Leveraging the Potential of Home Visiting Programs to Support Children of Immigrants and Dual-Language Learners:

Identifying and Addressing Gaps in Participation

National Home Visiting SummitFebruary 1, 2019

Presenters

© 2018 Migration Policy Institute

Maki ParkSenior Policy Analyst

Migration Policy Institute (MPI)

Pamela Williams Washington State Program DirectorParent Child Home Program (PCHP)

Aimee HiladoSenior Manager, The Wellness Program

RefugeeOne

MPI Immigrant and Refugee ECECPolicy Consortium

MPI NCIIP and five state immigration policy organizations: - The Spring Institute (Colorado)- ACCESS (Michigan)- Massachusetts Immigrant and Refugee Advocacy (MIRA)

Coalition- New York Immigration Coalition (NYIC)- One America (Washington State)

Support state level advocacy in: - Reducing bias in licensing and program regulations- Access to trauma-informed care for young children of

immigrants and refugees- Participation of immigrant families in Home Visiting Programs

© 2018 Migration Policy Institute

• Characteristics and Growth of:• Young children of immigrants (0-5) and Dual Language

Learners (DLLs)

• Parents of young children of immigrants

• The Potential and Promise of Home Visiting Programs for Immigrant Families

• Barriers to Participation

• Introducing Opportunities for Improved Policy and Practice

© 2018 Migration Policy Institute

Introduction & Context

Children from Immigrant & Refugee Families

Children of immigrants comprise 1 in 3 of all young children ages 0-5 in the U.S.– An even larger proportion are Dual Language

Learners (DLLs)– Accounted for all net growth since 1990– Rapid growth across the nation– 96% of immigrant-origin children are U.S. citizens– Linguistically diverse families– Less likely to be enrolled in pre-K – Exposure to trauma, especially for young children

in refugee families

© 2018 Migration Policy Institute

Immigrant parents of young children:Sociodemographic highlights

Immigrant parents are disproportionately low-income and more likely to lack health insurance

Many immigrant parents of young children have Limited English Proficiency (64%)

Many also have low levels of education (47% have less than a high school degree)

© 2016 Migration Policy Institute

Sociodemographic Portrait: Parents of Young Children in the U.S.

0%

10%

20%

30%

40%

50%

60%

70%

80%

Below 100% of poverty level 100-184% of poverty level At or above 185% of povertylevel

Shar

e of

Par

ents

Income and Poverty

Foreign Born

Native Born

• Almost half (49 percent) of all families with foreign-born parents have incomes below 185 percent of the Federal Poverty Level, compared to 31 percent of those with native-born parents.

Source: MPI analysis of U.S. Census Bureau pooled 2010-14 American Community Survey (ACS) data.

© 2016 Migration Policy Institute

Home Visiting Programs:A Promising Model to Reach Immigrant Families

• Reaches immigrant and refugee families “where they are”• Can connect otherwise “hard to reach” families with a

range of other critical services: systems navigation• Relationship-based model: builds trusting relationships as

a foundation for effective, tailored service provision• Opportunity to mitigate maternal and intergenerational

trauma and provide mental health supports through trauma-informed approaches

• Can promote home language support in critical 0-5 age period

• Can support lifelong parent engagement in children’s education

© 2018 Migration Policy Institute

Home Visiting Programs:Barriers to Participation

• DLL and immigrant families are currently underserved by Home Visiting programs• Not a targeted or priority population

• Scant research on promising practices and approaches• Insufficient data collection• In many cases, immigrant families may be fearful of

engaging with services, particularly in today’s policy climate

• Many programs lack training in cultural/linguistic sensitivity and/or lack home language capacity• Parenting is inextricably tied to culture

© 2018 Migration Policy Institute

Home Visiting for Immigrant & Refugee Families:Factors for Success

• Employing a diverse, culturally and linguistically competent workforce reflective of the community being served.

• Partnering with trusted and knowledgeable cultural brokers in the community.

• Using flexible models and approaches that empower parents (avoiding cultural normativeness).

• Taking a relationship-based approach and applying trauma-informed principles.

• Connecting immigrant families to a wide range of local supports and reducing “systems navigation” needs.

• Identifying and tracking outcomes for specific communities.

• Promoting home language support.

Leveraging the Potential of Home Visiting Programs to Support Children of Immigrants and Dual-Language Learners: Identifying and Addressing Gaps in Participation

National Home Visiting SummitFriday, February 01, 2019

Since 1965, PCHP has been providing under-resourced families the necessary skills and tools to help their children thrive in school and life.

