Tampa, Florida — Jamir Green wobbled through his living room in a red car-shaped baby walker with a balloon attached. His mother, Tiara Jones, didn’t take her eyes of her exuberant 8-month-old as she reported to the nurse sitting on the couch that breastfeeding was going well.
Polita Williams, in pink and brown scrubs, her hair pulled back in a tight bun, looked at a checklist on her lap and asked if Jamir had been to the emergency room for any reason in the past few weeks. They discussed birth control options and whether Jones could take medication while breastfeeding.
Then the nurse pulled out a piece of paper with her notes from the last visit, when she’d watched Jones playing with Jamir.
“You stayed very cheery and on his level,” Williams said. Jones smiled, keeping her eyes on Jamir. “Your verbal connection was amazing. All the time, you’re talking with him,” Williams continued.
The nurse also had some advice: She noticed that while Jones was playing with Jamir, she switched activities quickly, with no warning. She suggested Jones explain to Jamir what would happen next before transitioning to a new activity. “What that does, is it prevents those tantrums,” Williams said. “It’s just so they don’t feel confused.” Jones nodded.
Jones, who is currently unemployed, jumped at the chance to sign up when she found out about the home visiting program, called the Nurse-Family Partnership, from her doctor. She wanted to learn as much as possible and “get any support or help I can get.”
Williams visits Jones and her son every two weeks. She weighs Jamir on a portable scale on the floor of Jones’ home and then measures his head circumference and his height. She asks questions about Jamir’s health and development, and provides tips on how to deal with teething. As Jamir grows, she’ll help Jones tackle tantrums and watch for speech and language delays. She has encouraged Jones to keep breastfeeding and participate in incentive programs to earn toys and supplies for her son.
Every week, up to 75 home visitors like Williams from several home visiting programs fan out across Hillsborough County, which encompasses Tampa. They bring books, toys and reading materials about child development, provide tips on how to deal with tantrums and help parents navigate everything: their own mental health needs, safe sleep habits for their babies, and immunizations. These simple interactions between nurses and moms can have stunning results. Among families that participate in the county’s home visiting programs, child abuse and neglect rates are so low they are nearly nonexistent, nearly all children were up-to-date with immunizations, repeat pregnancy rates within two years were low, and a high percentage of mothers try breastfeeding. Between 1998 and 2013, the rate of children in the county dying from Sudden Infant Death Syndrome (SIDS) was more than cut in half.
Nationwide, high-quality home visiting programs have been found to have a profound impact on families, with some programs reducing language delays for children by 21 months and reports of behavioral and emotional problems of children at age 6, in addition to decreasing state-verified reports of child abuse and neglect. Other research has found the effects of home visiting programs can last a lifetime: A RAND analysis found that for every $1 invested in the Nurse-Family Partnership home visiting program, communities see a return of as much as $5.70 because they save in medical, social and criminal justice costs.
But the secret to Hillsborough County’s success may be the elaborate network of services women can access in addition to home visiting, like free parenting and childbirth classes for parents, breastfeeding support, mental health counseling and free play groups. One program, Healthy Families Hillsborough, has even helped families pay bills and buy food in times of need. In the 20 years the county has offered such services, more moms are breastfeeding and more women get prenatal care early in pregnancy.
These results are a big deal in a country that has the highest rate of infant mortality in the developed world. American babies are more than twice as likely to die of SIDS as infants in similarly wealthy countries, according to one study. But instead of going all in on a program with a track record of reversing those numbers, Congress has kept funding level, passing legislation earlier this year that provides $400 million each year for the next five years, the same funding as in prior years. Meantime, the Trump administration is threatening to chip away at the other pieces of the puzzle that have made Hillsborough a national model.
Even as funding for the home-visiting program stayed flat, the Health Resources & Services Administration identified “$112 million in savings by discontinuing smaller maternal and child health programs” in its 2019 budget plan. The Trump administration has proposed cutting funding for related programs that provide lifelines to women, such as food stamps, Medicaid, and money for family planning clinics. The administration has yet to make headway on paid family leave, one of Ivanka Trump’s main issues and a topic President Donald Trump pledged to take up during a 2016 campaign rally. Funding for the Children’s Health Insurance Program expired for several months and was in limbo until Congress renewed it earlier this year.
The ambivalence in the Trump administration and Congress around supporting vulnerable moms and babies worries experts. They caution that home-visiting programs can’t work if they operate in a vacuum. “We see home visiting in and of itself isn’t the one service that communities or families need, it needs to be part of a comprehensive system of support for parents and young children,” said Patricia Cole, senior director of federal policy at the nonprofit Zero to Three’s policy center.
A bi-weekly or even weekly visit from a home visitor isn’t enough to address deeper problems, like depression, neighborhood safety and the stress of juggling work and childrearing, and trying to make ends meet for a family on poverty wages. “As a country, we have a long way to go to assume shared responsibility for the most basic needs that all families with young children have,” said Jack Shonkoff, the founding director of Harvard University’s Center on the Developing Child.
