Families first

Working with parents to get their kids off to a great start in life

Dr. Kateryn Rochon with a blacklegged tick
Families First lays the development for a better childhood.
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Keys to baby's development

Winnipeg Health Region
Wave, September / October 2015

Tanya bends over her son Hunter's shoulder and offers words of encouragement as he manipulates wooden letters into place in an alphabet puzzle.

With the occasional assist from his mother, it doesn't take the pre-schooler long to complete his task.

It's a scene that not so long ago, when Hunter wasn't sleeping and Tanya was exhausted and suffering from post-partum depression, might have seemed like an impossible dream.

"I hate to be a gloating parent, but look at him now - he's thriving," Tanya says.

Tanya has dropped by the Winnipeg Health Region's Public Health office at the Youville Centre in St. Vital for a visit with Val Gregg, who has been working with the mother and son since Hunter was a newborn.

Approaching her final visit with Gregg as part of the Families First home visiting program, Tanya sees her time in the program as an essential lifeline. Families First helped her through the toughest times of the last three years, and has readied her and Hunter to move forward. "It's strengthened me as a parent, as a woman, as a person," she says.

Strengthening is a key word for Families First. The program is designed to help parents discover and build on their strengths so that they can provide a healthy home for the physical, emotional and intellectual growth of their children. This is important because studies show that kids who grow up in a positive family environment stand a better chance of reaching their potential in terms of doing well at school and going on to lead a healthy, happy life.

As such, Families First is in keeping with the Region's ongoing work to advance the goals of health equity, a term used to describe efforts to close health gaps between various groups within the community that may be attributed to socio-economic conditions.

While people of all ages can be negatively affected by these gaps, children are particularly vulnerable, a point underscored by the Region's Community Health Assessment, which was released earlier this year.

Among other things, it noted that as many as 23.9 per cent of Winnipeg newborns in 2011 were exposed to at least one of five prenatal risk factors (maternal alcohol drinking, maternal smoking, maternal anxiety/depression, family financial stress, and low maternal educational status). It also pointed out that as many as 28 per cent of kindergarten children were not ready for Grade 1 in one or more of the five categories measured by the Early Development Instrument, which is a tool used by teachers to measure a student's readiness for school. 

While Families First is not designed to directly help kids get ready for Grade 1, it does lay the foundation for better childhood development, says Darlene Girard, Team Manager for Healthy Parenting and Early Childhood Development for the Winnipeg Health Region.

"Early childhood development is a powerful equalizer," says Girard. "A good start in life sets the foundation for all future learning, health and well-being."

The Families First program is based in part on theGrowing Great Kids Prenatal - 36 months Parenting, Attachment, Child Development and Family Strengthening Curriculum, which was developed by Great Kids Inc., a Wisconsin-based not-for-profit that specializes in creating child development programs. The curriculum is rooted in attachment theory and the idea that babies have three major developmental stages that can be supported by certain actions known as "character builders." These three stages are categorized as Security, Discovery and Identity and Independence.

The program began as a pilot project at two sites in Winnipeg and one in rural Manitoba in 1998. It's now delivered across the province through various health regions and funded through Healthy Child Manitoba.

"The project went full-scale very quickly," says Girard.

Evaluations conducted in recent years have shown a number of measurable benefits for children and adults.

When the Manitoba Centre for Health Policy conducted an evaluation, comparing children involved in Families First to a statistically similar sample of children not involved in the program, several measurable health improvements stood out. Children in Families First were 10 per cent more likely to be fully immunized at age two, 25 per cent less likely to be taken into care by Child and Family Services, and 41 per cent less likely to be hospitalized for an injury due to maltreatment.

In addition to improving outcomes for children, the program also aims to improve mental health for parents.

A program evaluation completed in 2010 examined six measures of psychological well-being in parents and found measurable improvements in three of them: environmental mastery (the term for being able to manage daily life); purpose in life and self-acceptance.

In the daily interactions between parents and children, that boils down to parents talking, playing and laughing more with their children, praising them more, giving them more attention, and being less likely to be annoyed with their behaviour.

