Challenging Situations in Home Visiting

Challenging Situations in Home Visiting

Emmy Marshall: Good afternoon, everyone, and welcome to the home visiting webinar, Challenging Situations in Home Visiting, presented today by the National Center on Early Childhood Development, Teaching, and Learning. I'm Emmy Marshall, and I'm a senior training and technical assistance specialist with the Center, and I focus my work on home visiting, so I am so, so, so excited to see -- Right now, people keep joining. We have 975 participants online. It is so exciting to be here in our virtual room with so many colleagues and so many people that do this very important work. We are very fortunate today to have co-presenters Dr. Brenda Jones Harden and Dr. Treshawn Anderson.

Many of you know Brenda is a professor at the University of Maryland, where she teaches in early childhood education and early childhood special education, and we've had her with us before sharing her expertise, her very wide expertise in home visiting, so glad to have her back today, and we're very happy to welcome Treshawn Anderson, who has just joined the DTL team, and Treshawn is an expert in infantile development with us, so welcome to both of our co-presenters. Let's go over a few things about helping us connect with Adobe before we get started. You've already found the chat box, and thank you so much for sharing where you're from and how many years you've been doing this work, so very exciting to see all the years of experience and the new people that are joining as well, so thanks for sharing that. There's also a Question-and-Answer box, and that's to the lower right of your screen.

That's where you can type questions, and we'll also be monitoring that throughout the webinar so that we can answer your questions as we can. There are handouts for this session, and they are below in the bottom-left corner. Also, I want to let you know that if you happen to get disconnected because there's so many of us online, we're kind of stressing the system here, that if you happen to get disconnected, just use the same link that you did to join, and you can come back in with us, and we're recording this session so others can access it at a later time. And finally, there's an evaluation link on the last slide. If you complete that evaluation, and we appreciate it when you do, you'll be taken to a link where you can download your certificate of completion for attending, and if you have colleagues that are watching the webinar with you, you can share that link with them. So let's go ahead and get started. Okay. Next slide, please. Okay. I'm not seeing the next slide come up. Can one of my colleagues advance the slides, please? Okay. We're having a little technical difficulty here.

Okay. Here we go. Thank you. Thank you.

This is what we're going to go over today. We're going to look at challenging situations that home visitors face. We're going to look at strategies for working with those, including some self-care strategies, and then share some resources about that work. I know that many of you have been in homes that look very similar to this picture. You know, you're in the living room. There's a bed and not very many furnishings, but guess what? The parent is there. The child is off to the right, and they are having the home visitor come into their home to work with them, so even though there may be challenging situations, they're very interested in helping their children. Before we go into some of the strategies for working with these families, let's just look at a little bit of the research about the types of challenges that some of these families might face, and I know that all of you have had these experiences. You know these families. You work with these families every day, but it's just really important, and I think that we stop and acknowledge just, you know, how many challenges sometimes our families are dealing with. So there's one study that found that the families that were enrolled in Head Start, that nearly half of those families, or 48 percent, had experienced some depressive symptoms at the time of this study, and 12 percent of those families had actually had long-term depression, so that that's, you know, even more significant as something that they've been experiencing for some time and have been impacting their ability to parent well, I would imagine.

And then another study found that as many as 25 percent of Early Head Start and Head Start families have three or more risk factors, so that's something that we see, you know, in addition to just depression and the many consequences of that, that they have other risk factors as well, and this depression is not just among our Head Start mothers. There was another study that found that 12 percent of the fathers in the Early Head Start program were experiencing depressive symptoms. I know that many of you are familiar with the Adverse Childhood Experiences, or ACEs, study, but there was a study at the University of Washington that found out that 63 percent of the families in the sample, and that was a sample of over 600 families, that 63 percent of those parents had experienced three or more ACEs and that 40 percent of their 3- and 4-year-old children had experienced three or more ACEs by the time they were 3 or 4 years old, so just incredible circumstances that some of our families are having to face.

So I know that you may not have the ACE score for your families, but we're going to do a poll now and just see what you think. Do you think that your families' scores are somewhat comparable to the statistics that we're seeing from this ACE study? We were going to have a poll here. Okay. So if you could just chat. Type in the chat box if you think that your families' ACE scores might be similar to what we just shared, if they would be a bit lower or a bit higher or that you really just don't know, so if you want to share that in the chat box, we will get some feel.