Every state offers home visiting, with nearly 312,000 babies served nationwide in 2016 by an evidence-based program. States often pay for these programs with a mix of federal funding, state funding, and private funding. Since 2010, Congress has authorized $1.85 billion to support those efforts. But lawmakers this year delayed a vote to reauthorize the funds by several months. Home visiting programs nationwide were put at risk.
And advocates say the families served are just a small fraction of those who could benefit from the help. Programs supported by the federal Maternal, Infant, and Early Childhood Home Visiting Program served about 82,000 families. One report by the National Home Visiting Resource Center suggested all of the nation’s more than 18 million pregnant women and families with children under six could benefit from such services. Advocates estimate more than 9.6 million pregnant women and families could especially benefit from home-visiting and are “high-priority,” meaning they meet one of five criteria, including experiencing pregnancy or motherhood before age 21, having an income below the federal poverty line, or being single parents.
Monica Gadson, 47 and a single mother of seven, signed up for a home visiting program, Healthy Families Hillsborough, to help her with her youngest child, Ya’Don, now 3 years old. Gadson’s home visitor, Yamika McCalpine, visits every two weeks to discuss Ya’Don’s health and development, as well as Gadson’s personal needs and goals. On a recent morning, the two women sat down on the floor in Gadson’ living room, as Ya’Don sat between them clutching a sippy cup of juice and skeptically eyeing a SpongeBob coloring book on the ground in front of him.
For the next hour, the women talked about what was going on in Gadson’s life: She had taken away electronics privileges from several of her older kids after “progress reports from hell” were sent home. Ya’Don was still sleeping in Gadson’s bed, despite McCalpine’s urging that they both needed their own sleep spaces. McCalpine lit up at one of Gadson’s updates: Gadson had submitted paperwork to the University of South Florida to finish her college degree in psychology and was waiting to hear if she would be accepted.
As the life recap wound down, McCalpine took out a short quiz about toddler sleep needs and explained how sleep improves behavior and health. Gadson was surprised to hear toddlers need at least 11 hours of sleep a day, including naps and nighttime sleep, not eight at night as she had thought. They discussed Ya’Don’s need for more speech therapy. McCalpine said she would follow up on a referral to a free speech service.
Gadson has had her share of struggles while raising her children. Just two days after the birth of her first child more than 20 years ago, she had to return to work as the manager of a local McDonald’s. Her grandmother watched the newborn while Gadson reported for work as early as 4 a.m. and attended classes at USF in the evenings before returning for one last shift at McDonald’s. She only saw her son for a few hours after she got off work at 10 p.m. “It was either go back to work, help support your family, or bond with your child and not have a house,” Gadson said.
For many years Gadson’s life improved and she did not rely on outside assistance. Her now ex-husband was in the military and they were “well taken care of.” But the stress of divorce, depression, and a stroke in 2017 took its toll. Gadson was diagnosed with post-partum depression after giving birth to Ya’Don and now stays home with her son. She receives disability benefits through Social Security and her son has insurance coverage through Medicaid.
If it weren’t for McCalpine, Gadson said she doesn’t know where she would go for help; she still struggles with depression and doesn’t interact with many people out in the community.
“I’m thankful for [McCalpine] staying on me,” Gadson said. The lessons she has received from the home visits have trickled down into her relationships with her other children, she added. “It teaches me a lot of patience … I’ll use some things [I learned] when I have discussions with my older kids.”
The program also played an important role in identifying Ya’Don’s speech delays. McCalpine was able to refer the family to a speech therapist, paid for by Ya’Don’s insurance, who visited the child on a regular basis at home until he aged out of the program.
Florida, with its anti-tax, Republican-controlled legislature and executive branch, may seem an unlikely place to find a successful and widespread social support program. But a 1991 state law requiring doctors to screen pregnant women and babies for risk factors has helped the state become a national model in caring for vulnerable families. Since the law took effect, immunization rates for 2-year-olds rose from about 63 percent to more than 85 percent in 2015. The infant mortality rate dropped from nearly 9 per 1,000 live births to 6.2. The percentage of women receiving prenatal care in their first trimester of pregnancy increased from about 75 percent to more than 79 percent.
Hillsborough County, where Jamir and his mother live and where a quarter of children age 5 and under live in poverty, went even further than the rest of the state, to become a leader in the nation at providing a wide range of high-quality services, especially for the mothers and babies who are most at risk and impoverished.
In 2017, more than 30,000 children and adults were served at the county’s family resource centers, which offer services like well visits, classes, and play groups. Nearly 7,600 women received prenatal support from a program aimed at providing families with education and social support. More than 100 families were visited by a nurse through the Nurse-Family Partnership home visiting program. Nearly 2,000 children were served by Healthy Families, the home visiting program that McCalpine works for.
