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Angela M. Tomlin & Stephan A. Viehweg FOREWORD BY KATHERINE ROSENBLUM

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Tackling the Tough Stuff A Home Visitor’s Guide
to Supporting Families at Risk

by Angela M. Tomlin, PhD, HSPP, IMH-E Professor and Co-Chief of the
Division of Developmental Medicine

Indiana University School of Medicine

and ® Stephan A. Viehweg, ACSW, LCSW, IECMH-E, CPC-P Assistant Research Professor and
Associate Director of the Indiana LEND Program

Baltimore·London·Sydney

Excerpted from "Tackling the Tough Stuff: A Home Visitor's Guide to Supporting Families at Risk, Second Edition" by Angela M. Tomlin, Ph.D., HSPP, IMH-E $ ^{\circ} $ and Stephan A. Viehweg, ACSW, LCSW, IECMH-E $ ^{\circ} $ , CPC-P

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Library of Congress Cataloging-in-Publication Data Names: Tomlin, Angela M., author. | Viehweg, Stephan A., author. Title: Tackling the tough stuff: a home visitor's guide to supporting families at risk / by Angela Tomlin, PhD, HSPP, IMH-E, Professor and Co-Chief of the Division of Developmental Medicine, Indiana University School of Medicine, and Stephan Viehweg, ACSW, LCSW, IECMH-E, CPC-P, Assistant Research Professor and Associate Director of the Indiana LEND Program, Indiana University School of Medicine, IN. Description: Second edition. | Baltimore: Brookes, [2025] | Includes bibliographical references and index. Identifiers: LCCN 2024014896 (print) | LCCN 2024014897 (ebook) | ISBN 9781681257877 (paperback) | ISBN 9781681257884 (epub) | ISBN 9781681257891 (pdf) Subjects: LCSH: Home-based family services. | Developmentally disabled children— Services for. | Early childhood education—Parent participation. | Family social work. Classification: LCC HV697.T66 2025 (print) | LCC HV697 (ebook) | DDC 362.82/53— dc23/eng/20240429 LC record available at https://lccn.loc.gov/2024014896 LC ebook record available at https://lccn.loc.gov/2024014897

British Library Cataloguing in Publication data are available from the British Library.

2028 2027 2026 2025 2024

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Excerpted from "Tackling the Tough Stuff: A Home Visitor's Guide to Supporting Families at Risk, Second Edition" by Angela M. Tomlin, Ph.D., HSPP, IMH-E® and Stephan A. Viehweg, ACSW, LCSW, IECMH-E®, CPC-P

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Contents

About the Downloads . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Foreword Katherine Rosenblum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Getting Started . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 1 Connecting and Keeping Connected: Relationships Matter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 2 Looking Inside: Reflective Practice and Relationships for Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 3 PAUSE—A Problem-Solving Framework: Blending Relationship and Reflective Skills . . . . . . . . . . . . . . . Appendix 3A PAUSE Worksheet . . . . . . . . . . . . . . . . . . . . . . . Appendix 3B Provider Reflection Worksheet . . . . . . . . . . . . Chapter 4 What’s Going On in There? Understanding Causes of Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix 4A Exploring Challenging Behaviors—Pulling It Together Worksheet . . . . . . . . . . . . . . Chapter 5 When Caregivers Say... Calm Down! Early Regulation: Sleeping, Eating, and Soothing . . . . . . . . . . Appendix 5A Tips for Calming Your Baby . . . . . . . . . . . . . Chapter 6 Stop That! Biting, Hitting, Throwing, and Meltdowns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix 6A Timely Tips for Tolerating Challenging Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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iv Contents

Chapter 7 Why Won’t You Listen? Cooperating and Following Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Appendix 7A Practice Reframing Commands . . . . . . . . . . 149 Chapter 8 Don’t Be Such a Baby: Fears and Separation Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Chapter 9 What Else Might This Be? Family Challenges . . . . . . . . . . . . 175 Appendix 9A Practice Discussing Difficult Topics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 Chapter 10 You Can’t Do This Alone: Boundaries, Self-Care, and Supervision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207 Appendix 10A Reflection on Work–Life Balance . . . . . . . . 227

Last Reflection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229 Reflective Supervision and Consultation: What Is It, Why Do I Need It, and How Can I Use It Most Effectively? . . . . . . . . . . 231 Form 1: RSC Preparation Worksheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267

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About the Authors

Angela M. Tomlin, Ph.D., HSPP, IMH-E

® , Professor, Co-Chief of the Divi- sion of Developmental Medicine, Indiana University School of Medicine, Indianapolis