Yes, you're saying that, yes, it's very similar. I see a lot of yeses in there. Okay. Okay. That's what we thought, and that was a really very big sample size, so. Okay. Thanks so much for sharing that, and here comes the poll now, so if you want to share your responses there as well, we can see it in the poll window. Thanks so much for sharing. So most are saying yes. Okay. Let's go on to the next slide. Yeah, we're seeing that, overwhelmingly, they would be the same or even higher. Okay. Thanks so much. All right. Let's go on to the next slide. So it was not surprising at all for you to hear that it's very challenging for families to participate in home visiting when they're facing all of these challenges. Parents can be disengaged, and they may have a low priority for home visits and socialization. So we're very lucky to have Brenda Jones Harden with us today, and she's going to talk about some of the ways that she knows of from her experience that we can address working with these families. So, Brenda, can you take it over from here? Hi, Brenda. I think that you're muted, so if you want to unmute your phone line so that we can hear all the important things that you have to share with us.

Brenda Jones Harden: Thank you. Thank you so much. So hello, everybody, again. I'm happy to be with you all, and I'm happy to talk to you about families that face challenging situations, and I'd like to say these are the families who have more than poverty to deal with. So what I'm going to start with by talking to you about is what we can do generally to support these families. So the first thing I want to talk about is meeting families where they are. That means physically and psychologically, so going to homeless shelters, going to their homes as we do in home-based Early Head Start, meeting them where they are psychologically, if they're not so ready to make a move that we sort of stay with them wherever they are, but also thinking about when they're ready. You know, are they ready for services? Sometimes, we know that if Mom is depressed and we want to get her to treatment right away and then she doesn't go, and we're kind of upset about why she isn't going, and the truth is, she's just not ready, but through her relationship with us, she can get to the point where she is ready. Another important issue is working with other primary caregivers. One of the things that I've long-time thought about is how we should move beyond moms, and actually we have much, much data on that right now, that fathers, particularly lowincome fathers, play a very big role in the parenting of their children, but as many of you know -- I saw a lot of you with 20 years, 10 years experience.

You all well know that oftentimes it's the grandmother or the aunt or the uncle or somebody else who is taking on the parenting role, so part of our work as home visitors is to engage those folks as well because they can help make sure that the child gets the support he or she needs while their parent is going through the challenges that they're facing. Clearly, we can't do it alone, and we'll go back to address that again later. I wrote a little paper about that many years ago about how we certainly can't do it alone. We have to think about our home-visiting work in a larger systemic context where we're working with mentalhealth treatment, substance abuse, all kinds of other programs to help us meet our families' needs. So clearly, one of the things that I like to think about is what our message from us should be to families, and one of the important messages is that we believe in them unconditionally, that we know that they're going through lots of things, but we really believe that they will be able to overcome their obstacles, and I love to think about that in terms of unconditional positive regard, and when I talk to my supervisees, I talk about the importance of expressing to families that we care about them no matter what, no matter how many names they call us, no matter whether they meet our goals that we have on our plan for the home visit. We still care about them, and Jureed Paul has this phrase called an emotionally corrective experience, and I love that phrase because what it speaks to is that we give parents an experience that they don't get from anybody else, certainly not from a lot of other human-service providers who might tell them to get in line and wait in line and, "Why are you on welfare?" and all those kinds of things but also even some of the members of their family who are not really giving them the unconditional positive regard.

So we want to make sure that they are getting from us the experience that we are going to love them no matter what, and clearly we want to focus on strengths, and I'll just let you all know that, you know, I've been doing work in terms of strength-based home visiting for a long time. One of the things that I'm happy to see is that now we have data that suggests that if you focus on what a family does well, even if it's like looking for a needle in a haystack, if you comment on that, if you, you know, make that live for families, talking about it in the context of the home visit, that they're more likely to show benefits from the homevisiting experience.

So if you think about the kinds of things that we want to do to keep families in, because obviously one of the worries that we have in home visiting is how to engage families and how to retain them in the homevisiting experience, so there's some research on this that I just want to share very quickly. One of the things, and I'm sure I'm preaching to the choir here, but we have to give families some kind of tangible evidence that their experience with us is important, so we give diapers and socks and all kinds of things like that to say to parents, "There's a way that you can get something out of this," and I know we shouldn't be thinking about this, but we have to be, you know, always focused on how can we keep these families in, and one program I work with has even tied the concrete resources to things like how many visits the families make, how many socializations they come to, and they sort of get these extra concrete resources and incentives because of that. The data do show that the services need to be free, and certainly for all of us in Early Head Start home-based as well as many of you who are in PAC and other kinds of programs, we do offer these services free, and there's some evidence that that makes a difference. In terms of us, we always have to express how much we care about families. That's, you know, going back to that unconditional positive regard.