In addition, Girard says mothers involved with Families First also reported a stronger social support system of family, friends and neighbours and a stronger connection to the community.

In order to strengthen mental health benefits and to help prevent or combat maternal depression, the program has added a mental health promotion component called Towards Flourishing.

"We can see the positive changes in families," says Girard. "We see parents responding warmly to their kids - picking up on cues, for example."

"It's strength-based. It's based on the desire of every parent we've worked with to create the best environment they can for their children. And it's relationship-based," she adds, noting that families typically build a relationship with the same home visitor for the three years of the program.

Being strength-based means that the home visitor's job isn't to go into a home and point out where the parents are going wrong. Instead, they point out and celebrate how the baby, toddler or pre-schooler is responding to parents, how the parent-child bond is being forged and how the child is learning and growing all the time.

Some parents participating in the program have experienced childhoods with little trust, nurturing and support. 

"So how do you create something that you've never experienced?" asks Girard. "They (home visitors) give feedback to the family about all the good things they're doing," she says.

The starting point for Families First is the visit to new mothers or expectant families by a public health nurse. One of the nurse's jobs during these visits is to assess the strengths of new families and then offer supports and services that the family could benefit from.

Those families who need extra support in building a nurturing home - for any number of reasons - will be referred to Families First. The program is voluntary, so it's up to the family to decide if they want a home visitor.

If they do, the family will be referred to one of the program's home visitors working in the same community area. The public health nurse continues to provide support to the family while the home visitor regularly visits the family. Visits are weekly for the first year, every second week for the second year, and monthly for the third year.

Gaining the trust of the family is the first crucial task.

Gregg, who has been a home visitor in St. Vital for 15 years, says she and the public health nurse will go together for the first visit, and she'll introduce the concept of the program and talk about how she typically works with families.

"Some are on the fence at first, but it's very rare for them to say no," she says.

The program is structured with a curriculum based on the physical and emotional development of children and development of healthy families.

In the first year, home visitors will go through activities with parents and children focusing on subjects like teething, newborn rashes, feeding, sleeping, and crying.

They'll also work on activities to encourage physical growth and brain development at the various stages of infancy and early childhood. Activities promote sitting up, rolling, crawling and other milestones in early development.

Encouraging parents to give babies lots of tummy time - time out of the high chair, where they can practise crawling and exploring - is important in the Families First curriculum. Some of the later activities are focused on the emotional development of children as they begin to develop a sense of independence from parents. Home visitors have books filled with teaching games and activities to go with the various subjects covered over the three years. Some of the activities involve props that they leave with parents so that they can continue helping children to grow.

Families First is offered through all of the Region's community areas, and at any given time about 550 Winnipeg families will be involved in the program.

A new pilot project this fall aims at reaching out to involve more Indigenous families by making sure the program fits with cultural and community needs. Four new home visitors will deliver the program through two Indigenous family agencies - Ma Mawi Wi Chi Itata Centre and Wahbung Abinoonjiiag. The home visitors will work with a new public health nurse hired by the Region. Partnering with the two organizations will allow for the physical/emotional/cognitive development aspects of Families First to be delivered in a way that is culturally appropriate, building on strengths in the culture of the families, says Girard.

Home visitors don't just work with the families in the home. After each visit, they document their observations of the parent-child relationship, the subjects touched on in each visit, the tools or activities they used, and safety concerns in the home. Tracking the visits allows for progress to be monitored and allows home visitors and nurses to spotlight issues requiring extra attention.

The program also breaks down aspects of a healthy parent-child relationship into specific observable actions, such as responding to the child's cues, smiling at the child, holding the child, expressing empathy and others. Parents are encouraged to carry out a series of "daily do's" with their children - actions grouped under headings like "brain builders," "character builders," "body builders," and "e-parenting" (the "e" in e-parenting refers to empathy).

Home visitors make note of how the parents incorporate the daily do's into their everyday interaction with their children, and offer encouragement and suggestions.

For parents like Tanya, the home visitors and nurses are a wealth of life-changing information. "Babies do not come home with a manual," says Tanya. "This program is the manual."

