Native families get a head start with home visits


In the new trailer on Rotten Tree Road at Taos Pueblo, the floor underneath the long kitchen table is still unscuffed. New couches frame the living room. What would be the dining room is filled — like a lot of actual dining rooms — with kids’ toys.

This is the new space of Tiwa Babies, a home visiting program at Taos Pueblo that helps young families get off on the right foot.

Tiwa Babies is part of a larger movement of community-based, Native-led family preparedness efforts that use Family Spirit, a model of home visiting developed by the Johns Hopkins University in partnership with Southwest tribal communities. Today Family Spirit forms the basis for 79 home visiting programs in North America, and its proven, evidence-based approach is even being expanded beyond indigenous communities.

Local level

For most young families involved with Tiwa Babies, home visiting is a house call.

The team behind the program — April Winters, Jody Coffman and Jacqueline Martinez — visit with first-time parents monthly to talk through the challenges of raising a child. The Family Spirit curriculum tracks developmental milestones like teething and walking. And the home visitors offer gentle suggestions for participating in traditional Native customs.

Family Spirit is designed by and for Native people, and put into practice by community members themselves.

Researchers at the Baltimore-based Johns Hopkins Bloomberg School of Public Health developed the model during the course of a long partnership with Navajo and Apache communities, starting in the early 1990s. At first, the program was mostly intended to curb substance abuse and focused on breastfeeding.

Like a lot of adobe houses, more was added over time “as new needs arose,” said Alison Barlow, one of the original developers of Family Spirit and a behavioral health director with Johns Hopkins for more than 25 years. Today, the program teaches parents the basics of infant health care, child development and life skills. It also delves into topics that aren’t as easy to talk about, and that reach far beyond parenting an infant — family planning, sexually transmitted infections and the impacts of substance abuse.

Native culture is woven into the structure and spirit of Family Spirit and the local Tiwa Babies program, said Crystal Kee, training and implementation manager for Family Spirit.

At a basic level, that cultural emphasis manifests in the Family Spirit workbooks, with colorful illustrations of American Indian parents, grandparents and kids drawn by Native artists.

Incorporating Native culture into the program can be as simple as inviting a family to join in ceremonies and celebrations, like San Geronimo Feast Day, or as involved as buying a sewing machine so families without traditional clothes can make their own.

Each family — some with roots in tribes other than Taos Pueblo — decides how much they want traditional practices to be a part of their home visits and their path through early parenthood. Figuring this out takes a lot of maneuvering of the cultural mores of the community.

In Taos, that sort of navigating means grappling with Tiwa, the unwritten language unique to Taos Pueblo.

Even though it is widely known that Tiwa fluency is increasingly in jeopardy as time goes on, Winters said, some families still feel a sense of judgment and guilt about not speaking the language.

Tiwa Babies helps parents who are less than fluent introduce Tiwa language, songs, movement and dance when their child is around seven months old, the age at which the brain is primed for sensory development. Partners at Taos Pueblo Head Start have translated nursery rhymes into Tiwa. Winters and Coffman also help parents teach colors, numbers and directions — easy ways of folding Taos Pueblo’s traditions into parenthood.

Not every family latches on to the cultural practices, Winters said.

Some already have a tight-knit family and don’t need the support. Others back away from traditional practices because they’re colored with bad experiences and longstanding trauma — especially around drug and alcohol use.

“Alcohol is a predominant issue, not just for Taos Pueblo, but for Native communities in general,” Winters said. “And it’s a really difficult subject only because if a child grows up in an environment with drinking, that’s the norm. They don’t necessarily see the other side of it.”

Family Spirit departs in some important ways from other home visiting initiatives, which tend to rely on nurses and degree-holding professionals to do the day-to-day work. Such health workers, however, are often in short supply around Native communities, and the lack of staff can compromise the viability of those programs.

Instead, Family Spirit relies on the expertise of community members.

“Family Spirit is really shaped by those doing it at the local level,” said Kee.

“It really is an honor to be invited into someone’s home,” said Winters. “It’s an honor when they divulge very personal things they’re going through. We have built that trust.”

