Learning from experience: the impact of research about family support programs on public policy.

• Author: Minow, Martha
• Position: David L. Bazelon Conference in Science, Technology, and Law

Do public policies reflect the experiences of people who implement them or those who are supposed to benefit from them? This kind of question may seem remote from the work of an appellate judge, and yet Judge David Bazelon's abiding interest in the links and gaps between social science and law grew from concern with this basic question. I will focus on a particular social welfare program as I explore the failure of public policy to respond to social science findings. For those who did not know Judge Bazelon, however, here is a fuller explanation of why I chose this topic for this symposium honoring the Judge.

One day while I was clerking for Judge Bazelon, a classmate clerking at another court conjectured that the appellate world of the D.C. Circuit was narrow, given its focus on the records of administrative actions and its cloistered setting. I found myself replying that the world of Judge Bazelon was the opposite of narrow. I regaled my friend with the list of journalists, scientists, social scientists, and authors who had come either to chambers or to lunch with the Judge and his clerks to discuss topics ranging from the psychological dimensions of risk assessment to international responses to American television. Indeed, it was a heady world. Judge Bazelon drew a variety of intriguing people into his orbit and engaged them immediately in the opposite of small talk.

We would sit at the round table in the Judge's office, munching on cookies and pretzels, while the Judge pressed a visitor for answers about the origins of crime, relationships between reason and emotion, or the political dimensions of ostensibly scientific evidence. In these sessions, Judge Bazelon manifested his enduring ambivalence about experts. On the one hand, he looked to them for advice, insight, and answers; on the other hand, he brought a skepticism to the table that escalated with any expert's use of jargon or claim that the public could not understand. It is this ambivalence toward or dual approach to social science expertise that I will explore in this essay by asking: "What does social science offer policy-making - and vice versa?'

One additional theme from Judge Bazelon's work influences my choice of topics. Judge Bazelon persistently looked for the root causes behind a visible problem, whether the problem was the criminal offense of an impoverished defendant or the recalcitrance of a public bureaucracy. Opportunities for children lay close to his heart as he probed for causes and solutions. How could society alter the disadvantages of poverty, social isolation, or violence so that every child would have a fair chance? In the absence of that fair chance, Judge Bazelon believed that the criminal justice system must acknowledge the actual contexts of defendants' lives. More fundamentally, Judge Bazelon believed that the courts could never rectify the deep injustices in a society that assigns different opportunities to different kinds of children. In search of policies to rectify injustices of this nature, my tribute to the Judge addresses early childhood programs. As I turn now to home visiting social support programs, I hope to carry on Judge Bazelon's commitment to contextual Justice along with his ambivalence about social science.

1. Home Visiting: Social Science Evidence

and Public Policies

Can deliberate efforts to help disadvantaged children work? Debates over this question engage large issues about evaluation methods or, more basically, the nature of knowledge about a messy world. How would we define what it would mean for a program to work? How can we disentangle factors in people's lives that predate the social intervention and coexist along with it? Before getting lost in these issues, let's look at a social intervention that seems to work.

In my conversations with social service providers, policy analysts, and physicians about the needs of families, the phrase "home visiting" recurs. Encompassing a potentially broad spectrum of possibilities, home visiting typically refers to programs that equip individual "visitors" with information about pregnancy, infant needs, child development, nutrition, and parenting tasks, and help them to develop relationships with pregnant women or new parents through regular visits in the home.(1) Some of the programs tie directly to health care centers; others have referral arrangements with health and human services programs.(2) Some programs use professionals as visitors, others use lay people typically drawn from the community itself.(3) The benefits of these programs to infants and to parents can include support and friendship during stressful periods(4) and, perhaps more impressively, enhanced health and development for children and greater self-worth, self-reliance, and career development for their parents.(5)

Especially intriguing to me is the intensity of high-quality evaluations of home visiting programs. Dr. David Olds and his colleagues, for example, have conducted family support programs with teenage mothers who face real risks of poverty, poor health for themselves and their children, and child abuse and neglect.(6) Dr. Olds combined these programs with sophisticated research designs, including random assignment, and numbers large enough to achieve statistical significance. His results thus meet the demands for rigor devised by social scientists themselves.(7) His studies have compared the use of a home health visitor who met with young women from pregnancy until the child reached age two with interventions providing free transportation to health clinics for prenatal and well-baby care and diagnostic testing of the infants.

These studies concluded that the women who were visited by a nurse during pregnancy participated more frequently in childbirth classes, showed greater improvements in their diets, and were more likely to find a supporting person to accompany them during labor.(8) Those who received visits after the child's birth had fewer emergency room visits with their infants, and their children had fewer accidents and ingestions of dangerous substances than did those of the mothers who had no such visits.(9) Dramatic reductions in state-verified child abuse cases were also associated with home visits.(10) Home visits also reduced subsequent pregnancies and the costs associated with them, notably varied forms of public assistance.(11) Another study of similar home visiting programs for mothers who are depressed yielded this interesting result: while the mothers' depression did not change, their children showed enhanced cognitive and emotional development, compared with children of other depressed mothers who did not receive such visits.(12)

These are only a few among dozens of studies. The U.S. General Accounting Office has issued two recent reports examining home visiting.(13) The Packard Foundation's journal, The Future of Children, devotes an entire recent issue to home visiting and includes careful evaluations of the existing knowledge base by cautious social scientists. The summary of these evaluations frames its conclusions with caveats about the lack of high-quality studies comparing various intervention models and the absence of sufficient replications to permit generalized findings about different populations - a gap prompting the summary to call for more studies.(14) Nonetheless, the summary concludes that "[e]vidence for the effectiveness of home visiting programs is as good or better than the evidence for the effectiveness of many other programs that exist to serve children and families."(15) The summary recommends extension of services like home visiting to every community, because of the positive results emerging from programs that send visitors trained to provide information about health and parenting to the homes of pregnant women and families with pre-school children.(16) The summary concludes that home visiting programs lead to improvements in some children's physical health, cognitive ability, and motor development, and to better parent-child interactions and reduced use of emergency hospital services.(17) All of these results are consistent with a conclusion of lowered child abuse or neglect.

The federal government has registered some level of interest in home visiting: several existing programs, including Head Start, authorize home visits,(18) and several pending pieces of legislation would also support them. National commissions and advisory boards endorse home visiting.(19) Two states have adopted state-wide home visiting programs.(20) Foundations have funded both research and demonstration projects involving home visits. Other private groups currently treat home visiting as a topic worth advocating in the public sphere.(21) Yet I think it is still fair to say that home visiting is far from a household phrase, much less a prevalent practice in the United States, despite demonstrations by social science studies of its apparent effectiveness.

If there is as good or better evidence of the effectiveness of home visiting as there is of existing services, why don't more communities adopt such programs? The evidence supports three kinds of reasons for this failure. First, social scientists and policy makers inhabit different and apparently disconnected worlds in terms of approaches to knowledge. Second, home visiting programs fall prey to predictable policy cycles, dismantling social innovations in the absence of broad constituencies to support the programs. Third, cultural and historical experiences lead many to perceive home visiting as intrusive, insensitive, controlling, and bureaucratic - even though these perceptions remain largely absent from social science evaluations of the programs. I explore these three reasons in turn in the hope that this discussion will trigger a broader investigation into the relationship between social science and policy.

1. Two Worlds

   Why does social scientific evidence of effective programs fail to produce...