Nurse Home Visits: A Boost for Low-Income Parents

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Reed Kaestner / Corbis

Nurse home visitor Tammy Ballard has had some memorable experiences in close to a decade of helping new mothers raising their children in poverty in Dayton, Ohio. Once, she arrived at a new client's home to find a TV news crew waiting outside; apparently, someone fleeing gunfire had sought shelter there. Another time, she knocked on a door only to hear shrieking in response, but no one would let her in. Later she learned it was the family's parrots, which had been trained to squawk at visitors. (Read "The Year in Medicine 2008: From A to Z.")

Ballard's job — when she can get in the house — is to try to give low-income parents a leg up. She teaches them many of the same child-rearing techniques that give the children of middle-class and educated parents an edge socially and in school — and that instruction is often eye-opening for both Ballard and her clients. You would be surprised to know what new parents don't know, Ballard says, recalling the case of one father who thought babies couldn't hear at birth. He asked, "When do their eyes open?' He thought they were like puppies," she says. (See 9 kid foods to avoid.)

There's no doubt that low-income parents — indeed, most new parents — could use a little guidance. In some countries, like France, that guidance is institutionalized. Nurse home visits for all pregnant and new mothers are routine and free of charge, sponsored by the government. In the U.S. the national Nurse-Family Partnership program (NFP) covers about 16,300 families living in poverty in 25 states, but President Obama has said he plans to expand the benefit, extending it to every first-time poor mother in the country — about 570,000 women each year. The President's stimulus plan includes more than $3 billion in funding for early-childhood-intervention programs such as Head Start and Early Head Start. (See pictures of Barack Obama's family tree.)

The question is, will the money make a real difference in children's lives? In a recent Op-Ed in the New York Times, Douglas Besharov of the conservative think tank American Enterprise Institute and a colleague argued that expanding prekindergarten programs "without demanding reforms will not help children." Other critics have also opined that funding early-childhood initiatives is just a sop to liberal interest groups.

But the science supporting warm and fuzzy early-childhood interventions is sound and is only getting stronger. "There's converging evidence from neuroscience, social science and animal data," says Martha Farah, director of the Center for Cognitive Neuroscience at the University of Pennsylvania. "If you want to invest societal resources where they will have the biggest benefit for all of us, clearly the evidence is there now that protecting children from the worst kinds of deprivation in their youngest years will result in more functional, capable, prosocial citizens."

The NFP was developed in the 1970s by David Olds, a professor of pediatrics and preventive medicine at the University of Colorado Health Sciences Center. NFP involves about 64 home visits from a nurse during the first 2½ years of a child's life. Many of the new mothers who receive the benefit are single, are on welfare, have low education levels and are dealing with addiction, mental illness and family violence. Nurses visit once a week during pregnancy and early infancy, answering health questions, teaching basic parenting skills and, crucially, helping moms whose own early lives were often characterized by chaos build confidence that they can do better for their children. (See the most common hospital mishaps.)

These visits have a pretty good payoff. A 2005 analysis by the Rand Corp. found that for every dollar spent providing nurse visitors to high-risk families, the government could save nearly $6 in welfare, juvenile-justice and health-care costs down the line. Dividends for the families' well-being may be even higher. A study published in the Journal of the American Medical Association (J.A.M.A.) in 1998 found that children in upstate New York whose mothers were visited by nurses during pregnancy and two years after birth were 59% less likely to have been arrested 15 years later, compared with a control group. After receiving visits by nurses during their mother's pregnancy and during their first two years of life, visited children in upstate New York were 59% less likely to be arrested than those in the control group.

A 1997 study, also in J.A.M.A., found that nurse home visits were associated with a nearly 50% drop in rates of substantiated child abuse or neglect in new families and that visits increased the amount of time between a mother's first and second pregnancies. Rates of hypertension, which is known to interfere with fetal brain development, were also reduced. And mothers spent less time on welfare and worked more.

There's really no mystery to the program's success, says Olds. Simple interventions, like encouraging new parents to show affection to their children or to talk to them more, result in exponential rewards for babies. In poor families, adults tend to speak to babies only to issue commands, in a business-only style of parenting rather than talking to children to communicate affection, identify objects, introduce concepts or teach language — a phenomenon more common in middle-class and wealthy households. Studies have shown that by preschool age, children whose parents gesture or talk to them less in babyhood know significantly fewer vocabulary words than children whose parents engage them more often. That deficit can affect students' performance for years.

What happens early has a long-term impact, says Olds. Indeed, about 90% of a child's brain growth takes place before kindergarten, so it's critical to teach new parents what to expect as a child develops not only during pregnancy and early childhood but also as the child matures. A large part of nurse home visits are designed to teach parents how to respond to their children as they age and help them manage the extra burden of parenting with few resources. Says Olds: "Learning to understand children's motivations and abilities helps parents treat them more sensitively and responsively, and that makes it easier for children to accept guidance and not respond provocatively."

It also creates a less stressful environment and protects against child abuse and neglect, and those reductions can in turn cut children's risks of later engaging in crime and suffering from addiction, mental illness, obesity and cardiovascular disease. The key, according to Olds' research, begins with properly trained nurses; home visits by paraprofessionals aren't as effective. Despite the current shortage of nurses in the U.S., Olds says his program is ready to grow. "The NFP is shovelready for substantial expansion, as long as we recognize that serving 500,000 new families per year will take time." But it's an investment that self-propagates. Once the nurses have educated new moms, says Ballard, the mothers start educating one another. "It's so neat to watch," she says. "We give information to our clients, and they share with neighbors. One client was the go-to person for everything. She'd say, 'Talking to your babies makes them smart.' And the other moms would always come to her."

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