Those of us who have been in the field for a very long time, not only are we sort of viewed as having more knowledge, but it looks like our skill in working with both parents and children makes a difference in terms of engaging and retaining families in our home-visiting programs. Of course, this goes without saying. We cannot ever, ever pass judgment, and this has been a test that I've had to pass many times in my work because sometimes families don't do what I really want them to do, and it's not just about what I want them to do, what I know is best for children, but I can't let that come out. I have to express to them that I care about them and think they can be the best parent they can be no matter what they do. Flexibility, I like to talk about being like a prize fighter, even though I don't like aggression, but sort of thinking about always being on my toes, knowing that I have to get my curriculum across, but at the same time, being responsive to a family because, like you all have learned, I'm sure, about parallel process, that as we are responsive to parents, they will be responsive to their children, so we have to be so flexible in our work and making sure that we meet our own goals around child development and assessment and all those many things that home visitors have to do in addition to being where a family is, as we talked about. And then this idea of being calm in the face of a storm, and as many of you know, in home-visiting work, we end up being around families where there are people coming in and out of the house. There's lots of loud noise. There are lots of pets in the house, all kinds of things that we'd rather not deal with and certainly rather not have little children exposed to sometimes, but we have to keep going no matter what and show families that we're not distressed by this, that if they can deal with it, and they have to deal with it a lot more than we do because they live there, we certainly can, and we certainly will be there to help them through whatever kinds of experiences they have. So you all have heard of resilience before, right, this idea of overcoming adversity and having positive outcomes. So one of the things that we know about resilience, one of the things we know that promotes resilience, is having a relationship with an other who says to you, you know, "You're the best thing since sliced bread." Again, that's what we want parents to be for their young children, so as home visitors, we have to be that kind of person who says, "I'm connected to you emotionally and many other kinds of ways, and I will maintain that connection no matter what."

That unconditional positive regard, that emotionally connective experience, really helps families to move beyond the challenges that they face to move to where we know that they can be for their children. So this notion, and many of you have seen the work of Jack Shonkoff and those at the Harvard Center for the Developing Child, and they have this notion of really promoting certain core capabilities in children and adults as a way to buffer them against adversity and being able to move beyond, again, the challenging experiences they have to really meet the developmental capacities that they have. So some of those kind of core capabilities that we want to think about are really consistent with the Head Start program performance standards and what, certainly, we have to do in many, many home-visiting programs, including Early Head Start.

First is promoting child development, so always keeping in our mind that that's our goal, so as we reflect with parents on their challenges, we always want to bring them around to, "Let's think about what you think that means for your little person, for your son, for your daughter. How is the fact that you're homeless going to impact how they'll feel, their anxiety? What can we bring with you to the shelter to help your child feel a little more comfortable, like things haven't gone topsy-turvy?" So really focusing on child development no matter what the challenging situation, helping parents to really express their emotion. You know, there's a joke about therapists always asking, "How do you feel?" Well, there's a reason for that. If we can express emotion and think about it and wonder about it with a caring other, it doesn't have to stay bottled up and then come out in some kind of way that causes more stress on the parent. Another issue is self-regulation, and you all know as well as I that that is an important, important developmental construct for little children as we're moving children through Early Head Start and then in Head Start. We want them to gain these kinds of skills so they don't end up in Head Start throwing chairs.

Well, similarly, for parents, we don't want them in their WIC clinic throwing chairs, so we want to really promote self-regulation as much as we can, helping parents to stop and think and reflect with you about their problems and what's the next thing they should worry about and how they can maybe put something aside and focus on one thing, and then, clearly, trying to get them, and sometimes this is easier said than done, to put the elephant in the room out there, the trauma that they've experienced. Ask the question. I mean, even if we're not the ones who are going to help them with it in the long term, talk to them about these things. Talk to them about if they're feeling depressed. Ask them the questions. You're like the gatekeeper to get them into these kind of interventions and treatments that would address this, but if we don't bring it up, if we're afraid to put it on the table, then we might never know that a family is struggling with these kinds of things. And by the way, just having the opportunity to reflect on it with a caring other can mean a lot as well. Okay. So clearly these are strength-based things that all of you all know about and can work on, but the data suggest that these things are important for all families with whom we work but particularly for families who have these kind of challenges that we want to address today, so always, always -- Again, data here, not just our approach, but identifying families' strengths, always looking for an opportunity to say to a family in the context of a home visit, "Wow. Look at how you're kissing your baby whenever she reaches for you," right? And just like we tell 4-year-olds in a preschool classroom, you don't want to just say, "Good job." You want to find something that that parent is doing to support that child's development, to support their relationship, that you can identify, so that's part of your being flexible and always being responsive, looking for those opportunities to bring up positive things, positive behaviors, that you see in the family. We've talked about being nonjudgmental, but I'll just say it again.

This is critical, even when families do things. Like, one of the worst things for me is to see a parent yell at their kid. I just have to swallow and think about how I can help them instead of doing what I really want to do, which is yell at them back, so then I have to work on my own self-regulation. Think about what their own protective factors are. What are the things that help them to move better? Are they connected with a partner? It could be a partner who doesn't live there but somebody who means a lot to them. Do they have girlfriends? Is there a grandmother, although she gets on the mother's nerves, but is she somebody whom we can use to support the development of the child and the development of the young parent?

