Transcript Tackling Social Exclusion: the Role of Home Visiting Jane

Tackling Social Exclusion:
the Role of Home Visiting
Jane Barlow
Reader in Public Health
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
Social
Exclusion?
Parenting and Social
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…
• Promiscuous sex and teenage pregnancy
(Scaramella et al., 1998)
•
•
•
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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 outcomes
Attachment
Mental health
Education
Poverty
Unemployment
Etc
Smoking/drugs
Self-esteem
Promiscuity
Behaviour
Parenting
School failure
Emotional
Regulation
Relationships
Communication
Delinquency
Obesity
Parenting 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
Common
• 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
Support Parenting?
Key aspects of infant
development
Social/Emotional Intellectual
competence
Development
Behavioural
Competence
Infancy
Trust/attachment
Alertness/curiosity
Impulse control
Toddlerhood
Empathy
Communication/
mastery motivation
Coping
Childhood
Social
Relationships
Reasoning/problem Goal-directed
solving
behaviour
Adolescence
Supportive social
network
Learning
ability/achievement
Social
responsibility
Parenting That Meets the Needs of
the Infant
• Nurturance
• Behavioural and
emotional regulation
• Verbal and cognitive
stimulation
Nurturance/ Emotional and
Behavioural Regulation
Quality of parent-infant
relationship important:
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•
•
•
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Sensitivity/attunement
‘Mind-mindedness’
‘Mirroring’
‘Containment’
Continuity of care
Behavioural and Emotional
Regulation
• Scaffolding and
positive experiences
• Positive discipline
• Deleterious effects
of negative
discipline
Verbal and Cognitive
Stimulation
• Verbal
responsiveness
• Amount of verbal
interaction
• Being read to
• Scaffolding
• Physical (home)
environment
Key Points for
Supporting Parenting (1)
Pre birth – anxiety/depression; Substance abuse;
Domestic violence; Unresolved trauma; Dysfunctional
attitudes to pregnancy/baby
Birth – bonding
Early infancy (4-6 weeks) – empathic caregiving;
Postnatal depression
9 months – attachment and cognitive development
15-24 months (toddlerhood) – developing
independence – emerging behaviour problems
Key Points for
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 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
Pregnancy
Emotional preparation for
UNIVERSAL
new parents
• Parenting programme
e.g. PIPPIN
UNIVERSAL/SELECTIVE Two visits – ante and post
natal using promotional
• Promotional Interviewing
interviewing
e.g. European Early
Screening to identify
Promotion Project (EEPP)
problems
INDICATED
• Home Visiting (e.g. Health Supporting parents at highrisk of poor parenting
visitors; Home Start;
postnatally
Community Mothers etc)
Infancy
UNIVERSAL
• Infant massage/baby
dance/songs and music
• Touchpoints
• Infant carriers
• PIPPIN
UNIVERSAL/SELECTIVE
• Promotional Interviewing
(EEPP)
• Peers Early Education
Programme (PEEP)
• Solihull Approach
Promotion of parent/ infant
relationships
INDICATED
• Home visiting
• Parenting programmes
Interventions to address
problems in multi-risk
families
Early promotion of infant
intellectual development
Identification & treatment of
early parent/ infant
problems
Early promotion of infant
intellectual development
Toddlerhood
UNIVERAL/SELECTIVE
• Parenting programme
Prevent emerging
behaviour problems
• Videotape feedback e.g.
Sunderland Parent-infant
Programme
Identification of
attachment problems
SELECTIVE/INDICATED
Identification &
• Primary child mental health
treatment of early
workers (Leicestershire)
parent/infant
problems
Preschool 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
Supporting 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
effectiveness of
Home 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 SERVED
• Low income
pregnant women
– Usually teens
– Usually unmarried
• First-time parents
NURSE FAMILY
PARTNERSHIP’S
THREE GOALS
1. Improve pregnancy
outcomes
2. Improve child health and
development
3. Improve parents’
economic selfsufficiency
Visitation 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 Activities
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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 PROGRAM
Elmira, NY
1977
Memphis, TN
1987
Denver, CO
1994
N = 400
N = 1,138
N = 735
•
Low-income
whites
•
Low-income
blacks
•
Large portion of
Hispanics
•
Semi-rural
•
Urban
•
Nurse versus
paraprofessional
visitors
CONSISTENT RESULTS
ACROSS 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
Arrests
Convictions
Days in Jail*
61%
72%
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 & Neglect
48%
Arrests
59%
Adjudications as PINS*
90%
(Person In Need of
Supervision) for incorrigible
behavior
* Based upon family-court records of 116 children
who remained in study-community for 13-year period
following end of program.
15-YEAR FOLLOW-UP
Benefits Minus Costs of Child
Welfare & Home Visiting Programs
Nurse Family Partnership
Home Visiting for at-risk mothers/children
Parent-child interaction therapy
System of care/wrap around programs
Family Preservation Services Programs
Healthy Families America
Comprehensive Child Development Program
Infant 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 Continuum
Community-based
Public Health
Individual and Family
Public Health
For example
Smoking
cessation
For example
Parenting
groups
Screening
Immunisation
Obesity
programmes
Treating PND
Family plans