A psychiatrist-legislator's little-noticed provision in one of the 1,000-plus-page health care reform bills in Congress would create the first federally funded program for home visits to expectant mothers and families with children under age 6. However, the program has drawn criticism from some" family rights" groups over concerns about its efficacy and appropriateness.

The legislation to establish a regular funding stream for such a voluntary program was sponsored by Rep. Jim McDermott (D-Wash.), a child psychiatrist. He and other supporters said that existing nonfederal home-visitation programs have provided critical supports to families in need.

"Home-visitation programs have a proven track record of increasing the chances that a child will have a safer, healthier, and more productive life," said McDermott in a written statement in July. Home-visitation programs generally entail various types of health care workers—including nurses and mental health counselors—surveying the homes of families over many months or years and offering parenting advice.

Home-visitation programs, which have existed in various forms for several decades, have long received funding from state and local governments and private entities. The programs have functioned with a variety of purposes, but they are frequently touted as a way to prevent parental child abuse and neglect.

That laudable goal has led more than 40 state governments to fund various types of voluntary home-visitation programs that serve up to 500,000 children and their parents every year, according to research estimates. McDermott said, however, that those served are only 15 percent of the population that needs such assistance.

McDermott sponsored a bill (HR 2667) to fund home visitation earlier this year, but it never advanced. Similar legislation sponsored by Sen. Robert Menendez (D-N.J.) also stalled. However, much of the language from the McDermott legislation was rolled into the massive health care reform bill (HR 3200) approved in July by three House of Representatives committees.

The push for the federal funding through the health reform bill—$750 million in the first five years—stems from the contention by visitation advocates that a massive boost is needed to reach millions of children at risk for abuse.

President Obama's proposed budget also requests $8.6 billion for such programs, but congressional Democrats dropped the program from their budget bills.

Critics of the home-visitation program said they support the goal of reduced child abuse but worry that the "voluntary" provisions are poorly defined and thus could easily morph into a mandatory program for many parents, including those who home-school their children.

"Once the federal government gives the money to the states, there is no oversight or even mandate that states make sure the programs are voluntary," maintained Will Estrada, director of federal relations for the Home School Legal Defense Association. He and other critics note that although the current legislation describes the programs as voluntary, the language does not specify whether they remain voluntary if a parent changes his or her mind after agreeing to participate.

"If families want to choose these programs, that's great. But if you have to let a government official in to teach you how to raise your children and to monitor that your children are developing, then you could easily lose control of your children and have them taken away," Estrada said.

The nonspecific language leaves ample room for "mission creep" of home-visitation programs to require participation of large swaths of the public eventually, said Stephen Krason, Ph.D., president of the Society of Catholic Social Scientists.

"It's valid to be concerned that something that appears to be voluntary can evolve to be mandatory," Krason said.

McDermott's office did not respond to requests for comment from Psychiatric News about the potential for abuse in the program.

Supporters of home visitation maintain the programs effectively address a growing problem.

"The increase of child abuse and neglect cases ... is a sobering sign that our efforts to date are insufficient," said Joan Sharp, executive director of the Council for Children and Families, at a congressional hearing in June on federal support for home-visitation programs.

However, research on home-visitation programs generally has found that the programs do not achieve the highly touted goal of preventing child abuse or neglect, according to researchers who have reviewed the studies on home visitation.

"Of those programs that look at child abuse and neglect directly (i.e., substantiated cases), only a few have reduced child abuse and neglect," said Jeanne Brooks-Gunn, Ph.D., at the congressional hearing. She is a professor of child development at the Teachers College and College of Physicians and Surgeons at Columbia University who supports home visitation.

Others are supportive of the goals of the program, even as they question the premise that efforts are needed to prevent a nationwide wave of parental child abuse.

Richard Wexler, executive director of National Coalition for Child Protection Reform, highlighted the findings of home-visitation researchers that child maltreatment is relatively rare in the general population, which runs counter to suggestions of an abuse epidemic.

"That's worth remembering amid the hype about an 'epidemic of child abuse' and all the damage that hype can do to children, as well as helping to explain why any reduction in maltreatment caused by home visiting will be hard to detect," Wexler said.

Information on the visitation bills can be accessed at<http://Thomas.loc.gov> by searching on the bill numbers, HR 2667 and S 1267>. ▪