Marcia Hughes, Ph.D. Center for Social Research

1. Nurturing Families NetworkLeading the way in Connecticut:Where we’ve been, what we’ve learned, where we’re going Marcia Hughes, Ph.D. Center for Social Research

2. Purpose of today • Come to a common understanding of the Nurturing Families Network program and model for creating change • Locate the NFN home visiting model in the national context and highlight progress and accomplishments • Come to a common appreciation of the usefulness and importance of bringing evaluation research and practice together • Together, as a group, sort through next steps & develop plans

3. Overview of the talk • Chronology & evolution of program development & expansion • Highlights of stages of research and program development • Highlights of findings from national research • How the program model works: theory of change • Staff training and supervision is driven by the model • NFN standing in comparison with national models/research • Questions of where to go for the group

4. Healthy Families CT (1995) Healthy Families Initiative (2000) Nurturing Families Network (2003) Evolution of the program • The charge of Children’s Trust Fund: Prevention • Adopted a National model: Healthy Families America • From 2 sites in 1995 to 42 sites in every geographic region • Urban focus: Hartford (2005) & New Haven (2007) “go to scale” • Statewide infrastructure: All 29 birthing hospitals, ob-gyn clinics

5. Nurturing Families Network:Three Components • Nurturing Connections: Gateway to the network Also phone support and referrals to families screened as low-risk • Nurturing Parenting Groups:Prenatal and parenting group support and education in community; available for all parents • Nurturing Intensive Home Visiting for high risk, first time mothers:Bring services to the home and also help to link families with needed resources and assistance.

6. Nurturing Families Network: A statewide system of care

7. Nurturing Connections Number of first time mothers screened each year

8. Nurturing Parenting GroupBased on the Nurturing Program, developed by Stephen Bavolek. • Curricula tailored to different populations: Birth to Five, Nurturing for Prenatal Families, Nurturing for Parents of Children ages 5-11, and Nurturing for African American Families. Four parenting patterns: • Inappropriate developmental expectations of child • Lack of empathy • Strong belief in physical punishment • Parent-child role reversal

9. Goals of Home Visiting • Child safety and well-being, and prevention of child abuse & neglect • Child health • Positive parent-child interactions • Improvement in mother’s trajectory: education, employment, and self-sufficiency

10. Nurturing Intensive Home Visiting Program

11. Nurturing Home Visiting Participation Program Participation by Year Since 1998

12. A statewide infrastructure Program sites are located in every geographic area of CT and in all 29 hospitals, pre-natal and ob-gyn clinics. 2005: Harford goes from 2 to 10 program sites 2007: New Haven goes from 2 to 8 program sites

13. NFN Research & Program Development • Pre-post design and analysis of outcome data • Process evaluations: interviews, focus groups, surveys & ethnographic field work • “Reflections on a program” (1996) • Cultural Broker Model (1998-2000) • Study Circles (2001) • Continuous Quality Improvement (2002 and ongoing) • Life Stories of Vulnerable Families in Connecticut (2002-2003) • Expanded analysis of child abuse & neglect reports (2004 and ongoing) • Hartford NFN: neighborhood analysis (2005) • Focus groups: identifying family needs and linking to resources • Analysis of NFN in comparison with National models

14. Home Visiting at the National Level: Research findings show mixed results Interpretations of the research • Problem is the paraprofessional model • Problem is program implementation and quality assurance • Problem is staff training and supervision • Problem is who is being targeted • Problem is that programs need an explicit “change theory” • Problem is the change theory itself • Problem is families w/multiple problems: Big three • Problem is engaging and retaining families • Problem is methodological/research design in evaluating these programs

15. Research on child abuse Bringing research to practice: Cultural Broker Model Parent & Child Outcomes Improved parenting attitude and behavior Poor parenting skill, attitude, behavior Baby Expert Home visits as a strategy: Two generation approach Using nationally recognized curricula History of family violence and maltreatment Decrease in likelihood of child maltreatment Prevalence of first time mothers in CT at risk for poor parenting & child maltreatment Advocate Decrease in prevalence of CT first time mothers at risk for poor parenting & maltreatment Time! Little Steps Social Isolation; low levels of social capital Friend Child receives health care & other services The Big three: Mental Health, Substance Abuse, Domestic Violence Fictive Kin Mothers enroll in education, get jobs, financial self-sufficient Living in poverty How does the NFN create a change?