Again, this idea of focusing on positive behaviors, looking for that needle in the haystack, but sometimes parents will give you lots of things that you can address, and, really, don't be afraid to go to the risks. Talk to them about them. Help them think about them. Help them think about what it means for their young child to experience drug use in their house, to experience family violence, domestic violence, all those kinds of things that we know occur with children, what it means when they watch their mother cry because somebody died. Help them to really think about that and focus it in on the child's well-being, and, again, always -- Victor Bernstein calls it the pivoting. Always use the opportunity when families talk about risks to bring them back to, "What does this mean for your little person, and how can you help your child because you are the best -- Not only are you the best teacher for your young child, but you're the best buffer for your young child against all these things that might impact them." Okay. So I'm going to ask Treshawn to jump in and talk about motivational interviewing a little bit.

Treshawn Anderson: Hi, guys. Yeah, so, sure. So motivational interviewing has really been demonstrated to be an effective tool in promoting relationships and behavior change, and these principles and strategies can be used to enhance the relationship that you have with your family and help you feel more comfortable when addressing challenging issues. So in the box, you guys are very active in the chat box, and that's great, talking amongst each other, but if you can share your experiences with motivational interviewing, that would be great. Have you used it before? Have you found it to be very helpful, and if you haven't used it before, are you interested in learning more about it? What do you guys think? Great. We have lots of people interested. And some have been trained in it. That's wonderful. It's going so fast. I'm so glad you guys are in it. So refreshers are needed. That's great because we're going to talk a little bit about it today, and lots of people really want to know more about it and have the training.

Some people actually use it in their positions, and that's great. So good. So let's dive into some of the principles of motivational interviewing, some that need a refresher and some that just want to know more about it. So motivational interviewing is a problem-solving approach that really helps families change their behaviors that may be harmful to themselves or to their families, and sometimes family members are on the fence about changing their behaviors. For example, a caregiver may understand that smoking in the house is harmful to their family members, but they continue to do so, or a caregiver may want to stop drinking, but at the same time, they really don't want to. So we use motivational interviewing because it helps caregivers identify, independently make a decision about their harmful behaviors without being pressured into a decision by someone else, so ultimately it gives them the power over their own lives, and that's a great way to tackle issues with families. Some principles -- Some principles that we have -- Sorry. Some strategies that we have for motivational interviewing -- So, sorry, going back into these principles a little bit, that, for motivational interviewing, is that we want to respect the caregiver's feelings and listen carefully to the caregiver's needs and struggles through this whole reflective listening, and also through motivational interviewing, we can learn what the caregiver's goals are or their hopes for their future, for themselves and for their families, and then show them how their current behaviors just don't match up to their goals. We especially don't want to argue with caregivers who are unsure about or unwilling to change no matter how much you know it will help. This only increases their resistance to change. Instead, we want to help caregivers understand how their behaviors don't match up to their goals instead of arguing with them about it.

With regards to resistance, a family's resistance to change is oftentimes just a way to let us know that they have a different perspective on the situation, so as practitioners, we need to be able to adjust to and accept this resistance and use that as a starting place to find a solution that works for the family. And finally, self-efficacy is a critical component of behavior change. When a person feels confident in themselves to change, the more likely they're going to change, so recognize the family's strengths and bring those to the forefront in all the discussions, the needle in the haystack that Dr. Jones Harden was talking about. Help the family to understand just what they're capable of. So some strategies that we have now that researchers suggest that we use when we do motivational interviewing is, first, we want to ask open-ended questions, and this helps you understand the family's point of view about the particular stressor or about the behavior that they're having challenges with. Next, we want to listen reflectively, and this demonstrates that you've accurately heard the family's concerns by restating what they said or what they meant, and this helps you not to assume. Third, we want to summarize, so after a while, during the discussion, communicate back what you've heard from the family.

This lets them know that you are listening. Fourth, we want to affirm, so validating the family's experiences and feelings. This lets them know that you understand or respect them and their opinions and behaviors. And finally, we want to elicit motivational statements, self-motivational statements, and this engages the family in the process of change. You help them realize how their life might be better if they changed their behaviors. When families have identified how they can be better, agree with them by nodding your head and saying affirming statements like, "That must have been very difficult for you," or, "I think it's great that you want to do something to change for your family," and this will motivate them to identify even more positive behaviors, which is what we want to do with motivational interviewing. So on the ECLKC website, there is a motivational interviewing video. You can find the motivational interviewing suite, and there's a short set of videos that provide examples of how to use motivational interviewing strategies when having difficult conversations with families, and you can go on and watch them as much as you want because they're very helpful and nice professional-development tools for you there on the ECLKC website, and we'll provide that resource for you towards the end of this presentation. So in thinking about and considering families of cultural and linguistic differences, it's important to consider. So it's important to consider that sometimes it's inappropriate or taboo in some cultures to talk about adversities or mental-health issues with other families, with families outside of the immediate family, and so a person's cultural and linguistic experience can affect how they talk about their needs, the kinds of resources they're willing to use or how a person describes how they're feeling. For example, language differences makes it challenging to discuss hard topics.