13

Our rigorously trained and supervised community-based early learning specialists provide

1-on-1 modeling of reading and play activities with parent and child together

Our early literacy specialists are hired from within the community, making them uniquely suited to understand the culture and language of the diverse families they serve.

71% of WA PCHP staff speak two or more languages

Design

• 2 program cycles• Families receive 92

visits, 46 books and toys

• Connections to diverse community and educational resources.

Diverse Curriculum

PCHP in Washington State

State Population• 7.5 million people• 14% are foreign born• 19% language other than

English spoken• 69 % are White

King County• Most populated county in

the state with 2.2 million people

• 22% are foreign born• 26.7% language other than

English spoken at home• 60% are White

Yakima County• 18% are foreign born• 40% language other than

English spoken at home• 43% are White

Yakima County – 45King County - 1287

Cannot Speak English

Percent Relation to Child

None 11.7 Custodial Parent

None 9 Other Adults

Some 30.3 Custodial Parent

Some 24 Other Adults

Yes 58 Custodial Parent

Yes 67 Other Adults

Art by Norma Maldonado, Site Coordinator @ Children's Home Society of Washington

PCHP

families

speak over

50

languages

and dialects

King County Growth

• 8 agencies• Large CBOs

connected to community

• 17 agencies• 6/8 agencies

expanded• 9 new small CBO's

Diverse OrganizationsAgency Focus Population (in contract) Area within CountyAtlantic Street Center African American Families, Renton School DistrictChildren’s Home Society of Washington Open Seattle/South King

Chinese Information & Service Center +Chinese, Vietnamese & East Indian Families

Seattle, East/South King

Congolese Integration Network Congolese Immigrants/Refugees All of KingDenise Louie * Latino, and either African

American, African Immigrant, or Asian

North Seattle

El Centro + Latino Seattle/South KingEncompass + Open Greater Snoqualmie ValleyHorn of Africa * East African Families Seattle/South KingInterCultural Children and Family Services *

African American Families, Native American/Alaskan Native Families

Seattle/South King

Iraqi Community Center * Arabic Speaking Families Kent

Kindering OpenBellevue Families in Stevenson & Lake Hills Elementary neighborhoods

Neighborhood House Immigrant & Refugee Families SeattleSEYFS * African American, African

Immigrant & Southeast AsianSeattle, South King

Southwest Youth & Family Services +Open, Amharic & Oromo speaking Families at Windsor Heights Apts

Seattle & Families at Windsor Heights Apts(South King)

Voices of Tomorrow * East African Families Seattle/South KingWest African Community Council * West African Families Seattle/South King

YWCA+Homeless & African American Families

Seattle/ South King, African American Families

West Valley School District OpenFamilies in the West Valley School District (Yakima)

Outcomes

Key Findings In WA

PCHP is narrowing the preparation gap by increasing children’s kindergarten readiness, English language proficiency, and academic performance.

Increased Kindergarten

Readiness

Increased Kindergarten

English Language

Proficiency

Increased Grade 3 Academic

Performance

These results add to a growing

body of evidence showing the

effectiveness of PCHP

Pamela S. Williams, MSPCHP Washington State Program DirectorThrive Washington

pwilliams@parent-child.orgpam@thrivewa.org

484-843-1674

Supporting Immigrant and Refugee Mental Health through Home Visiting

Aimee Hilado, Ph.D., LCSW ~ ZTT Fellow, NEIU, RefugeeOne

Presentation Agenda

• Overview – Understanding global/local immigration trends and needs in the community.

• Defining mental health – The universal themes of immigration trauma among refugee and immigrant populations.

• Home visiting as intervention: NREPP Promising Practices – The Baby TALK Home Visiting Protocol as a relational, culturally sensitive intervention.

• Impact: Findings from RCT studying the intervention

• Final remarks with Q & A session

“The paradox of trauma is that it has both the power to destroy and the power

to transform and resurrect” ~ Peter Levine

The images…

Poor mental health in very young children: What does it look like? (Resource: NCTSN)

Birth 0-2 years Age 3-6 years• Cognitive: Poor verbal skills, memory problems

• Behavioral: Excessive temper*, attention-seeking (+/- behaviors)*, regressive/aggressive behaviors*, cries excessively, easily startled*, separation anxiety*, irritability*, sadness*, withdrawn*

•Physiological: poor appetite, low weight, poor sleep*, sleep difficulties*

• Cognitive: Difficulty learning, poor skill development

•Behavioral: Acts out, imitates traumatic events, verbally abusive, unable to trust and make friends, believes they are to blame, anxious, fearful, avoidant, lack self-confidence

•Physiological: Experiences stomachaches/headaches, regressive traits including bed-wetting

Infant-early childhood mental health (I-ECMH) refers to how a child develops socially and emotionally from birth to three

The intergenerational model of trauma

Trauma has the ability to freeze the relationship between parent and child.

