The 19-year-old in your office hands her newborn to a companion and looks at you with confusion and startling honesty. “I just don’t think she likes me. I don’t feel like she is my baby.” The father of her child is uninvolved, and both mother and child are in a faith-based group home. You are relieved to find out that the companion is a home visiting social worker trained in trauma-focused cognitive behavioral therapy, alerted to the high-risk situation by a community health worker assigned to the group home.
For over 150 years, public health nurses, social workers and community advocates have visited homes of marginalized families, particularly mothers and children, to relieve suffering related to poverty and social isolation, to make living environments healthier and to prepare children for a more successful life. Inspired by social justice movements of late-19th century Britain, home visitors before the Great Depression of the 1930s reached into immigrant and poor communities to aid acculturalization, to improve family hygiene practices, and to support maternal and child health during the critical first years of life.
This tradition of compassionate work with families in their natural environments continues in the 21st century supported by both federal and state funding, and backed by mounting evidence of effectiveness. Rigorous national program evaluation has confirmed that public health programs utilizing home visitors can enrich family relational health, promote school readiness, improve perinatal outcomes, enhance environmental safety and increase family self-sufficiency.
In the policy statement Early Childhood Home Visiting, available at https://doi.org/10.1542/peds.2017-2150, the Academy recommends continued and expanded federal and state support for home visiting programs.
The policy, which will be published in the September issue of Pediatrics, is from the Council on Community Pediatrics, the Council on Early Childhood and the Committee on Child Abuse and Neglect.
Supportive, effective networks
Integration of home visiting into the pediatric family-centered medical home can be a powerful way to extend team-based care into the medical neighborhood. Pediatricians do not need to stand alone when faced with high-risk and complex problems, even when the complexity includes medical, relational and social determinants.
Home visitors can link families to community support services, assess the home environment for hazards, encourage positive parenting, provide early childhood developmental stimulation and support adherence to comprehensive care plans. When integrated with a multidisciplinary team, a home visitor can coordinate with the medical home to reinforce advice given in the office and facilitate communication between the family and the primary care provider. Home visiting may be most valuable when connected to a system of care for early childhood that has a family-centered medical home as its coordinating hub.
By establishing the Maternal, Infant, and Early Childhood Home Visiting Program (known as MIECHV), the Affordable Care Act of 2010 not only funded state home visiting programs for at-risk populations but also established a national evaluation program to help states choose and sustain services with measurable benefit and cost-effectiveness. At present, 19 models meet criteria for federal support, including the Nurse Family Partnership, Healthy Families America and Parents as Teachers.
All 19 have evidence of effectiveness in at least one or more outcome domains such as maternal and child health, school readiness, positive parenting practices and family economic self-sufficiency. By linking young mothers and fathers to services such as occupational training and educational opportunities, home visitors may increase the possibility for both the parents and children to escape the generational transfer of poverty.
Because of the trusting relationships established between families and home visitors, as illustrated in the vignette, high-quality home visiting can reduce social isolation, improve relational health and potentially buffer the effects of early childhood adversity. The policy recognizes the many potential benefits to children and families provided by home visitors, supports continued federal funding for evidence-based models and encourages integration of home visiting into a comprehensive, coordinated system of pediatric care in the medical neighborhood.
Recommendations for pediatricians
- Provide community-based leadership to promote home-visiting services to at-risk young mothers, children and families.
- Be familiar with state and local programs to identify and refer eligible children and pregnant mothers.
- Consider ways to integrate or co-locate home visitors in the family-centered medical home.
- Recognize home-visiting programs as an evidence-based method to enhance school readiness and reduce child maltreatment.
- Recognize these programs as a strategy to buffer the effects of stress related to the social determinants of health, including poverty.
Dr. Duffee, a lead author of the policy, is vice chair of the AAP Council on Community Pediatrics Executive Committee.