Case for school readiness

Family Spirit has spread quickly, thanks in large part to its proven track record of success. Over the program’s 20 years, multiple studies have shown that it improves knowledge and skill for parents, and has positive impacts on social, emotional and behavioral development in children.

The most recent trial – a three-year study published in 2015 by the Johns Hopkins Center for American Indian Health – showed that mothers who went through Family Spirit had lower rates of depression and substance abuse. Kids were less disruptive, got into fewer fights and felt less anxious. Thanks to this substantial body of data, Family Spirit is now listed on the National Registry of Evidenced-based Programs and Practices and is considered one of the best-proven home visiting interventions in the country.

Preparing young children for school, known as “school readiness,” is not the primary objective behind Family Spirit, but it’s a significant part of fostering healthy families.

Intervening during early childhood is especially important for Native children, who are often underserved compared to white peers. A 2008 study from the Harvard Graduate School of Education found that 15 percent of American Indian and Alaskan Native students in third grade received special education — a higher rate than any other racial group. They also found that the strongest predictor of requiring special education was academic readiness when entering kindergarten. Those findings point to the toll of the achievement gap, a phenomenon in which small differences early in education grow into dramatic disparities later in life.

Of course, school readiness cannot be measured in newborns. But preparing children within the first several years of life is still critical, said Johns Hopkins’ Alison Barlow.

“We do know that more often than not kids who have not developed the behavioral repertoire to keep on track won’t be ready for school. What that ends up looking like in the classroom is that kids can’t stay seated, they can’t pay attention to lessons or are easily provoked and get in conflicts. Or they’re shy and withdrawn. In later childhood, it’d look more like delinquency and even suicidal thoughts,” said Barlow.

Family Spirit does what it can within the confines of its federal guidelines and funding to promote early literacy and a sense of educational curiosity.

During every home visit each month, Tiwa Babies gives each family a book, most of which show American Indians as central characters. Winters and the team also make sure to reinforce the importance of reading to kids every day.

Tiwa Babies also helps families incorporate other academic skills like math into everyday work and play by doing things like counting rocks when fishing by the rio, or counting apples during trips to the grocery store. They aren’t grand interventions, but for busy parents who struggle to find the time, they’re doable.

“A parent is a kid’s first and most important teacher,” said Coffman. “Home should be a learning environment and it starts in the womb.”

Growing pains

As effective as Family Spirit has been across the U.S., the model has its challenges.

For one, the distinctions between home visiting and other types of social services aren’t always clear to families in the throws of parenthood and other sorts of hardships.

“We struggled when we saw families who just needed social support, like food stamps or housing. You can’t introduce solid foods when abuse or housing issues are going on. And we’re not allowed to do a lot of case management, which is a big part of it. At first we didn’t know where to send families,” said Coffman.

So Tiwa Babies partnered with a non-Native group, Youth Heartline in Taos, to hire a family navigator to help the families whose needs fall outside the typical boundaries of what Family Spirit can offer.

Training for home visitors has proven to be another shortcoming. The leaders behind Family Spirit know there’s only so much phone calls and webinars can do against the nuanced and deep-seated issues that families face. “Nothing takes the place of training in person and on the ground,” said Barlow.

Training became especially relevant when the Affordable Care Act made money available for tribal communities to pursue home visiting programs. According to Family Spirit, the model took off in a big way almost overnight. Before 2012, Family Spirit was only used in five or six communities. Since then, it’s grown to 79 — from the Dakotas to Oklahoma and all along the Pacific Coast.

“After the last trial was finished, we felt we needed to share Family Spirit with other tribes who’ve requested it over the years. We made that a focus of our work,” said Barlow. It’s also expanding beyond indigenous communities: Family Spirit’s approach to “mindful parenting” is now being used with African American and Latino families in Chicago and other locales in the Midwest.

Tiwa Babies got its start five years ago with an initial pool of funding from the Affordable Care Act and was recently renewed for a five-year extension.

Now, Tiwa Babies is gearing up to expand the program, starting with their new headquarters on Rotten Tree Road — a place the families they serve can call home.