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

Purpose of today

• Come to a common understanding of the Nurturing Families Network program and model for creating change

• Come to a common appreciation of the usefulness and importance of bringing evaluation research and practice together

• Locate the NFN home visiting model in the national context and highlight progress and accomplishments

• Together, as a group, sort through next steps & develop plans

Overview of the talk

• Chronology & evolution of program development & expansion

• Highlights of findings from national research

• Highlights of stages of research and program development

• 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

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

• Healthy Families CT (1995) Healthy Families Initiative (2000) Nurturing Families Network (2003)

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.

Nurturing Families Network: A statewide system of care

First time mothers in CT are screened for risk of abuse

LOW RISK for child maltreatment & poor parenting

HIGH RISK for child maltreatment & poor parenting

NURTURING HOME VISITING

NURTURING CONNECTIONS

Family accepts Family declines Family declinesFamily accepts

Family is referred to other services

Family is referred to other services

NURTURING PARENTING GROUP:Available to all parents in the NFN system (and community) at any time.

Nurturing Connections

1,172

2,047

3,702 3,754

5,472

3,151

3,4783,416

0

1,000

2,000

3,000

4,000

5,000

6,000

1999 2000 2001 2002 2003 2004 2005 2006

Number of first time mothers screened each year

Nurturing Parenting Group

Based 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.

• Inappropriate developmental expectations of child

• Lack of empathy

• Strong belief in physical punishment

• Parent-child role reversal

Four parenting patterns:

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

Nurturing Intensive Home Visiting Program

293

525 538

275

484 511

0

100

200

300

400

500

600

2004 2005 2006

Families Offered Home Visiting

Families Accepted Home Visiting

Nurturing Home Visiting Participation

407509

600 637 639 668 689859

1201

0200400600800

100012001400

1998 1999 2000 2001 2002 2003 2004 2005 2006

Families Starting Families Active During the Year

Program Participation by Year Since 1998

A statewide infrastructure

2007: New Haven goes from 2 to 8 program sites

2005: Harford goes from 2 to 10 program sites

Program sites are located in every geographic area of CT and in all 29 hospitals, pre-natal and ob-gyn clinics.

NFN Research & Program Development

• Pre-post design and analysis of outcome data

• Cultural Broker Model (1998-2000)

• Study Circles (2001)

•Life Stories of Vulnerable Families in Connecticut (2002-2003)

• “Reflections on a program” (1996)

• Process evaluations: interviews, focus groups, surveys & ethnographic field work

• Expanded analysis of child abuse & neglect reports (2004 and ongoing)

• Hartford NFN: neighborhood analysis (2005)

• Focus groups: identifying family needs and linking to resources

• Continuous Quality Improvement (2002 and ongoing)

• Analysis of NFN in comparison with National models

Home Visiting at the National Level: Research findings show mixed results

• Problem is program implementation and quality assurance

• Problem is that programs need an explicit “change theory”

• Problem is the change theory itself

• Problem is the paraprofessional model

• Problem is who is being targeted

• Problem is staff training and supervision

• Problem is families w/multiple problems: Big three

Interpretations of the research

• Problem is methodological/research design in evaluating these programs

• Problem is engaging and retaining families

How does the NFN create a change?

Prevalence of first time

mothers in CT at risk for

poor parenting & child

maltreatment

Poor parenting skill, attitude, behavior

History of family violence and maltreatment

Social Isolation; low levels of social

capital

The Big three: Mental Health,

Substance Abuse, Domestic Violence

Research on child abuse

Living in poverty

Improved parenting

attitude and behavior

Decrease in likelihood of

child maltreatment

Child receives health care & other services

Mothers enroll in education,

get jobs, financial self-

sufficient

Parent & Child Outcomes

Decrease in prevalence of CT first time mothers at

risk for poor parenting & maltreatment

Bringing research to practice: Cultural Broker Model

Home visits as a strategy:

Two generation approach

Using nationally recognized curricula

Baby Expert

Advocate

Fictive Kin

Friend

Time!Little Steps

Connecticut’s Vulnerable Families

12%

23%

33% 32%

0%

5%

10%

15%

20%

25%

30%

35%

Patterns of Vulnerability

CognitivelyImpairedMothers

Young-YoungMothers

Mothersliving incrises

Mothers inLess Distress

Cognitively Impaired Mothers (N=21)

