Examining program quality in early childhood home visiting: From infrastructure to relationships

Although there are many examples of evidence-based early childhood home-visiting programming, the field itself struggles with modest outcomes and variable levels of program effectiveness. This article documents the experience of creating a statewide monitoring system to assess home-visiting program quality and compliance to identified standards, integrating multiple sources of information across different domains of functioning. Monitoring results from 57 programs are summarized, with variable but promising levels of quality. Programs generally report satisfaction and benefit from the process. In addition, the relationship between direct observations of home visits and home-visitor report of their approach to working with families is analyzed. Results suggest significant, albeit small, associations. Although there are trade-offs between comprehensiveness of information gathering and practical application, the use of monitoring findings to support home-visiting programs holds potential for quality improvement.     

Quality home visits: Activities to promote meaningful interactions

Examination of and support for specific practices that promote high-quality home visiting are essential as family support programs continue to expand across the country. The current study used direct observation of 91 home visits across 41 home visitors to examine relations among interaction partners, content of the interactions, the home-visitors’ activities, and quality of home-visitors’ practices and family-members’ engagement within programs funded by the Maternal, Infant, and Early Childhood Home Visiting program. More time spent in triadic interactions focused on child-related content, as measured by the Home Visit Rating Scale-Revised, was related to higher quality of family engagement in home visits, as measured with the Home Visit Observation Rating Scales. Time spent in adult-focused interactions and administrative tasks, however, was related to lower quality of home-visiting practices and family engagement. Implications for research and practice are discussed.     

Observing home-visit quality with the home visit rating scales: Introduction to the special section

Evidence-based home-visiting programs aim to address one of the most important challenges facing our species—setting the next generation on a healthy path of development that prepares them for a future that is simultaneously uncertain and promising. Diverse research literatures have pointed to practices to effectively meet this challenge and better achieve the unfulfilled promise of home visiting by more effectively engaging parents in supporting their children's early development and well-being. Measures of home-visit quality practices drawn from social work, pediatric nursing, early childhood, and early intervention research literatures have identified building relationships with families and focusing on their strengths as effective, practices that are particularly important for vulnerable families. The articles in this special section used the Home Visit Rating Scales to examine stability in home-visit quality over time, study specific home-visiting processes linked with quality, validate a supervisor checklist of home-visiting implementation, and consider the home visit in relation to an array of indicators reflecting overall home-visiting program strength and stability. These articles exemplify progress in home-visiting research over recent decades, including advances in direct observational methods and measurement as well as examinations of home visiting as an observable process across various home-visiting program models and populations.     

Observing home-visiting quality at scale with the home visit rating scales and a supervisor checklist in Peru

As home-visiting programs expand, there is a need to develop cost-effective tools to monitor their quality at scale. We compare the Home Visit Rating Scales (HOVRS), an instrument to measure home-visit process quality widely used in the United States, to a checklist designed for the Peruvian national home-visiting program, Cuna Mas. Both instruments were administered to a sample of 554 home visits and an equal number of mother–child dyads by their 176 home visitors. While the HOVRS was scored on video recordings of the visits by trained coders, the checklist was scored live by Cuna Mas supervisors. We assessed the validity of both measures in their first application in rural Peru, compared their performance, and selected a subset of items in the checklist to propose a simplified, shorter, and more cost-efficient instrument. To this end, we reorganized checklist items into constructs that best mapped those covered by the HOVRS and selected the highest performing according to predefined criteria. We found that both the HOVRS and the checklist had high reliability and acceptable levels of validity. We argue that the simplified checklist could prove useful for quality monitoring of service delivery of at-scale home-visiting programs and as a tool to support in-service training.     