For example, when we use terms like, "I'm feeling blue," or, "I'm feeling down," those may not translate well into other languages, so it's important for home visitors to be sensitive and responsive and respectful to these cultural and linguistic differences, and so if you look in the bottom left-hand side of your screen, you'll see a box that says, "Files," and in that box, there's a handout called, Understanding Depression Across Cultures, and this provides a description of depressive symptoms, how to handle any language barriers when talking about depression with families and strategies for building cultural sensitivity. It's a great professional development piece that may help you in talking about these sensitive issues with diverse families, so make sure you take a look at that. We'll also provide a link for you at the end of the presentation as well. A growing of number of Head Start and Early Head Start programs are successfully screening for parental depression, so there is an increased screening for specific risks happening within our program, which is great. It's also a good idea for agencies to provide professional development to the support staff working with families facing these challenges, and home visitors and other professionals can be trained to administer standardized and validated screening pools and to follow up with parents about their results, and once families are assessed, screening pools must then be scored and acted upon quickly so that parents that are in distress are recognized and supported as soon as possible. When we have community partnership, we can work with families to transfer, refer or follow up with another agency that can better assist them with their needs, and this warm handoff should occur in front of the family, allowing them to hear what is said, and it also gives them the power and the opportunity to be involved with their own care, giving off that autonomy. So we've been talking about best practices, but we also need to know that there are some practices that are particularly critical. For example, our particular Head Start performance standards tell us that it's important to have a mental health consultation available because we have a professional obligation to be prepared to respond to families in crisis and in a timely manner. Do you guys in the chat box, can you tell us if you have your mental health consultation available to you? Great. I'm seeing lots of yeses.

That's wonderful. So in the resource segment of this webinar, we'll share the links to a mental health consultation model that is available on the ECLKC website, especially for those saying that they don't have that person in place. Next, it's important to plan ahead with policies and procedures for adjusting crisis situations and to review and receive training in these policies or procedures regularly such as when should you complete a child maltreatment referral, or when should you report violence in the home or principal active substance abuse? As we said earlier, we can't do all this work alone, so it's important to partner with community service providers, and having an understanding and connection to them in advance of needing their services will make connections for families much more smoother. Partnerships can include your local domestic violence center, your local mental health center and local substance abuse programs as well. So, Brenda, back to you. I know you have a lot of knowledge about parenting interventions that are targeted to specific risks. Would you mind sharing some of those with us now?

Brenda: Sure, and I want to start by saying that I really feel that as home visitors, we have to sometimes think beyond our curricula and look at the risk factors that our families are presenting and think about how we can incorporate specific kinds of parenting interventions into our work. We just did that with a program in Early Head Start home-based programs in our area, which I'll mention a little bit about, but as you all know, there are a lot of evidence-based parenting interventions that are out there now. McVee has a ton of them on its list, but also there are some specific to certain kinds of risk factors, so we should learn about those as much as we can, and I'm going to give you some examples in just a second, but we should also, with families in the context of our home visit, while we're working on child development and using our curricula as the office of Head Start requires of us, to really think about the risk factors that present themselves like maternal depression. You all probably know that one out of two families in Early Head Start, according to the Early Head Start research and evaluation project, were reporting depressive symptoms, so we know if one out of two are reporting, the rate is probably much higher. So that's just one of the many, but we should really explore with families how they think these kinds of things affect their roles as parents.

How does it get in the way of them being able to be responsive to their child's needs, to get up in the morning and give them their cereal or to change their diaper or to not hit them if they're doing something inappropriate and unsafe when they're a toddler? So we really need to be thinking with them about this as much as we can and then try to incorporate strategies that we know work, sort of these general strategies that work for these challenges across the board. Like, one of the things that we've been thinking a lot about, and you'll hear this in a lot of the parenting programs now, is really incorporating mindfulness, and my good colleague, Rebecca Shahmoon-Shanok talked to me all the time about it, about how you can get quiet with yourself, and it doesn't have to be a half an hour. It doesn't have to be 15 minutes. It could be 1 minute, and teaching parents how to breathe in and breathe out to keep themselves from, you know, hitting their kid or getting mad at their partner or something like that. So really trying to take in strategies like mindfulness or desensitization against trauma kinds of experiences, being afraid to walk past a home, kind of reappraisal, really rethinking about how they want to imagine their lives, you know, going to a good place, thinking about feelings, all that kind of stuff, to make that a part of your home visiting work with families because it will help them across the board with any challenge. So just to kind of talk about some exemplars for these specific risk factors -- Now, mind you, I'm not endorsing them. The office of Head Start is not endorsing them, but I wanted to give you all some examples that have been -- of these kind of interventions that have been used in home visiting that do work for these specific risks. For example, there's a program, Moving Beyond Depression, coming out of Cincinnati where they have actually integrated it into home-visiting program where they use cognitive behavioral therapy approaches with parents in the context of a home-visiting service delivery system to help move them literally beyond the depression so that they could be available to their children. Another one that comes out of Yale is called Minding the Baby.

