1. Home Visitation: The Cornerstone for Effective Early Intervention Deborah Daro Ph.D

2. Key concepts Review current thinking regarding the child abuse prevention framework Place home visitation within the context of early intervention Review lessons emerging from research on home visitation programs The “Managing Expectations” Dilemma

3. Evolution of CAN Prevention Framework Horizontal Image Multiple age cohorts Replicating Models Alter Participants Universal OR Targeted Vertical Image Birth to Five Replicating Best Practices Alter Participants AND Context Universal AND Targeted

4. Factors Contributing To New Paradigm Early Intervention Early brain research and its accessibility to the general public Political support for early intervention Emphasis on Primary Prevention Need to broaden public engagement in this issue Limits of prediction models to appropriately target at-risk Evidence-informed practice Concerns with accountability Improve the quality of the program/policy planning process

5. Why home visitation programs? Recommendation from the U.S. Advisory Board on Child Abuse and Neglect Success of the Nurse Family Partnership and other home visitation efforts in achieving positive outcomes Hawaii’s statewide expansion of Healthy Start Established a promising pathway for reaching the most challenged families

6. How valuable is home visitation in short-run? New Parents Better birth outcomes Enhanced parent-child interactions More efficient use of health care services Enhanced child development and early detection of developmental delays Toddlers Early literacy skills Social competence Parent involvement in learning

7. How valuable is home visitation in long-run? New Parents Reduced welfare dependency Higher school completion and job retention Reduction in the frequency and severity of maltreatment Toddlers Stronger school performance Fewer behavior problems Higher high school graduation rates

8. Promising service characteristics Solid internal consistency linking program elements to desired outcomes Begin at birth or sooner (for CAN outcome) Engage families in services and sustain involvement long enough to achieve outcomes Provide direct assessment and services to children as well as parents Solid organizational capacity Build strong linkages among local providers

9. Promising staffing patterns Prevention is about building relationships not delivering a product – hire relationship builders For the most intensive services, maintain low caseloads (15 per worker) Provide staff comprehensive initial and in-service training opportunities Provide staff multiple opportunities for individual and group supervision

10. What elements remain unclear? The appropriate target population The importance of curriculum consistency The optimal service duration and intensity The critical qualifications for home visitors The appropriate locus of administrative control

11. Are we getting better … in using data to improve outcomes? in working collaboratively across models? in setting appropriate expectations for home visitation services?

12. Progress in using data Major models operate management information and quality assurance systems More honest reflection on identifying program shortcomings and adjusting the models as necessary Expanded research base, including more rigorous assessments utilizing stronger evaluation designs, larger samples and more reliable measures

13. Progress in fostering collaboration Participation in a Home Visit Forum to Strengthen empirical and clinical capacity to assess and improve service Develop multi-model research inquiries and link findings to practice Create and support efforts to better place home visitation within a broader system of early intervention

14. Home Visit Forum members Early Head Start (EHS) Healthy Families America (HFA) HIPPY Nurse Family Partnership (NFP) Parent Child Home Center Parents As Teachers (PAT)

15. Forum products and outcomes Revision of each model’s theory of change and identification of common as well as unique goals across models Identification of a shared set of lessons regarding supervision Joint advocacy efforts to expand Federal and state support for home visitation

16. Progress on managing expectations Conducting more critical assessments of the available research Drawing lessons from implementation studies as well as outcome studies Establishing stronger conceptual models that better articulate proximate and intermediate outcomes

17. Key Pitfall to Avoid In Moving Forward Debating the quality of a model ( technical solutions ) without paying comparable attention to the types of contextual changes needed to maximize impacts ( adaptive challenges ).

18. Home Visitation As Leverage Not Solution Technical solutions Creating programs and supportive services for new parents Adaptive challenges Creating a culture which validates seeking help and giving help Altering institutional structures and openness to collaboration and shared responsibly for common objectives Altering the political process to embrace investment in young children

19. Use of “Evidence-Based” Decision Making Carefully review research findings in light of your theoretical assumptions and participant needs Value both implementation and outcome research Seek programs that recognize the need for continuous self-assessment and adaptation Be as critical of potentially positive findings as you are of negative findings Accept the fact that not all things can be “proven”

20. Data Sources for Assessing Effectiveness Basic research on human physical and social-emotional development Randomized clinical trials on highly specified interventions Administrative data on incidence and service levels Descriptive studies on service implementation and the public policy response

21. Strategies for Managing Expectations Better methods Utilize a diverse array of evaluation designs Craft implementation as well as outcome studies Better theory Link program efforts to realistic outcomes Articulate models linking proximate and distal outcomes Better synthesis Meta-analytic techniques More critical assessments of the available research Draw on findings from other disciplines

22. Staying the Course The Great Society asks not how much, but how good; not only how to create wealth but how to use it; not only how fast we are going, but where we are headed. It proposes as the first test for a nation: the quality of its people. This kind of society will not flower spontaneously from swelling riches and surging power. It will not be the gift of government or the creation of presidents. It will require of every American, for many generations, both faith in the destination and the fortitude to make the journey. And like freedom itself, it will always be challenge and not fulfillment. LBJ (1965)