16. Connecticut’s Vulnerable Families

17. Cognitively Impaired Mothers (N=21) • Unexpected but desired pregnancies • Older mothers (in their 20s) with previous pregnancies • Support networks...not always supportive

18. “Young Young” Mothers(N=40) • Victims of statutory rape • Pregnancy is normalized • A mix of “good girls” and “bad girls” who were a little older • Being “scared” • Immaturity and Bonding issues with their child • Added problem: finishing school while they were pregnant

19. Mothers living in crisis(N=52) • Violence:violent parents, spouses, neighborhoods, and behavior on the part of the mother • Poverty:inadequate housing, insufficient food, problems with transportation and health care, utilities being turned off, evictions, sanitation problems, bug and rat infestations • Substance Abuse: linked to violence, criminal activity, courts, prisons, and treatment centers • Psychological problems: high rates of mental illness, depression, dysfunctional relationships, anxiety, and stress related illnesses • Medical problemsas consequence of poverty, abuse, and poor health care: asthma, diabetes, botched deliveries, and children with low birth weights, respiratory problems, and complications from deliveries

20. Mothers in less distress(N=51) • Linguistic isolation, immigrant status, & economic insecurity • Social isolation as a result of life transition • History of mental illness and currently receiving treatment • Mothers recovering from substance abuse

21. First Time Mothers in Connecticut at risk for poor parenting and child maltreatment Percentage of mothers scoring as severe risk each year, 1995-2006

22. Marginality Bicultural competence Cultural broker Cultural Broker Model Home Visitors are at the frontlines. They translate the theory into practice, research findings into real life expectations. Efficacy of the model depends on assuming the role of cultural broker model. • Interaction between Home visitor and family member is the heart of the program • Interaction between Home Visitor and clinical supervisor is equally important

23. Home Visitor talking about supervision “Job is very frustrating, if you take it personally, you’re in trouble. For this program to be effective, it needs a good clinical supervisor. The clinical supervisor makes the program work or not work...we unload ourselves on her... to balance...need good clinical supervisor and good program manager to make this program work”

24. Home Visitor as a Baby Expert • Bonding & Communicating w/ child • Importance of spending time w/child • Verbalizing intentions and reasons • Encouraging child to do the same • Info on their child • Stages of Development • Temperament • Behavior issues • Foundation of parenting: patience • Medical health: • Colicky babies • High temperatures • Ear problems • Routine health care • When to contact a physician • Strategies & coaching • Control own emotional intensity and anger • Don’t sweat the small stuff • Use creativity • Self-esteem: remind them that they are doing a good job • Developmental Delays • Help to identify/ accept delays and problems • When serious, arrange for treatment • Parenting Strategies • Temper tantrums • Excessive crying • Terrible twos • Alternatives to spanking

25. Home Visitor as an Advocate: • Copious referrals to local agencies • Lists of resources with contact information • Role modeling assertiveness and persistence • Refer moms to their own doctors, landlords • Serve as a reference for moms • Accessing Public entitlements: Section 8, insurance, food stamps • Mediating interactions with state offices and help with Bureaucratic procedures • Overcoming language and cultural barriers • Translating letters, phone calls • Visits to doctors, state offices & schools • Accessing help for mental health problems • Making referrals for signs of depression & connecting them with mental health services • Working directly with established counselors & therapists • Making sure children are taken care of • Provide lay counseling • Collect an unending amount of supplies: • Diapers, formula, milk, cribs, changing tables, rattles, toys, stair gates, high chairs • Winter coats, blankets, clothes • Gift certificates, vouchers, bus tokens

26. Home Visitor as a friend • Emotional connection articulated as friendship • “The only person I can talk to” • Someone to rely on • Someone to keep you on track • Someone that you can speak to in confidence • Negates negative influences of peer group • Establish an egalitarian and humanistic working relationship • Treat with respect and dignity • Not a hierarchical service-directed attitude • Establishment of friendship role • “No matter what I did, my home visitor was trying to help me” • “Ever since the first day she came, she’s been the same person” • “When I need her she was always there” • Share similar backgrounds, racial and ethnic characteristics • “Walked in the same shoes” • Same language-culture can be central to the relationship • Reduces awkwardness or misunderstandings “[Home visitor] is a real nice person. She is always laughing. When she comes over I laugh. Anybody can see that. I laugh when she’s over. I change...my whole personality changes to a different person just because she is around.”