In addition to working through the regular curriculum of activities and observations regarding the child's development, Families First staff and the public health nurses they work with can help parents find other support they need. "As a parent, you do have overwhelming moments," Tanya recalls. "He wouldn't sleep, he wouldn't stop crying. So sleep was a huge issue."

Gregg connected Tanya with a respite program that provided some child care so that the exhausted new mom could get some sleep. Gregg also let her know about a program at Victor Mager School where kids can play - so that Tanya could meet some other new mothers - and helped her to get Hunter into daycare, which helped him to develop his speech. And when the isolation and fatigue were contributing to post-partum depression, Tanya was also referred to therapy.

Tanya's not the only mom who says Families First was a lifeline.

"We had a card arrive last month that said, 'I couldn't have done it without you,'" says Sheryl Bates Dancho, Team Manager for Public Health in Point Douglas.

At first glance, many of the activities during Families First visits might look simply like play. But there's a child development goal for each one.

Tanya says she and Hunter still play with the microphone they made out of a toilet paper roll and packing tape during one session. The microphone was a prop for "Play-by-Play," a Families First activity in which the parent describes what the child is doing, almost as if he or she were a sports announcer during a game: "And now you're picking the ball up. What does it feel like? It's round. Is it soft? Yes it is. What colour is it?"

Play-by-play is an important activity for many reasons, one being that it's a way of stimulating language development as the child hears the parent's voice and comes to understand the meaning of the words.

Other games and activities are focused on building other skills or other aspects of physical and emotional development. Hunter did beading during visits as a way of building his fine motor skills. When Hunter was an infant, Gregg gave the family a set of laminated cards depicting different shapes. Home visitors do activities with infants to demonstrate how their eyes follow movement.

Another activity that was a hit with Tanya and Hunter was "building a brain."

"We built a brain out of packing tape and bubble wrap, to show how the brain actually grows as we learn," says Tanya. "It was a nice hands-on tool for learning."

In fact, they still have the bubble-wrap brain at home.

Children come to look forward to the visits as play time. For parents, especially those like Tanya who feel isolated at home, the visit can be a much-needed opportunity to talk to another adult.

"It was hard for me to get out of the house," she recalls. "I wasn't mentally prepared to face the world with my child."

Building confidence and capability is a key part of the program, so that by the time parents graduate from the program they don't need the support - they feel more confident in their parenting and know how to get access to information and resources in the community.

"In the beginning, they would do the footwork for you," Tanya says. "But as the program progressed, it would be 'here's the phone number, you do the call to make the appointment.'"

Now she says she's gained the confidence she needs so that when Hunter starts school she will be able to resume her career or go back to school to retrain.

Home visitors throughout the city help parents to take control of their lives like that. Thelma Roulette, a home visitor in Point Douglas with 12 years of experience in the program, says helping clients to set goals is important.

"With goal-setting, a lot of them want to go back to school, so we encourage that."

Her colleague at Point Douglas, Debbie Paul, talks of moms who've gone back to finish high school or college, or who have struggled in the past with addictions and have stayed clean and sober since being involved in the program.

"Some of the families, they move in baby steps. Even getting the mom to get on the floor with baby for tummy time, that's a big step," says Roulette.

Working with fathers, and encouraging them to get actively involved in the care and nurturing of their children, is also an important part of Families First. Roulette refers to a father she worked with who was reluctant to get down on the floor to play with his child, until one day when she arrived for her visit and there he was. "He said, 'Look, I'm on the floor. I wish I'd done this earlier.' After that, you couldn't keep him off the floor."

Home visitors take pride in knowing they've helped parents find their parenting strengths. And after three years of working closely with a family, a strong bond can be formed between visitor and family. In the Point Douglas office, one wall is covered with paper cutouts of leaves on a tree representing families who have graduated from the program.

"I recently went to a community event in North Point Douglas," says Paul. "This boy runs up to me and hugs me and says, 'Debbie!'"

"It's a satisfying feeling to see families you've worked with for years looking healthy and happy together. I grew up in this area, so it has that much more meaning to me. I feel like I'm giving back," she says.

Bob Armstrong is a Winnipeg writer.

Wave: March / April 2015

About Wave

Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books.

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