Parent availability is compromised.

Leads to additional stress that disrupts the architecture of the brain in a young child.

Supporting refugee and immigrant mental health: What do we know?

• Immigration trauma can have a cumulative effect on mental health.

• Unaddressed I-ECMH and adult needs influences adjustment and overall health outcomes for all family members. Family-centered approaches are valuable.

• New arrivals are less likely to seek formal mental health services due to the priority of other needs, misinformation about mental health, Western treatment models being inappropriate, and the lack of knowledge of general resources available.

• The current sociopolitical climate increases reluctance to seek services and engage with unfamiliar programs/professionals.

Supporting refugee and immigrant mental health: Why home visiting could be an answer?

First, the delivery mechanism – services in the home – matters.

• Removes the barriers of families having to find services, navigate transportation needs, and families are generally more comfortable.

• We see the true needs of a family when we are in their home.

• Reduces fears of families encountering ICE or other federal agents who may threaten their sense of safety.

• Provides an opportunity to identify needs and refer for additional clinical & non-clinical services.

Second, the nature of engagement builds a relationship within which promotes positive home visiting and mental health outcomes.

The RefugeeOne Wellness Program:Our home visiting goals

• The RefugeeOne Wellness program is the first mental health program in the state to have received a ISBE home visiting grant to deliver home visiting services using the Baby TALK Model.

• We have four clinicians, five refugee home visitors, psychiatrist, and a team of interpreters who provide services.

The Baby TALK Model: Relational approaches to engaging trauma-

experienced, culturally-diverse families

Quick Facts about the Baby TALK Model:• Since 1986 the Baby TALK Model has trained professionals in 32 states

across the country and in Canada.

• Over 1,400 professionals trained through Baby TALK’s National Learning Institute.

• In Illinois, more than 100 publicly-funded programs use Baby TALK as their model for working with families.

• As of FY17, 6,781 of 13,330 children (51%) served by state funded (ISBE) Prevention Initiative program were served using the Baby TALK Model in Illinois.

General Model Components

1. Building a staff of trained Baby TALK professionals to provide relationship-based, trauma-informed universal screening;

2. Strategic placement of Baby TALK staff throughout the community;

3. Creating a “trustworthy system of care” for participants; and

4. Providing extensive early childhood family support services through personal encounters employing Baby TALK “critical concepts” and using Baby TALK protocols and curriculum.

– Component 4 includes the BT Home Visiting Protocol used at RefugeeOne which guides home visits

Home visiting goals include….

• Using a developmental parenting approach; focusing on the parent-child dyad

• Supporting parent mastery through:– Facilitating parent-child interactions– Observation, Narrating behavior– Listening and engaging to understand the meaning the parent is making

• Sharing information and reflecting• Further supporting parent confidence and competence through

meaningful goal-setting in support of the parent/family, the child’s development, and the parent/child relationship

• Ongoing case management to support overall family wellbeingAn attuned relationships is the vehicle for

achieving these goals!

Trauma-informed home visiting as a pathway to supporting mental health and child outcomes

• In addition to the Baby TALK Model curriculum, all home visitors were trained on topics related to:

– mental health terminology, – trauma-informed practice, and – how to look for common mental health symptoms that warrant

referrals.

Home Visiting is NOT therapy but…

Home visiting is culturally-sensitive approach to engagingfamilies and supporting them in a therapeutic way.

The goals of home visiting can be realized in addition to supporting adjustment to life in a new country.

Trauma-informed home visiting creates a pathway to talking about mental health and getting families to appropriate clinical services more effectively.

• We saw greater success in identification of need and engagement from participants who came through the home visiting program.

• Some families didn’t want services but said they felt better knowing they had a consistent source of support in their home visitor.

Refugee Home Visitor: Manar Matti, BA

Refugee from Iraq• Arrived in the U.S. in April 2008.

• Displaced 2 years in Syria prior to resettlement in Chicago.

• Fluent in Arabic, Assyrian and English.

• Interests in social-emotional development and learning.

• Home visitor for Iraqi and Syrian refugees.

Home Visitor: Ashley Ruiz, MSW

First generation immigrant from Mexico • Fluent in Spanish and English.

• Interests in social-emotional learning and impact of fear around separation/deportation.

• Home visitor for refugees from Ecuador and Columbia, parolees from Cuba, and undocumented immigrants from Mexico.