Expulsion prevention: Framework for the role of infant and early childhood mental health consultation in addressing implicit biases

Young children of color—especially boys—are at disproportionate risk for suspension and expulsion from early care and education settings. Infant and Early Childhood Mental Health Consultation (IECMHC) is an approach associated with lower than expected expulsion rates, but the mechanisms through which it may influence preschool expulsion are unknown. This paper reflects on the parallels between IECMHC and interventions created to reduce implicit bias. Based on interviews with leaders in IECMHC practice, implementation, and evaluation, a theoretical framework was created to articulate how IECMHC is hypothesized to affect expulsion by first reducing the influence of implicit bias on disciplinary decisions. Implications for practice and research are provided.     

Lay counselors: Thoughts on the crossing of ecological frameworks and the use of lay counselors in the scale up of early infant mental health interventions

The recent call for the scale-up of evidence-based early childhood development interventions, in lower and middle-income countries and for minority groups in high-income countries, has seen numerous suggestions to train greater numbers of lay mental health workers to fulfill these functions. While studies have found that concepts from developed country settings, such as attachment, parental sensitivity, and containment, find purchase and relevance within developing settings, the management of contextual and cultural factors and the tensions of cultural interfacing in the rollout of these programs in developing country settings require consideration. Drawing on the experiences of two successful South African mother–infant home-visiting programs as examples, this article discusses some of the challenges in provision of attachment-based infant mental health programs and highlights the need for careful consideration of a number of factors pertaining to the recruitment, supervision, and management of lay mental health workers before large-scale rollout is conducted.     

Implementation of a mental health consultation model and its impact on early childhood teachers' efficacy and competence

Early childhood mental health (MH) consultants work closely with childcare teachers onsite to serve as a resource for childcare providers as they foster and enhance children's early development. The increase in the quality of care that can be supported through an early childhood MH consultation program makes this type of consultation an optimal tool for enhancing the childcare environment and overall child development. This article details the initial launch of the MH consultation program to childcare centers in the state of Louisiana. Analyses support the assertions that (a) a model of MH consultation can be implemented successfully at a statewide level, (b) MH consultation is associated with an increase in teacher self‐efficacy, and (c) teachers' report that the MH consultation increased their competence in specific areas related to children's socioemotional development. Analyses indicate that there is a differential impact on teachers based on their age and level of experience. The clinical implications of these findings are discussed.     

Observing home-visiting quality across time: A longitudinal reliability study of the Home Visit Rating Scales

Empirical examination of home-visiting quality over time is lacking in the research literature. To this end, this study examined the most recent edition of a widely used observational measure of home-visiting quality, the Home Visit Rating Scales (HOVRS), over four repeated assessments spanning an average of 6 months. Psychometric quality for the HOVRS Total and Home Visitor Practice Scales, including item ratings and calculated scores, across time was demonstrated. Stability indicators for the Family Engagement Scales varied, with superior reliability often indicated for individual ratings over the calculated score. The exploration of interrelationships among family demographics and change in HOVRS scores over time were largely insignificant. Interestingly, a decline in the Home Visitor Practice Scale significantly related to increased symptoms of maternal depression, possibly suggesting that home-visitors’ focus shifted from children's needs to those of parent s when mental health concerns were observed. Although this study is an examination of one program model and poses limited generalizability, it sets the stage for advancing the HOVRS and longitudinal measurement of home-visiting quality.     

Evaluation of a statewide initiative to reduce expulsion of young children

This program evaluation study describes 3 years of implementation of Arkansas's BehaviorHelp (BH) system, a statewide expulsion prevention support system for early care and education (ECE). BH coordinates three tiers of supports to ECE professionals, including phone support, on‐site technical assistance (TA), and infant and early childhood mental health consultation (IECMHC). We examine differences in characteristics of those served across BH service tiers, describe short‐term case outcomes, and explore factors associated with expulsions. BH accepted referrals for 1,195 children in 488 ECE programs. The majority of referrals involved male children over the age of three, and most cases were assigned to the TA tier (68.5%). Cases assigned to receive IECMHC (28.4%) were more likely to involve children in foster care, receiving developmental therapies, and with higher rates of exposure to potentially traumatic events. The expulsion rate among referred children was 2.9%, and reported teacher engagement with the support process was high. Teachers receiving IECMHC services reported significant improvements in children's symptoms of emotional and behavioral problems. Exploratory analyses revealed that risk factors for expulsion included being a male, in foster care, in a lower quality ECE environment, and having a teacher with less training in social–emotional development.     

