The Future of Children, Princeton - Brookings: Providing research and analysis to promote effective policies and programs for children.

In practice, most home visiting programs place differential and selective emphasis on one or more of the identified eight domains of functioning. Often home visiting programs address first, and with greatest intensity of effort, those needs that appear to home visitors and/or to family members to be the most pressing. For instance, some home visiting programs invest substantial time and resources in helping families to meet needs in the domains of survival (for example, by providing assistance with housing, food, clothing, and transportation) and health (for example, by providing routine checkups and monitoring, encouraging positive health habits, and taking family members to medical appointments). Other home visiting programs emphasize the domains of social interaction and social support for the mother, or systematically seek to change the domains of communication and basic intellectual skills by providing educational programs and direct instruction to mothers and/or their children.

The reasons that programs emphasize different domains of functioning, and may even fail to consider some domains, include the following: (1) the anticipated and most pressing needs of the population with which the program is working, (2) the professional orientation and expertise of the individuals designing and implementing the program, (3) the resources available to the program, and (4) the philosophical orientation of the program (such as whether some domains of functioning are judged to be more or less important or whether home visitors are encouraged not to become involved in some domains for reasons of professional competence or safety). Often, the implicit assumption or hope is that, once the most urgent family issues have been resolved satisfactorily, then there will be time and energy to address other less pressing but important aspects of young children's health and development.

Limiting the focus in home visiting programs to supporting the family first, without special efforts to target the child's early development as well, may be self-defeating. The article by Olds and Kitzman in this journal issue reviews the effectiveness of diverse home visiting programs. What is clear from their excellent review of the empirical studies is that there is little evidence that programs which are not intensive and comprehensive, but instead target for change one or a few domains of functioning, are likely to have a lasting beneficial effect, even on the targeted aspects of the lives of children. Those areas may show some improvement; however, in the absence of continuing resource allocation, such changes are unlikely to occur in a robust or lasting manner. In addition, short-term change in one or a few domains will not have a domino, or spillover, effect to other equally important domains of children's functioning. Unfortunately, the nature of developmental processes in young children is such that not one of their needs can wait until other needs are met; children's development does not go on hold while family problems are being solved.

This does not imply that attending to survival and health is less important than focusing on a child's social or intellectual development (or vice versa), but rather that there is a pressing need in the first few years of life to consider simultaneously and to coordinate all of the important needs of a young child. Meeting this need challenges many home visiting programs, especially those in which the amount of time allotted to each home visit is constrained and the frequency of home visits is not sufficient to provide effective assistance in multiple domains. Although a given home visiting program may appear initially to do better at achieving its goals if the scope is narrow and clearly focused, this does not necessarily ensure that the families—and especially the infants and young children—will directly benefit in a lasting way from a narrowly focused program.

A home visiting program does not have to be comprehensive in and of itself. The home visits can be an integral part of a broader early intervention and family support program. (See the article by Weiss in this journal issue.) In this situation, the issue of coordination across different program components, as well as across the domains of functioning, is highly significant. It is an important challenge in such efforts to minimize fragmentation and duplication.