Home Visitor & Play Therapist: Allegra Magrisso, LCSW

Licensed mental health professional specializing in play therapy and sand tray therapy. • Serves all families with the use of interpreters.

• Facilitates in-home therapy in addition to home visits when necessary.

• Interests in play-based, narrative interventions and culturally-appropriate practice with refugees.

A glimpse into the work of our home visitors and their experiences

The Baby TALK – RefugeeOne Study: A randomized controlled trial examining home visiting services with refugees and immigrants

Principle Investigators: Aimee Hilado, Ph.D., LCSW and Christine Leow, Ph.D.

RCT Participants

Baseline Outcome Measures

RCT Findings: Among refugee and immigrants, the Baby TALK Home Visiting Protocol…

• …has a statistically significant impact on social-emotional development (p=0.00) and language development (p=0.02).

• …has an impact on parental stress and trauma symptoms (maternal health).

• …has an impact on access to linkages and referrals.

• …has an impact on economic self-sufficiency.

• Preliminary evidence shows the protocol has an impact on positive parenting practices.

“Tell me about your baby:”Understanding the experiences of immigrant and refugee families

receiving Baby TALK home visiting services~ Qualitative sub-study ~

General findings: Themes across all participants

• Child development was understood only in terms of physical development/health.

• Participants said the priority in the early years is sheer survival and meeting basic needs (food, shelter, clothing) – “We were just focusing on surviving and whatever we had – we give it to the children to eat…we had no people to go to when we were living in the refugee camps. We had no place to go”

• Needs were only identified when a doctor/professional told them something was needed or the child himself could articulate need.

• Majority of parents did not believe a fetus or young child under age 3 had needs or a developmental agenda. “Maybe I’ll say in Africa, we—there’s a saying that a child is the child that you have in your arms. So, we don’t put much thought about the child before it’s born because don’t know whether or not they’ll die or survive.”

Qualitative Findings:Relationships matter

Lessons Learned

• Understanding immigration trauma is critical to understanding the experiences of refugees and immigrants of undocumented status.

• Home visiting can produce significant effects on developmental outcomes among refugee and immigrant children.

• Frontline providers, including home visitors, can also be effective in supporting mental health among this group.

Resources• Hilado, A., Leow, C., & Yang, Y. (Unpublished, 2018). The Baby

TALK – RefugeeOne Study: A randomized controlled trial examining home visiting services with refugees and immigrants. Report submitted to the U.S. Department of Health and Human Services, Home Visiting Evidence of Effectiveness (HomVEE) Review.

• Hilado, A. (Unpublished, 2018). ‘Tell me about your baby’: Understanding the experiences of immigrant and refugee families receiving Baby TALK home visiting services. Qualitative Study report submitted to Baby TALK, Inc.

• Hilado, A. & Lundy, M. (Eds) (2017). Models for Practice with Immigrants and Refugees: Collaboration, Cultural Awareness and Integrative Theory. Sage Publications. Thousand Oaks, CA.

• United Nations High Commission for Refugees (www.unhcr.org)

• U.S. State Department Website (www.state.gov)

• Refugee Processing Centers Admissions Data http://www.wrapsnet.org/admissions-and-arrivals/

Contacts

Aimee Hilado, Ph.D., LCSW, ZERO TO THREE FellowAssistant Professor, Northeastern Illinois UniversityFounding Manager, RefugeeOneEmail: ahvilla3@neiu.edu

Implications for supporting immigrants and refugeesPractice & Research

Practice• Collect and track data (at practice and policy levels) to enable targeting of

immigrant and refugee communities as well as program improvement for this group.• Consider alternate pathway for clinical and non-clinical providers to support the

mental wellbeing of infants and toddlers.• Increase home visiting programs within immigrant/refugee-serving agencies (and

provide appropriate training). • Promote home language support and train staff on importance of home language

development.

Research• Continue research specific to this group, bringing refugees and immigrants to aid in

the design. • Expand study of immigrant subgroups (e.g. African, Asian, Hispanic) to achieve a

better understanding of varying needs and successful approaches within the immigrant and DLL population.

Implications for supporting immigrants and refugeesPolicy & Advocacy

Policy/Advocacy• Provide flexibility for program models and smaller CBOs skilled in working with

immigrant and refugee communities to access home visiting funds.• Include indicators such as LEP status or home language in state needs assessments

to promote equitable access and report on outcomes for subgroups.• Increase knowledge on the value of home visiting in support of mental health

outcomes in addition to other documented outcomes.• Advocate that such prevention services be covered as a health service. • Improve linguistic and cultural competency and diversity of mental health service

providers.