Tackling Social Exclusion:Tackling Social Exclusion:the Role of Home Visitingthe Role of Home Visiting

Jane BarlowJane BarlowReader in Public HealthReader in Public Health

Structure of Paper Structure of Paper

• Relationship between parenting and social exclusion

• Focus on the evidence about parenting of infants

• What works for mothers and infants?

• Supporting vulnerable parents – the role of home visiting

Parenting and Parenting and Social Social

Exclusion?Exclusion?

Parenting and Social Parenting and Social Exclusion…Exclusion…

• Parenting is a significant determinant of developmental outcomes that are critical for social and economic success in adolescence and adulthood

• Parenting mediates the effect of poverty

The Evidence…The Evidence…• Promiscuous sex and teenage pregnancy

(Scaramella et al., 1998)

• Healthy eating (Kremers et al., 2003)

• Smoking (Cohen et al., 1994)

• Alcohol misuse (Garnier et al., 1998; Egland et al., 1997)

• Educational achievement; School drop-out (Desforges, 2003)

• Behaviour problems, delinquency, criminality, violence (Patterson et al., 1989; Farrington, 2003)

• Drug and Mental and physical health in adulthood (Stewart-brown and Shaw, 2004)

Parenting and later outcomesParenting and later outcomes

Parenting

Self-esteem

Behaviour

Emotional Regulation

Relationships

Attachment

Communication

Mental healthEducationPovertyUnemploymentEtc

Smoking/drugs

Promiscuity

School failure

Delinquency

Obesity

Parenting Is Socially PatternedParenting Is Socially Patterned

• Child abuse higher where there is social deprivation

• Lower SES parents more likely to use physical punishment and other authoritarian methods

• Maternal depression nearly twice as high among mothers living in poverty

• Parenting attitudes – lower SES parents value conformity and higher SES parents value self-direction

• Lower SES less likely to use to use positive methods of parenting

Unsupportive Parenting Is Unsupportive Parenting Is CommonCommon

• Approaches to discipline - 52% of population sample of parents hit/smacked children under 1 year at least one a week (Nobes and smith, 1997)

• Communication with/closeness to teenagers - half of adolescents do not think they can confide in their parents; Substantial minority do not feel loved or cared for (NFPI, 2000)

How Can We How Can We Support Parenting?Support Parenting?

Key aspects of infant Key aspects of infant developmentdevelopment

Social/Emotional competence

Intellectual

Development

Behavioural

Competence

Infancy Trust/attachment Alertness/curiosity Impulse control

Toddlerhood Empathy Communication/

mastery motivation

Coping

Childhood Social Relationships

Reasoning/problem solving

Goal-directed behaviour

Adolescence Supportive social network

Learning ability/achievement

Social responsibility

Parenting That Meets the Needs of Parenting That Meets the Needs of the Infantthe Infant

• Nurturance

• Behavioural and emotional regulation

• Verbal and cognitive stimulation

Nurturance/ Emotional and Nurturance/ Emotional and Behavioural RegulationBehavioural Regulation

Quality of parent-infant relationship important:

• Sensitivity/attunement• ‘Mind-mindedness’• ‘Mirroring’• ‘Containment’• Continuity of care

Behavioural and Emotional Behavioural and Emotional RegulationRegulation

• Scaffolding and positive experiences

• Positive discipline

• Deleterious effects of negative discipline

Verbal and Cognitive Verbal and Cognitive StimulationStimulation

• Verbal responsiveness

• Amount of verbal interaction

• Being read to• Scaffolding• Physical (home)

environment

Key Points for Key Points for Supporting Parenting (1)Supporting Parenting (1)

Pre birthPre birth – anxiety/depression; Substance abuse; Domestic violence; Unresolved trauma; Dysfunctional attitudes to pregnancy/baby

BirthBirth – bonding

Early infancyEarly infancy (4-6 weeks) – empathic caregiving; Postnatal depression

9 months9 months – attachment and cognitive development

15-24 months15-24 months (toddlerhood) – developing independence – emerging behaviour problems

Key Points for Key Points for Supporting Parenting (2)Supporting Parenting (2)

• 2-5 years (preschool) – ongoing use of ‘helpful’ parenting practices including positive methods of discipline

• 6- 12 years – Sibling and peer relationships; academic achievement; good self-esteem etc

• Teenage/Adolescence – Developing Independence; Difficult feelings; Transitions

Health Visitors Supporting ParentsHealth Visitors Supporting Parents

• Intervening to support parents

• All have some evidence of effectiveness

• All can be used by health visitors to support parenting across the developmental spectrum

• Examples of Universal; Selective and Indicated Interventions

PregnancyPregnancy

UNIVERSAL • Parenting programme

e.g. PIPPIN

Emotional preparation for new parents

UNIVERSAL/SELECTIVE• Promotional Interviewing

e.g. European Early Promotion Project (EEPP)

Two visits – ante and post natal using promotional interviewing

Screening to identify problems

INDICATED• Home Visiting (e.g. Health

visitors; Home Start; Community Mothers etc)

