Outreach and home visiting are important

Because families who would benefit most from parent management training also tend to those least likely to attend training sessions, home visiting has been an important component of several well-evaluated prevention schemes, (25,26) particularly the Rochester nurse home visitation programme for socially disadvantaged pregnant teenagers, the Perry preschool project, and the programme for health visitors developed by Davis and Spurr(27) which shows tangible mental health gains for children. However, this cannot be a sanction for all home visiting schemes. Two of those widely employed in the United Kingdom to promote child development have either not been subjected to rigorous evaluation (Bristol Child Development Programme) or else have been found wanting. (28> The use of non-professional befrienders for mothers and young children (Homestart and Newpin in the United Kingdom) is quite widespread but evaluation has yielded mixed results, generally positive but not definitive. Exceptions are the Community Mothers Programme in Ireland and Pippin in the United Kingdom; each showed superior outcomes in a controlled trial, though the measures did not include hard information about child mental health. A major problem with such programmes has been high drop-out rates.

It is often argued that the earlier and more comprehensive the intervention, the greater and more persistent will be the subsequent impact. This concept is being explored in two large intensive prevention examples which take an ecological approach: the Better Beginnings, Better Futures Project in 11 impoverished communities in Ontario(29> and the Fast Track Program implemented across four areas in the United States.(39 These projects each combine a range of seven interventions including parent management training, home visiting, and educational enrichment. The Canadian project is orientated to the whole community, empowering residents who are parents to set priorities for childcare, home visiting, and so on. Fast Track combines universal and targeted interventions to promote social skills in the children, notably the PATHS curriculum which teaches the recognition of affective cues in themselves and others. These ambitious projects are being evaluated but no results are yet available

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