The 19-year-old in
your office hands her newborn to a companion and
looks at you with confusion and startling honesty.
“I just don’t think she likes me. I don’t feel
like she is my baby.” The father of her child
is uninvolved, and both mother and child
are in a faith-based group home. You are
relieved to find out that the companion is
a home visiting social worker trained in
trauma-focused cognitive behavioral therapy, alerted to the high-risk situation by a
community health worker assigned to the
For over 150 years, public health
nurses, social workers and community
advocates have visited homes of marginalized families, particularly mothers
and children, to relieve suffering related
to poverty and social isolation, to make
living environments healthier and to prepare children for a more successful life.
Inspired by social justice movements of
late-19th century Britain, home visitors before the
Great Depression of the 1930s reached into immigrant
and poor communities to aid acculturalization, to improve family hygiene practices, and to support maternal and child health during the critical first years of life.
This tradition of compassionate work with families
in their natural environments continues in the 21st
century supported by both federal and state funding,
and backed by mounting evidence of effectiveness. Rigorous national program evaluation has confirmed that
public health programs utilizing home visitors can enrich family relational health, promote school readiness,
improve perinatal outcomes, enhance environmental
safety and increase family self-sufficiency.
In the AAP policy statement Early Childhood
Home Visiting, available at https://doi.org/10.1542/
peds.2017-2150, the Academy recommends continued and expanded federal and state support for home
The policy, which is published in the September issue of Pediatrics, is from the Council on Community
Pediatrics, the Council on Early Childhood and the
Committee on Child Abuse and Neglect.
Supportive, effective networks
Integration of home visiting into the pediatric family-centered medical home can be a powerful way to
extend team-based care into the medical neighborhood. Pediatricians do not need to stand alone when
faced with high-risk and complex problems, even when
the complexity includes medical, relational and social
Home visitors can link families to community sup-
port services, assess the home environment for hazards,
encourage positive parenting, provide early childhood
developmental stimulation and support adherence to
comprehensive care plans. When integrated with a
multidisciplinary team, a home visitor can coordinate
with the medical home to reinforce advice given in the
office and facilitate communication between the fam-
ily and the primary care provider. Home visiting may
be most valuable when connected to a system of care
for early childhood that has a family-centered medical
home as its coordinating hub.
By establishing the Maternal, Infant, and Ear-
ly Childhood Home Visiting Program (known as
MIECHV), the Affordable Care Act of 2010 not only
funded state home visiting programs for at-risk popula-
tions but also established a national evaluation program
to help states choose and sustain services with mea-
surable benefit and cost-effectiveness. At present, 19
models meet criteria for federal support, including the
Nurse Family Partnership, Healthy Families America
and Parents as Teachers.
All 19 have evidence of effectiveness in at least one
or more outcome domains such as maternal and child
health, school readiness, positive parenting practices
and family economic self-sufficiency. By linking young
mothers and fathers to services such as occupational
training and educational opportunities,
home visitors may increase the possibility
for both the parents and children to es-
cape the generational transfer of poverty.
Because of the trusting relationships
established between families and home
visitors, as illustrated in the vignette,
high-quality home visiting can reduce
social isolation, improve relational health
and potentially buffer the effects of early
childhood adversity. The policy recognizes the many potential benefits to children
and families provided by home visitors,
supports continued federal funding for
evidence-based models and encourages
integration of home visiting into a comprehensive, coordinated system of pediatric care in the medical neighborhood.
Recommendations for pediatricians
• Provide community-based leadership to promote home-visiting
services to at-risk young mothers,
children and families.
• Be familiar with state and local programs to
identify and refer eligible children and pregnant
• Consider ways to integrate or co-locate home visitors in the family-centered medical home.
• Recognize home-visiting programs as an evidence-based method to enhance school readiness
and reduce child maltreatment.
• Recognize these programs as a strategy to buffer the
effects of stress related to the social determinants
of health, including poverty.
Dr. Duffee, a lead author of the policy,
is vice chair of the AAP Council on Community Pediatrics Executive Committee.
Home visiting programs draw on a rich history of care and improved outcomes.
The new AAP policy Early Childhood Home Visiting supports continued federal
funding for evidence-based models and encourages integration of home visiting
into a coordinated system of pediatric care in the “medical neighborhood.”
Home visiting programs expand medical home into communities
by James H. Duffee, M.D., M.P.H., FAAP
No longer recommending “
arbitrary age limits on pediatric health
care,” an updated AAP policy statement leaves the decision to individual patients and pediatricians.
Age Limit of Pediatrics, https://doi.org/10.1542/
peds.2017-2151, has evolved since the Academy’s
first version was published in 1938. At that time, the
statement considered an upper patient age limit to
be the patient’s 16th or 18th year of life. Gradually,
the policy was expanded to include patients before
birth and up to age 21 with exceptions for older
children with special health care needs and other
The latest version leaves the decision to individual
patients and pediatricians or pediatric, medical or
surgical subspecialists in consideration of the pa-
tient’s physical and psychosocial needs. Among the
considerations is growing evidence that brain devel-
opment does not reach adult levels of functioning
until well into the third decade of life. Financial and
developmental reasons also are noted, and the policy
acknowledges the growing number of children with
special health care needs surviving into adulthood
whose only access to specialized services is through
The policy advises discussing the transition to an
adult care provider well before transition is necessary. It calls for an extension of guidelines such as
Bright Futures to cover recommended services for
those in their 20s. Likewise, health care insurers and
other payers are advised to avoid placing limits that
affect the patient’s choice of care solely based on age.
Policy does away with age limits in pediatric care