Supporting parents at high-risk of poor parenting postnatally

InfancyInfancyUNIVERSAL• Infant massage/baby

dance/songs and music• Touchpoints• Infant carriers• PIPPIN

Promotion of parent/ infant relationships

Early promotion of infant intellectual development

UNIVERSAL/SELECTIVE• Promotional Interviewing

(EEPP)• Peers Early Education

Programme (PEEP)• Solihull Approach

Identification & treatment of early parent/ infant problems

Early promotion of infant intellectual development

INDICATED• Home visiting• Parenting programmes• Parent-infant psychotherapy

Interventions to address problems in multi-risk families

ToddlerhoodToddlerhood

UNIVERAL/SELECTIVE• Parenting programme

• Videotape feedback e.g. Sunderland Parent-infant Programme

Prevent emerging behaviour problems

Identification of attachment problems

SELECTIVE/INDICATED• Primary child mental health

workers (Leicestershire)

Identification & treatment of early parent/infant problems

Preschool yearsPreschool years

UNIVERSAL•Training of nursery workers•Parenting programmes - Triple P; Webster-Stratton

Supporting parents to develop boundaries and use positive discipline

SELECTIVE/INDICATED•Parent Advisor Service•Parenting programmes - Triple P; Webster-Stratton

Parental support for parents of children with behavioural problems

Treatment of early parent/child problems

The Role of Home Visiting in The Role of Home Visiting in Supporting Vulnerable ParentsSupporting Vulnerable Parents

Home Visiting Programmes

• Widespread visiting of pregnant women and new mothers at home by public health nurses in many countries

• Based on growing recognition of importance of first three years of life

• HDA review of reviews of home visiting programmes (Bull et al., 2004): A need for ‘more UK trials of home visiting which address the methodological limitations’ identified

Health Visitors and Home Visiting

Universal home visiting

Child Development Programme(Percy and Barker, 1986)

First Parent Visitor Programme(Emond et al, 2002)

Recent Home Visiting Studies

(Barlow et al., in press) (Wiggins et al., 2005)

Recent UK evaluations of the Recent UK evaluations of the effectiveness of effectiveness of

Home Visiting programmesHome Visiting programmes

• Child Development Programme (CDP) – Percy and Barker (1986)

• First Parent Visitor Programme (FPVP) – Emond et al., 2002

• Postnatal support workers – Wiggins and Oakley et al., 2005

• Oxfordshire Home Visiting study – Barlow et al., in press

Home Visiting Programmes: the evidence

Home visiting programmes can be effective in:• Improving parenting and child behavioural

problems• Cognitive development• Reducing accidental injury and improving

detection and management of PND

(Bull et al., 2004. Ante and post-natal home-visiting programmes: a review of reviews. HDA. )

NURSE FAMILY PARTNERSHIP

• Program with power

– Nurses visit families from pregnancy through child age two

– Makes sense to parents

– Solid empirical & theoretical underpinnings

– Focuses on parental behavior and context

• Rigorously tested

FAMILIES SERVEDFAMILIES SERVED

• Low income pregnant women

– Usually teens

– Usually unmarried

• First-time parents

NURSE FAMILY NURSE FAMILY PARTNERSHIP’SPARTNERSHIP’STHREE GOALSTHREE GOALS

1. Improve pregnancy outcomes

2. Improve child health and development

3. Improve parents’ economic self-sufficiency

Visitation ScheduleVisitation Schedule

• 1/week first month

• Every other week through pregnancy

• 1/week first 6 weeks after delivery

• Every other week until 21 months

• Once a month until age 2

Nurse ActivitiesNurse Activities

• Goal-driven• Motivational Interviewing• Self-efficacy theory - behavioral change• 3 volumes of program guidelines• Not a cookbook• Adapted to families’ needs and concerns• Professional judgment• Essential for participant engagement• Balance between protocol- and family-driven

TRIALS OF PROGRAMTRIALS OF PROGRAM

• Low-income whites

• Semi-rural

• Low-income blacks

• Urban

• Large portion of Hispanics

• Nurse versus paraprofessional visitors

Elmira, NY1977

N = 400

Memphis, TN1987

N = 1,138

Denver, CO1994

N = 735

CONSISTENT RESULTS CONSISTENT RESULTS ACROSS TRIALSACROSS TRIALS

Improvements in women’s prenatal health

Reductions in children’s injuries

Fewer subsequent pregnancies Greater intervals between births

Increases in fathers’ involvement

Increases in employment Reductions in welfare and food

stamps

Improvements in school

readiness

ELMIRA SUSTAINABLE RESULTS: Benefits to Mothers

Arrests61%

Convictions72%

Days in Jail* 98%

* Impact on days in jail is highly significant, but the number cases that involved jail-time is small, so the magnitude of program effect is difficult to estimate with precision 15-YEAR FOLLOW-UP

ELMIRA SUSTAINABLE RESULTS: Benefits to Children

Abuse & Neglect48%

Arrests 59%

Adjudications as PINS*

(Person In Need of Supervision) for incorrigible behavior

90%

15-YEAR FOLLOW-UP

* Based upon family-court records of 116 children who remained in study-community for 13-year period

following end of program.

Benefits Minus Costs of Child Welfare & Home Visiting Programs

Nurse Family PartnershipHome Visiting for at-risk mothers/childrenParent-child interaction therapySystem of care/wrap around programsFamily Preservation Services ProgramsHealthy Families AmericaComprehensive Child Development ProgramInfant Health and Development Program

Summary Report:

http://www.wsipp.wa.gov/rptfiles/04-07-3901.pdf

$17,180

$6,197

$3,427

-$1,914

-$2,531

-$4,569

-$37,397

-$49,021

Public Health ContinuumPublic Health Continuum

Community-based Public Health

Individual and FamilyPublic Health

Smoking cessation

Parentinggroups

Obesity programmes

Family plans

ScreeningImmunisation

For example For example

Treating PND