Reflective Capacity: An Antidote to Structural Racism Cultivated Through Mental Health Consultation

Effecting a paradigm shift from “reproductive health” to “reproductive justice” within the perinatal field requires changes simultaneously at the levels of the individual healthcare provider and the system of care. The Infant-Parent Program at the University of California, San Francisco (UCSF) has extended its pioneering infant and early childhood mental health consultation to perinatal service systems applying an infant mental health approach to programs caring for expecting and new parents. In partnership with two nursing programs, UCSF consultants direct their efforts at supporting reflective practice capacities and use-of-self in patient–provider relationships. Both nursing programs serve vulnerable groups of expectant and new parents who grapple with challenges to health and well-being stemming from structural racism. As reflective capacities are supported within the consultation case conferences, providers spontaneously identify the need for tools to effectively address issues of race, class, and culture and to combat structural racism throughout the healthcare system. Policies and procedures that uphold structural racism cease to be tolerable to providers who bring their full selves to the work that they are trained to do. Using these nurse consultation partnerships as organizational case studies, this article describes a range of challenges that arise for providers and delineates steps to effective engagement toward reproductive justice.     

Opportunities in public policy to support infant and early childhood mental health: the role of psychologists and policymakers

Infant and early childhood mental health practices can be supported by policies and professional standards of care that foster the healthy development of young children. Policies that support infants and toddlers include those that strengthen their families to provide a family environment that promotes mental wellness. Policy issues for infants, toddlers, and young children have come to the forefront of thinking as children need a "voice" to advocate for their support and care. This article (a) highlights several important policy areas that support the social-emotional development of very young children and (b) gives examples of current policy accomplishments and challenges. The article offers a policy agenda to promote the mental health of infants and young children and suggests ways that psychologists can engage with policymakers to promote policies that foster infant mental health, including contributing to the knowledge base that informs policy decisions, educating the public and policymakers about early childhood development and mental wellness, forming community partnerships to identify and address infant mental health risks, and participating in the development of policy recommendations that improve access to evidence-based practices in infant mental health.     

Stress and coping among early childhood intervention professionals receiving reflective supervision: A qualitative analysis

Reflective supervision/consultation (RS/C) is an important component of infant mental health training and practice. Given high levels of job stress reported by a variety of early childhood professionals, the present study offers a qualitative examination of early childhood intervention professionals’ perceptions of stress and coping before and after receiving regular RS/C. Thirty-one professionals received 9 months of RS/C and completed semistructured interview questionnaires at the pre-/postassessments. Questionnaires focused on job-related experiences, including what participants found stressful and how they coped with job-related stress. Inductive analysis techniques were used to identify themes that arose from the data. Relationships between themes were discovered through axial coding. Three key themes of individual, relational, and organizational stress were identified across the pre-/postassessments. Similar themes were evident in reports of coping. Following 9 months of RS/C, analysis revealed greater detail and reflection among the majority of participants. These results contribute to the literature through identification of multiple levels of stress and coping as well as areas of continuity and change among participants receiving RS/C. Future research should consider how professionals’ reports of stress and coping relate to reported self-efficacy and observed competence with young children and families.     

Psychoeducation and managed care: Clinical issues for the 1990s

Managed care has challenged mental health professionals to develop more efficient ways of addressing patient care needs. Psychoeducational programs, for patients and their families, have emerged as a medium by which relevant education and mutual support can be provided to participants. A review of the literature, a comprehensive model of psychoeducation, and the advantages of such models within the managed care program are offered. Also addressed are issues and import, treatment and research considerations.     

