways of Thinking." Institute of Medicine. 1999. Revisiting Home Visiting: Summary of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/9712.

Considering the Community Context

Many workshop participants spoke about the need to view home visiting programs and evidence of their effectiveness in the context of the larger community of which they are a part. As stated by Deborah Daro, of the National Center on Child Abuse and Prevention Research in Chicago, Illinois, and an evaluator of the Healthy Families America program, “home visiting is a portal, [which can and should be used] to introduce families to broader systems of support.” It is not unusual for the same program implemented in different sites to yield different effects, indicating the significant role played by the many factors that impinge on a given program in a given neighborhood.

A home visiting program that exists in a community with other quality intervention programs and services to support it will be better able to help families and demonstrate success. Similarly, families that live in a supportive and financially stable environment may be better able to benefit from what home visiting programs have to offer. As observed by Gina Barclay-McLaughlin, of the Chapin Hall Center for Children in Chicago, Illinois, parents seem to think differently about their interactions with their children when they move from a financially depressed area to a more affluent community, and they may be more likely to put into practice the information they learned earlier from home visitors.

The embeddedness of home visiting programs has not been examined carefully, nor explicitly considered as a crucial feature of program design. Yet growing awareness of the importance of this broader context in determining program success may serve to reframe how both program designers and evaluators consider the place and role of home visitation approaches to service delivery.

Developing Team Approaches to Home Visiting

The role of the home visitor in linking families to other services in the community is extremely important, and one that other approaches to intervention do not necessarily fulfill. This is especially true when a family is dealing with mental health issues, such as maternal depression, substance abuse, or domestic violence. Carrilio described a new concept in home visiting programs that institutionalizes and facilitates case management services. In this design, the home visitor is the main point of contact with the family and is supported by a multidisciplinary group called the Family Support Team. This team is composed of a variety of specialists, including but not limited to, a nurse, a mental health specialist, a substance abuse specialist, and a child development specialist. These specialists often accompany home visitors on home visits and are available to home visitors as a resource. One advantage to this arrangement is that it helps put issues such as substance abuse in the forefront of home visitors ’ minds. Because the families get to know the entire team, it is also one way of providing continuity for the families despite the high turnover of home visitors.

Suggested Citation:"New Ways of Thinking." Institute of Medicine. 1999. Revisiting Home Visiting: Summary of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/9712.
Page 11
Suggested Citation:"New Ways of Thinking." Institute of Medicine. 1999. Revisiting Home Visiting: Summary of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/9712.
Page 12
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