Dr. Tomlin is Professor of Clinical Pediatrics and Co-Chief of the Divi- sion of Developmental Medicine at Indiana University School of Medicine (IUSM). She is also Director of the Indiana LEND Program, a nationally recognized interdisciplinary leadership training program supported by the Maternal and Child Health Bureau at IUSM. Her credentials include endorsement as an infant mental health mentor in both clinical and research scopes. She is also a certified perinatal mental health specialist. Dr. Tomlin provides clinical services to very young children and their families, sup- ports the training of interdisciplinary learners within the LEND, advances the knowledge and skill of medical learners rotating in her clinics, and promotes the professional development of the infant and early childhood workforce as a provider of reflective supervision and consultation. She is passionate about supporting and growing a diverse infant and early child- hood workforce through scholarship and mentorship. Dr. Tomlin is the author or co-author of 30 publications on topics that include infant mental health, autism spectrum disorder, and workforce development. Dr. Tomlin has served the university and the infant and early childhood field, and her community by serving on boards, including leadership roles in Infancy Onward, Indiana’s infant mental health association, committees and work- groups of the Alliance for the Advancement of Infant Mental Health, and other state and local groups. She was the 2022 recipient of the Alliance’s Deborah J. Weatherston Award for leadership in infant mental health. With her husband of over 40 years, Dr. Tomlin is the proud parent of two adult daughters and two wonderful grandchildren.

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About the Authors vii

Stephan A. Viehweg, ACSW, LCSW, IECMH-E

® , CPC-P, Assistant Research Professor of Pediatrics, Associate Director of the Indiana LEND Program, Indiana University School of Medicine, Indianapolis

Mr. Viehweg is Assistant Research Professor of Pediatrics and Associate Director of the Indiana LEND Program, a nationally recognized interdisci- plinary leadership training program supported by the Maternal and Child Health Bureau at the Indiana University School of Medicine, Department of Pediatrics, Division of Developmental Medicine. He is also Associate Director of the Center for Translating Research Into Practice at Indiana Uni- versity–Indianapolis. He currently serves as the Centers for Disease Con- trol’s Learn the Signs. Act Early. Ambassador to Indiana. Mr. Viehweg is author or co-author of many publications, book chapters, and webinars on reflective practice, interdisciplinary education and service delivery, early childhood mental health, early detection, translational research, and open access. He is the founding chair of Infancy Onward, Indiana’s infant/tod- dler mental health association, and founding president of Family Voices Indiana (now Indiana Family to Family). He is passionate about children and families and is a fierce advocate for policies and programs that sup- port family-centered, community-engaged best practices. He volunteers on various boards and committees that focus on children and families at the local, state, and national levels. With his wife of over 35 years, he is the proud parent of an adult son and daughter, and Papaw to his amazing grandchildren.

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Foreword

As a university professor and infant mental health mentor, I have spent many years teaching, researching, and advocating for the fields of home visiting and infant and early childhood mental health practice. At the core of this work is a commitment to relationship-based, reflective, and cultur- ally responsive practice, and I have therefore always greatly appreciated the opportunity to share the work of Professors Angela Tomlin and Stephan Viehweg. The original volume of this book, Tackling the Tough Stuff: A Home Visitor’s Guide to Supporting Families at Risk, helped countless numbers of pro- fessionals enter and engage in this critical field. And so it was with great delight that I learned that a second edition of their foundational book was in preparation. As the authors acknowledge from the outset of this volume, home visiting is both an intimate and an intense experience, and while this is most certainly true, this book, and the wisdom it holds, is certain to leave home visitors feeling more prepared, less alone, and more supported in their home visiting practice. The work of the infant mental health home visitor is indeed profound. We are invited into the family’s personal space, and to hear and see them in often very intimate ways as they navigate the incredible challenges of being human and being a parent. We hold the family’s stories, both those we hear and those we see and feel. We keep the baby’s experience at the center, but also the experiences of the parent, as well as the emerging dance that unfolds between parent and child. We often say that our work is two-generational—powerful because it has impact on both caregivers and infants and toddlers in the present. And it doesn’t stop there. Our work touches on multiple generations, including experiences that parents have had that contribute to shaping the present. These experiences span joys and sorrow, hopes and dreams, suffering and grief, as well as current and his- torical experiences of structural oppression, including economic and racial oppression, marginalization, and trauma. The home visitor is called upon to both recognize these challenges and celebrate the strengths and unique beauty of each parent–child relationship.