• Unexpected but desired pregnancies

• Older mothers (in their 20s) with previous pregnancies

• Support networks...not always supportive

“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

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 problems as consequence of poverty, abuse, and poor health care: asthma, diabetes, botched deliveries, and children with low birth weights, respiratory problems, and complications from deliveries

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

First Time Mothers in Connecticut at risk for poor parenting and child maltreatment

0

20

40

60

80

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Childhood history of maltreatment

Substance abuse, mental illness, or criminal history

Low self-esteem, social isolation, depression

Multiple stresses

Percentage of mothers scoring as severe risk each year, 1995-2006

Cultural Broker Model

Marginality Bicultural competence Cultural broker

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

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”

Home Visitor as a Baby Expert

Info on their child• Stages of Development• Temperament• Behavior issues• Foundation of parenting: patience

Bonding & Communicating w/ child• Importance of spending time w/child• Verbalizing intentions and reasons• Encouraging child to do the same

Medical health:• Colicky babies• High temperatures• Ear problems• Routine health care• When to contact a physician

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

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

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

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

Overcoming language and cultural barriers

• Translating letters, phone calls• Visits to doctors, state offices & schools

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

Home Visitor as a friendEmotional 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

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

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”

“[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.”

Home Visitor as Fictive Kin

Become part of child’s life earns 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

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!!

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

• 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

• Making improvements in parenting capacities, attitudes and behaviors.

A good job of identifying a high-risk population

0

20

40

60

80

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Childhood history of maltreatment

Substance abuse, mental illness, or criminal history

Low self-esteem, social isolation, depression

Multiple stresses

Percentage of mothers scoring as severe risk each year, 1995-2006

293

525 538

275

484 511

0

100

200

300

400

500

600

2004 2005 2006

Families Offered Home Visiting

Families Accepted Home Visiting

and recruiting a high-risk population

Less likely to have rigid expectations

0

5

10

15

20

25

30

35

40

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Entry Rigidity 1 Year Rigidity

Entry & 1 year Outcome Data on Child Abuse Potential Inventory Rigidity Subscale

A good job of preventing abuse

1.6%3.0%

6.4%6.1%

2.2%1.8%0.0%1.0%2.0%3.0%4.0%5.0%6.0%7.0%

7/1/00-6/30/01

7/1/01-6/30/02

7/1/02-6/30/03

7/1/03-6/30/04

7/1/04-6/30/05

7/1/05-6/30/06

Annualized Rates of Child Maltreatment in the NFN Program

How does the NFN create a change?

Prevalence of first time

mothers in CT at risk for

poor parenting & child

maltreatment

Poor parenting skill, attitude, behavior

History of family violence and maltreatment

Social Isolation; low levels of social

capital

The Big three: Mental Health,

Substance Abuse, Domestic Violence

Research on child abuse

Living in poverty

Improved parenting

attitude and behavior

Decrease in likelihood of

child maltreatment

Child receives health care & other services

Mothers enroll in education,

get jobs, financial self-

sufficient

Parent & Child Outcomes

Decrease in prevalence of CT first time mothers at

risk for poor parenting & maltreatment

Bringing research to practice: Cultural Broker Model

Home visits as a strategy:

Two generation approach

Using nationally recognized curricula

Baby Expert

Advocate

Fictive Kin

Friend

Time!Little Steps

Program Model is driven by the research…

Cultural Broker Model:

• Relationship between Home Visitor and parent is at the heart of the program

• Clinical Supervisory-Home Visitor Role is equally important

Life Stories of Vulnerable Families In Connecticut:

• Typologies of families

• Roles of the Home Visitor

and the model & research drives training...

• 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

• NFN in Action

• Professional development/education

•Introduction to Nurturing (Bavolek)

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

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

NFN Compared at National level

• Problem is program implementation and quality assurance

• Problem is that programs need an explicit “change theory”

• Problem is the change theory itself

• Problem is the paraprofessional model

• Problem is who is being targeted

• Problem is staff training and supervision

• Problem is that home visiting is not addressing the Big 3

√√

√√

√√

!

• Problem is methodological/research design ?

Questions/Issues for the group

• How can we address the Big 3: mental health, domestic violence, substance abuse?

• What do we want to learn/study about child outcomes?

•How do we strengthen the program’s focus on fathers? What do fathers need?

•How do we recruit and engage fathers and men?

• Universal screening and capacity building