This really is for moms who are experiencing high stress and trying to learn how to cope, teaching them how to be responsive to their infants. Another one coming out of Yale that is really for moms, it's an attachment-based program for parents who have substance abuse problems called Mothering From the Inside Out, and again, we have these as resources for you on this PowerPoint, and the trauma example that I wanted to tell you about is actually the intervention that we did integrate into our Early Head Start programs in our area. This was part of a buffering toxic stress initiative, and we use Attachment and Biobehavioral Catch-up that is meant for children who have experienced trauma, children in the child welfare system, short, brief intervention that we were able to integrate into the regular sort of Early Head Start home-based service delivery with some nice effects in terms of changing parents' capacity to respond. One of the things that is very similar across these programs is the emphasis on parent-child interaction and literally, as the depression example says, moving beyond the risk factor to be more responsive to their children, and certainly that kind of approach is very consistent with what we want to do in Early Head Start. Okay, I just also wanted to bring your attention to The Compendium Of Parenting Intervention. This was published through ACF prior to the changes in the Head Start Performance Standards, but still reflect some very, very solid parenting interventions that you might want to learn about and incorporate in your ongoing Head Start service delivery, and of course it is available off the ECLKC website. Okay, I just want to talk about safety and self-care for a minute, because the truth is, as you all know, when we work with these families, we are exposing ourselves in some instances to the same challenges that the families are experiencing. So ever since I was a young home visitor in Brooklyn, New York, when I was walking up dark stairways and things like that, I started to think about, "Hmm, I better think about how to be careful and how to take care of myself." Well, actually, the taking care of myself is something that I continue to work on, as old as I am, but the safety, I certainly learned way back then. So let's think about that because really your health and well-being is critical. If you're not safe and secure, you can't help your parents to do better with their children. So some of the things we want to think about, that mindfulness that I was talking about, meditation activities, you don't have to be a yoga aficionado. You don't have to do this for half a day.

You can sit at your desk when you're writing those notes from your home visits and do some breathing in and out. You can do it in the car or on the subway. I saw some of you are from New York. You do home visits on the subway. I did many of those myself, and you can do those kind of breathing exercises or imaging exercises right while you're going from house to home. Also, physical health, I just read a book about walking is the best form of exercise because that's about all I can do these days, but, you know, think about making sure you incorporate that in your experience for yourself on a daily basis. It will help you certainly with your own health outside of the work, but it certainly will help you inside the work. One of the things that I learned about early on is attending to my own mental health and wanting to do that with the staff and the programs that I've worked in, so we instituted what we call "mental health days," where it's a time for home visitors to put down their pens and not run around to a million houses and really think about, "How is this work affecting us?"

One of the things that I used to do with my staff is every other week, we would have some kind of person come in and teach us about belly dancing or something like that, anything like that to help us be more available to our families. Using other home visitors as peer support turns out to be critical, and of course I'm going to talk about supervision. You all know that, but I think getting support from your peers can sometimes be just as important as getting reflective supervision from a person who is in your program to provide that, and really one of the things that we like to talk to home-visiting programs about is making sure that they have mental health support for the home visitors, so using that mental health consultant not just to think about what to do with this kid who's acting out or this parent who is a substance user or who's depressed, but really how to help home visitors with this very, very challenging work with these most challenging families. So again, I mentioned reflective supervision.

Any of you who have done this work know how critical this is, and I don't mean supervision where somebody is asking you how many home visits you have, and I don't mean once in a while seeing somebody walking through the hall. I mean sitting down with home visitors, asking them how they feel, asking them what families are they struggling with the most, helping them to think about how to get past some of the barriers that make them want to shut out families who might have domestic violence because they are afraid or something like that. Anything like that is fodder for reflective supervision, certainly not -- We don't want this to become therapy for home visitors, but we want it to be a place, a safe place, a consistent place, where home visitors are able to bring up these challenging issues that really affect the work. Clearly mental health consultation is important, and really thinking about using crisis lines. You all know it would be great if our families just had a crisis when we were in their home, but of course they always have it at 5:00 on a Friday, and by the way, we should not be dropping and going to deal with them at 5:00 on a Friday. We should be going to do something for our own self-care, but then giving them resources that they can use when we're not there.