“Anyone that’s had a baby understands that time can be amazing but also scary,” said Allison Meisch, deputy project director for the National Home Visiting Resource Center. “So you’re really with home visiting able to connect with families, give them a trusted person that can support them to be the parent they want to be … sometimes we just need some extra support and resources.”
Home visitors see their role as extending beyond the scope of their program. Visits can quickly evolve from the planned “lesson,” to covering whatever moms or babies seem to be dealing with that day, especially if it’s an urgent safety concern. Williams, the visiting nurse, said that’s okay. “It’s not about my agenda,” Williams said. “It’s about her.”
“This is their child,” Williams said. “We will bring them research … I am not here to tell you what you’re doing wrong.”
Meisch from the National Home Visiting Resource Center said home visitors play an important role in identifying issues and getting help for families. “One of the key things that I think is important about home visiting is screening mothers for depression or screening for developmental delays or intimate partner violence. The home visitor doesn’t have to be everything to everyone, they can help connect them to other resources, [which] can be really important,” she said.
In Hillsborough County, officials are trying to figure out how to improve care for the most at-risk families without additional funding that would allow the program to grow. In July, the Hillsborough County Coalition will start reducing its caseloads to provide more intensive services to high-risk moms who need them most. They will refer low-risk women to other community-based programs.
The limited funds also mean salaries tend to be low for home visitors, which has led to some turnover, officials said. Visiting nurses tackle tough situations: trying to gently guide a frustrated mother to stop yelling at her child; urging families to practice safe sleep habits; visiting families in homes that are unstable or, in some cases, unsafe.
But many staff members say they stay because they know the job is important, and despite the challenges, it’s rewarding. They see families trying their hardest to raise children against great odds and systemic challenges.
On a recent afternoon, home visitor Mercedes Castillo arrived at the west Tampa apartment of Richard Morales. Morales, who is legally blind, takes care of his 2-and-a-half-year-old daughter Sonja by himself each day. Morales said he was “afraid” when he and his fiancé found out they were expecting a baby, and sought out the Healthy Families home visiting program online. Healthy Families has helped the family buy food when they had financial problems, gave the family a car seat, and provided a bright teal and royal blue comforter for Sonja.
The family qualifies for the federal Women, Infants and Children program (WIC) and has also taken advantage of services offered by the coalition. Morales and his fiancé worked with a free birth coach to deliver Sonja at home. Sonja did not have health insurance for the first year of her life, so Morales took her to the local community center for checkups and immunizations. With the support of Castillo, Sonja’s mother is still breastfeeding. Sonja now has health insurance through her mother’s employer.
“It’s hard being a first-time parent,” Morales said as he sat on the floor of Sonja’s toy-filled bedroom while she played with a doll. “Mercedes, she checks on all of us. She doesn’t judge us. She helps us.”
After an hour of singing with Sonja, talking to her father about how to help when the little girl gets frustrated, and watching her play, Castillo made plans to return in two weeks.
Castillo agrees there are challenging aspects of the job, especially when families are difficult to work with, or don’t heed advice about health and safety. But seeing parents like Morales succeed despite the challenges has made it worth it, she said. “Seeing parents doing good with their kids … guiding them to have better families … that’s why we do this job,” Castillo said. “At the end of the day, we know we made a difference.”
How Poverty Affects the Brain
Services that provide support to parents and children are especially critical to ensuring healthy brain development during the first years of life, when the brain develops fastest. Research shows that when children are exposed to negative experiences like neglect, mental illness in the household, or abuse at a young age, the brain’s ability to build circuits that allow different regions of the brain to communicate and process information can be impeded. If those circuits are weak, the development of executive function needed to regulate behavioral control, impulse control, which allow children to focus and follow directions can be hindered.
Although negative life experiences and stress can be present in homes at all income levels, experts say extra stressors like food and housing insecurity and violence in the community, can greatly impact development and are often present to a greater degree in low-income homes. Children who live in poverty are especially vulnerable because their families frequently face daily stressors, said Jack P. Shonkoff, the director of Harvard University’s Center on the Developing Child. “[T]hat stress interferes with a parent’s ability to be consistently responsive to their children and to provide a pretty predictable, well-regulated, relatively low stress environment day by day,” Shonkoff said. Research shows socio-emotional development, language development, and brain structure can be impacted by the effects of poverty.
These changes are so pronounced, it’s even possible to see them on brain scans. A 2015 study that examined the brains of 1,099 children and young adults found those who came from higher-income homes and had parents with higher educational attainment had larger surface areas in their brain, especially in the areas that control language and executive functioning, than their peers who were poorer and had less educated parents.
That’s why, in addition to limited funding, home visiting programs are often focused on parents and children deemed to be more at-risk, including families living in poverty or teen mothers. Less than half of all counties in the nation have at least one home visiting agency offering an evidence-based home visiting program. In ten states, home visiting services are available in fewer than 25 percent of counties.
This story was produced by The Hechinger Report, a nonprofit, independent news organization focused on inequality and innovation in education. Read more about early education and sign up for its newsletter.