Challenges and opportunities in moving toward a public health approach in school mental health

These three outstanding papers are important for the discipline of school psychology, the field of school-based mental health, and more generally for systems of education and mental health for children and adolescents. As the authors emphasize, there is an unprecedented focus on improving programs that remove barriers to learning and enhance development, health, and mental health in youth, in the most universal natural setting—the schools. The authors also correctly highlight that school psychology is uniquely positioned to play a leading role in this reform and change effort. Two interconnected themes of the public health approach—applying the evidence base and moving toward preventive and population-focused interventions—are emphasized in these papers, and while they focus on school psychology, the issues discussed are generalizable to the many disciplines that operate within educational and mental health systems. In the following discussion, I react to the papers' two major themes, discuss realities that should be addressed for progress to be made, and comment on their implications for school psychology.     

Early childhood mental health consultation: Care providers’ experiences of the consultative relationship

This article presents findings from a qualitative research study exploring child care teachers’ experiences receiving early childhood mental health consultation (ECMHC). As an emerging intervention in early childhood education, ECMHC is already yielding promising results, namely in helping teachers better address challenging behaviors in their classroom and promote a more nurturing classroom environment. However, there remains a lack of personal testimony from teachers who receive this intervention. Considering that teachers are the primary focus of most ECMHC interventions, the purpose of this study was to examine child care teachers’ personal experiences receiving consultation. Eight child care teachers were interviewed for this study. Results from this study illuminate key interpersonal processes in the development of the consultant–consultee relationship, indicate what teachers consider to be the most helpful components of consultation, and speak to the challenges that teachers experience in consultation. By examining the personal testimony of child care teachers who have received ECMHC services, consultants and researchers can consider ways to expand and improve future implementation of ECMHC.     

Collaborative Consultant: A New Role for Counselors Serving At-Risk Youths

School and community counselors have important roles in developing and implementing mental health programs for youths and families. Counselors who are working with the more complex issues of at-risk youths can enhance implementation of prevention programs by altering their roles to function within a collaborative consultation model. This model represents a new paradigm in that counselors interdependently and collaboratively partner with people previously considered their “consultees.” Such collaboration can result in more comprehensive and integrated programs, and it can prevent fragmentation and duplication of efforts. Collaborative consultation is described and contrasted with more traditional consultation models, and a 5-stage implementation process is presented. Personal and systemic factors that support the collaborative process are examined.     

The helping relationship and program participation in early childhood home visiting

As researchers have focused on better understanding those circumstances under which home visiting can lead to positive effects on parent and child outcomes, there has been growing interest in examining variation in the experiences of families within these programs, including the quality of the helping relationships between home visitors and parents. The current study examined how participating mothers perceive the helping relationship, using information collected from the Early Head Start National Research and Evaluation Project. Results suggest that although maternal report of the helping relationship is biased towards positive ratings, it remains a significant predictor of program participation, over and above general program satisfaction. Implications for measurement development and program interventions are discussed.     

Early Childhood Mental Health Consultation: Promoting Change in the Quality of Teacher–Child Interactions

The goal of this study was to examine the relationship between characteristics of early childhood mental health consultation (ECMHC) and changes in the quality of teacher–child interactions. One hundred forty‐one early childhood teachers, serving 3‐ to 5‐year‐olds in publically funded early education programs in the state of Arkansas, participated in this study. All childcare sites and preschool programs participating in the study received ECMHC through the Arkansas Early Childhood Mental Health Consultation Project over a period of 3 years. Findings from this study suggest that teachers exposed to ECMHC through their employment at one of the project sites made significant gains toward high‐quality teacher–child interactions relative to their initial levels of quality. In particular, delivery aspects of ECMHC and teachers’ experiences of ECMHC predicted change in quality of teacher–child interactions. Findings suggest that ECMHC may be a promising professional development intervention for teachers in early childhood settings and that specific characteristics of consultation may be particularly influential in impacting change in those settings.