Okay, and just quickly really insist upon training and support in terms of reflective supervision, in terms of coaching, and actually I think those might even be a little more important than training, about how to recognize signs of trauma. When is a family telling us that things have fallen apart? When does a little person tell us that they're so traumatized that they're dissociating from what happened, helping us to understand how to desensitize ourself from the trauma? You all might notice that sometimes you just don't want to go to a particular family's house. What is that about? What has being with this family caused in us, and certainly thinking about the secondary traumas. You all know we are traumatized just like our families are, and the more trauma they experience, the more trauma we experience, the tired-er we get, the more jaded we get, the more we don't want to do the work. So those are often signs of secondary trauma that can be addressed in a supportive environment with the help of supervisors or peers or trainers who understand these issues. Just a couple more things, and I will move this back to Emmy. I really want you all to think about getting training on some of these parenting interventions. We are all getting really good at our capacities to promote child development. Let's move this beyond that and really think about how we can incorporate some of these with specific parenting interventions in our work, and again, we've done it with Attachment and Biobehavioral Catch-up.

Other people have done it with "Moving Beyond Depression." Learn about substance abuse. Learn, learn, learn, you know, and really that includes alcohol and cigarettes, and now we have this opioid addiction, right, that's going on. Many of our most challenged families use substances to help them deal with depression and anxiety, so we need to understand these things. We need to understand the language around it, the street language, the phrases, the trends, where we see them, where we don't. I used to think that opioid addiction was just in rural areas. Now we're learning about it in many urban areas. We need to be paying attention and seeing what resources are available in our community. Learn, learn, learn about the impact of trauma on the child, on the parent, and I might add on yourself. Learn about intimate partner violence. We're now seeing really, really high rates of this among some of the children. We used to think, "Right, they're little babies, this didn't affect," but we now know about data that children, when they are 3, their brains show different reactions when they hear parents argue than when they hear parents speak in a nice, normal tone. So this is getting under the skin of our youngest children, and we need to be able to understand that and help parents understand it. Learn as much as you can about how to help parents put a Band-Aid on their own mental health issues.

Right, we want to get them to treatment. That's our goal, but while we're working on them, making them more ready for treatment, really helping to think about how they can manage it, how they can recognize when they're getting depressed and what they can do to overcome it, and certainly you all, make sure, make sure, please, to go get as much support and training around how you can be careful, how you can take care of yourself. Get the police department to come talk to you about safety. Leave -- Learn to leave homes when you see violence. All that kind of stuff that community-based policing can help you to learn. Okay, so, Emmy, I think I'm going to turn this to you to talk about resources.

Emmy: Thanks so much, Brenda. Really, really appreciate everything that you shared with us from your years of experience with working with families. There's so many things to think about, and we have gone over so much during this time together, so I appreciate all that you've been able to cover in this short amount of time. It is a little bit like, "Wow, we certainly have a lot of work to do," so I really appreciate you reiterating the support and how important that is, how important it is to have a time for reflective supervision and a time for peer support, and those things are so important in our work with family, so thank you for that really helpful information. I want to talk about some resources, and I'm going to share with you, so hang on. I'm going to share with all of you a place that we can post those handouts today so that Tammy, who graciously volunteered to send handouts, won't be overwhelmed with that task because I saw lots and lots of e-mails coming up, but we're going to post those, and if you're not already a member of the MyPeers home-visiting community, we'll show you how to join that.

It's super easy, and I'll post all of the handouts there, get them up by the end of the day today, but I'll show you that in just a second. Let's look at some other resources. So here's one of the things that Treshawn mentioned a while ago, the mental health consultation model. This is on the ECLKC called Family Connections, and it's, you know, talking about ways to have those difficult conversations. It covers understanding depression across cultures, how we promote resilience and really lots of lots of resources for supporting these families that are going through these difficulties, and just also to just remind you that you shouldn't be going through supporting these families on your own. So this is an excellent resource.