27. Home Visitor as Fictive Kin • Become part of child’s lifeearns the home visitor her place in the family • Maternal relationship with the mother of the child • Sometimes a parenting model • Maternal support • Reduces anxiety • Help to cope with emotional problems • Reliable mother figure • Consistent, reliable, support for moms from traumatic familial relationships • First time experiencing maternal support

28. Critical Components for Creating Change • Universal Screening and targeted recruitment • Two generation approach, curricula based on research on neuroscience and social processes in child development • Establish a trusting and significant relationship that is directed toward specific goals/outcomes • Time!!

29. Is Connecticut making a difference? • Research over the past eleven years overall have yielded positive results. • A good job of identifying and recruiting a high-risk population • Making improvements in parenting capacities, attitudes and behaviors. • A good job of reducing child physical abuse • An excellent job of linking families to services in the community • Mothers who remain in the program for one or two years often achieve educational and employment goals

30. A good job of identifying a high-risk population Percentage of mothers scoring as severe risk each year, 1995-2006

31. and recruiting a high-risk population

32. Less likely to have rigid expectations Entry & 1 year Outcome Data on Child Abuse Potential Inventory Rigidity Subscale

33. A good job of preventing abuse Annualized Rates of Child Maltreatment in the NFN Program

34. Research on child abuse Bringing research to practice: Cultural Broker Model Parent & Child Outcomes Improved parenting attitude and behavior Poor parenting skill, attitude, behavior Baby Expert Home visits as a strategy: Two generation approach Using nationally recognized curricula History of family violence and maltreatment Decrease in likelihood of child maltreatment Prevalence of first time mothers in CT at risk for poor parenting & child maltreatment Advocate Decrease in prevalence of CT first time mothers at risk for poor parenting & maltreatment Time! Little Steps Social Isolation; low levels of social capital Friend Child receives health care & other services The Big three: Mental Health, Substance Abuse, Domestic Violence Fictive Kin Mothers enroll in education, get jobs, financial self-sufficient Living in poverty How does the NFN create a change?

35. Program Model is driven by the research… • Life Stories of Vulnerable Families In Connecticut: • Typologies of families • Roles of the Home Visitor • Cultural Broker Model: • Relationship between Home Visitor and parent is at the heart of the program • Clinical Supervisory-Home Visitor Role is equally important

36. and the model & research drives training... • NFN in Action • Introduction to Nurturing (Bavolek) • Professional development/education • Family Development Credential (80-hour) community-based, comprehensive, skill- building training that is interactive, experiential learning, and requires completion of comprehensive portfolio • Parents as Teachers: Born to Learn Training (6-day training): neuroscience research on early brain development and learning • Touchpoints(16-hour training) for healthcare, childcare, education, and social service professionals in anticipatory guidance

37. and drives the quality of clinical supervision • Implementation of clinical supervision: • Managing feelings and reactions to families • Frequency and scheduling of supervision • Joint home visits • Group supervision • Professional development/education • Listen, ask questions, provide feedback • Help home visitor think about how she might need to adjust her approach to reflect and accommodate the family. • Help the home visitor identify red flags that might alert her to specific problems. • Help the home visitor identify and address specific problems or circumstances. • Provide feedback and impressions of the Kempe assessment & plan for first visit • Help home visitor to organize her thoughts and her work with a family over time • Provide opportunity for home visitor to explore & learn how to manage feelings

38. drives program implementation... • Assessment and transitioning families • Engaging families and building trust: getting to know each other, establishing purpose of relationship; establishing a mutually trusting relationship • Introducing and developing the Action plan • Identifying strengths and weaknesses • Looking for the little steps • Scheduling and conducting visits • Determining visit frequency • Implementing creative outreach when necessary • Preparation: length and content of visits (i.e., curriculum/lesson plan) • Working with significant others • Working with families with child who have cognitive delays • Parents with multiple children • Families with acute problems • Working with families after the death of a child

39. NFN Compared at National level √ • Problem is the paraprofessional model √ • Problem is program implementation and quality assurance √ • Problem is staff training and supervision √ • Problem is who is being targeted √ • Problem is that programs need an explicit “change theory” √ • Problem is the change theory itself ! • Problem is that home visiting is not addressing the Big 3 ? • Problem is methodological/research design

40. Questions/Issues for the group • Universal screening and capacity building • How can we address the Big 3: mental health, domestic violence, substance abuse? • How do we strengthen the program’s focus on fathers? What do fathers need? • How do we recruit and engage fathers and men? • What do we want to learn/study about child outcomes?