These are referrals to the interventions that Brenda mentioned, and these interventions that she mentioned are all programs that were developed and are incorporated into home visiting. So as all of you know, working the field sometimes it's really challenging to find resources that are specifically for home visiting, but these programs were developed to meet the particular needs of working with families in their home. They are interventions that are provided a lot of times by therapists and clinicians. It's not something that we're saying that you should be doing, but I think it's something that your program might want to check into if you're having trouble finding additional resources for families or if you can check and see if any of these programs are in your area. It's something that you can work with your program's staff to add or to partner with community organizations or agencies that might be able to provide these to your families in addition to your weekly visits and your support. So here is the ECLKC link for the motivational interviewing suite, the services that Treshawn was telling you about, and then there's also on ECLKC the Depression in Mothers: More Than the Blues tool kit for family service providers, and then Brenda mentioned The Compendium of Parenting Intervention. There are parenting groups and parenting support programs to provide additional services, additional parent education support to families that could benefit from that. So these are all services -- resources that may be helpful, and more resources, Understanding Depression Across Cultures, some more information about that study that we mentioned at the beginning about ACEs and children in Head Start, a place on SAMSA's website to locate behavior health treatment services, and then there are a ton of resources at the National Child Traumatic Stress Network site, so that's another really good one to point out. So here is the MyPeers home-visiting community. We have about 800 or 900 home visitors that are a member of that community. If all of you join today, we'll have about 2,000 members.

So it is easy to join. This is the contact form at the bottom of the screen here that you can go onto MyPeers and join that community. A lot of the information that you've shared with each other today -- You've answered each other's questions. You've provided connections to other resources. You've shared information about how you address challenging situations with families, and this MyPeers home-visiting community is a place that you can do that, where you can ask each other questions and share resources with each other, but I will be posting today's handout at this site by the end of the day today. There is no cost to join the MyPeers community. The MyPeers community is an online community that is open to all Head Start and childcare community partners to support each other. We have heard that you like to have a way to connect with each other, so we are offering that opportunity and get a lot of great resources being shared there by your peers. So please do check that out.

Okay, we have about 5 minutes left today. There's a question. "Is MyPeers open to non-Head Start home visitors?" I know that it's open to the childcare community. Katrina, do you know if it's open outside of the Head Start community? I don't believe I've had that question come up before. Great question. Okay. So here is the link to the evaluation. As soon as you complete your evaluation, it will be taking you to your certificate, and you can download that. If there's someone that's watching the webinar with you, and you only have one computer there, you can forward this link to your colleagues. Okay, so we have an answer to the question, "Can anyone join the MyPeers community?" And the answer to that is yes. So let your colleagues know that they can participate in that. So we have just a few more minutes. Are there any questions for Brenda while we have her? We're so thankful to have Brenda and Treshawn with us today.

Do you have any questions for our presenters? You can type them into the chat box. There's a question. "Are there any conferences for home visitors?" I think that one of the best things that I've seen, Maria, is that a lot of states have something that's going on in their state that might be affiliated with the Maternal, Infant, and Early Childhood Home Visiting Program, and even though not every state has Head Start as part of that, they often will include -- Head Start and other home-visiting models may be allowed to attend those trainings or encouraged to attend those trainings. I don't want to make them think like they're exclusive, but that might be worth checking into, and then, I would also -- I'm going to type this into the chat box. It's called the Institute for the Advancement of Family Support Professionals, and they have excellent online training, and even though they call it family support professionals, I think that it's really for home visitors across the country. So I would -- Looks like I mistyped that, but I would type that into your browser address, and then see if you can get connected to that Institute for the Advancement of Family Support Professionals. Okay, well, thank you all. We have a question, "What is the program from Yale for substance abuse?" Brenda, could you type that answer in here or come online and answer that? Why don't you just come off of mute?

Brenda: Yes, it's called "Mothering From the Inside Out." If you just go on the Yale website, you'll see the work is Nancy Suchman, S-U-C-H-M-A-N. So she's done some great work. She's been using attachmentbased intervention in the home to support substance-abusing moms.

Emmy: Okay. Thank you, Brenda. Here we have time for about one more question.

Treshawn: Also for those of you that had trouble hearing while you were online with us, this video, this webinar will be posted on MyPeers. The link will go up on MyPeers, so you can watch this video again if you had trouble hearing it.

Brenda: And Emmy, I'd type this in, but so many people are typing that it will be forever. There is a home visit summit that occurs every January. I would encourage you to try to go if you could, where, like, the latest, best practice is discussed, and the conference is usually given by the Ounce of Prevention Network out of Chicago. It's usually in D.C. in January.

Emmy: Thanks, Brenda. I just went to that summit week before last. It was excellent.

There were -- I did meet lots of Head Start home base staff there, and there was a lot of innovative ideas, and people liked the presenters, the developers of the HOVRS and people from the Home Visiting Research Network, so we're going to be sharing some of the information that we've learned from these sources and others on future webinars, so we look forward to you joining us then, and really appreciate your interaction today, and please do join MyPeers, and we can continue this conversation online. I'm going to leave this evaluation link up just a few more minutes. Some people are still having trouble getting that evaluation link. Thank you all so much for the work that you do every day and for joining us today, and thanks to our presenters. We'll see you next time in April. We'll be talking about socialization on our next webinar.

Bye-bye.

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