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Foreword ix

Our work also spans relationships: infant with parent, but also infant and parent with the home visiting provider. With such a broad calling it is therefore not surprising that the challenges and questions we face as home visitors are many: how can we help parents and caregivers and their young children feel seen, heard, and supported as they navigate the myriad chal- lenges that infancy and early childhood hold? How do we help parents respond to challenging child behaviors, hold developmentally appropriate expectations, cope with mental health challenges, and access resources? How do we embrace and celebrate culturally diverse parenting and rela- tional experiences and maintain a commitment to anti-racist, anti-ableist, and culturally humble practices? How do we steward our own responsibil- ity to care for ourselves in this work, sustaining our capacity to see and hear and respond effectively, and to feel efficacious and successful in our work? Remarkably, this book covers all of this, and more, conveying a clear conceptualization of what is tremendously complex in a straightforward manner, offering highly relevant and relatable case vignettes (without dic- tating a one-size-fits-all approach) and specific and tangibly useful tools and strategies for the home visitor. The authors center their work around the foundational early relationships that are at the heart of home visiting and infant mental health practice, and make space for acknowledging the cultural stories that can vary and reflect the beliefs, practices, and values of families and communities. There are so many things that make this book invaluable. It is clear and tangible, easy to access, yet rich and deep in content. Tables throughout pro- vide incredibly useful summaries of content and offer a great reference for providers working with families. The case vignettes are respectful, thought- ful, highly relevant, and illustrate concepts clearly. The authors do not offer a simple, reductionistic “do this” approach. Instead, they offer concrete and clear but varied possibilities of things to do, reflecting a humble, culturally responsive approach. They introduce and use psychodynamic strategies such as parallel process and behavioral approaches to address challenging behaviors. Every chapter concludes with a clear summary of Key Points to Remember, a set of Tips for Practice, and suggestions for further reading and learning. Importantly, this volume retains the authors’ incredibly useful PAUSE framework for approaching challenges. PAUSE stands for Perceive, Ask, Understand, Strategize, and Evaluate. Ultimately, the PAUSE framework helps scaffold a reflective process for the provider. Worksheets provided offer a concrete way to think through a challenge, taking into account mul- tiple layers of information, and ultimately helping the provider reflect and generate ideas for action. These worksheets are incredibly helpful tools to support the reflective process and help equip home visitors with a way to select strategies and approaches they believe will be most supportive of the infants and families they serve.

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x Foreword The authors suggest that three important functions of parents and caregivers are to 1) show interest and attention towards their infants and young children; 2) accurately read their child’s signals and needs; and 3) respond in a timely and sensitive way. In writing this wonderful book, Professors Tomlin and Viehweg have offered home visitors the same; the authors 1) demonstrate clear interest and attention to the complex, intimate, and important work of the home visitor, 2) accurately read the signals and needs of the workforce; and 3) address many of the challenges providers face, responding sensitively and thoughtfully by sharing their accumulated wisdom gen-

ing sensitively and thoughtfully by sharing their accumulated wisdom generated through years of work in the field with all of us, the readers. There are no simple answers to the complexities of this work, but this volume absolutely helps scaffold the work of the home visitor, validating that there are many ways providers can do the right thing. As the authors note, there is no one “right way” for all people across all situations, yet the home visitor can nurture and develop their skills and embrace a reflective practice approach to strengthen their thinking and enhance best practices.

A great way to start that learning begins with reading this book!

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Getting Started

It is often acknowledged that the work of home visitors, although very rewarding and satisfying, can be challenging. Each child and family pres- ents a different situation, which must be understood from many different contexts, including culture, race, and identity, as well as the values, beliefs, and experiences of all individuals involved. To work effectively and sensi- tively, home visitors must find ways to think broadly, remain flexible, con- sider multiple perspectives, and be prepared with reliable information and resources that can be shared. Furthermore, because it involves helping fami- lies with very young children, is provided in the family’s home, and often addresses very personal information, home visiting can be an intimate and intense experience. It’s not uncommon for home visitors to have many responses and reactions. Altogether, home visitors frequently find that they need more than just information; they also need strategies and supports. In this book we will present the PAUSE (Perceive, Ask, Understand, Strategize, and Evaluate) framework, a set of strategies for partnering with caregivers that blends relationship-based practice, reflective skills, and con- crete information in a way that home visitors can use in everyday interac- tions. Our goal is to take evidence-based strategies and translate them into practical concepts and actions you can use. Using the PAUSE framework to observe, listen, and ask questions, the home visitor can better under- stand child behavior and development, understand sources of challenging behaviors, recognize and respond to stressful family situations and needs, acknowledge and celebrate family and caregiver strengths, and find ways to manage their own reactions to this intense work. Throughout the chapters you will find many vignettes, examples, and worksheets with opportunities to think and try out skills you can use in your everyday practice. Throughout the book, we invite you to recognize, respect, and honor the culture and identities of families, colleagues, and yourself and to consider how these similarities and differences play a role in our work. The first three chapters provide an overview of relationships

xiv

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Getting Started and relationship-based practice, of reflective practice, and of how these two practices can work together. Chapter 4 covers how to understand and address common behavior problems in early childhood: a frequent reason for which families seek home visiting services. Chapters 5 through 8 explore specific typical and challenging behaviors. These include developing self-regulation, aggression, compliance, and anxiety. Chapter 9 focuses on stressful family issues such as parental mental illness and disability. Chapter 10 revisits relationship and reflective practice from the perspective of some of the more significant struggles that many families encounter. In this chapter we encourage recognition that home visitors can be affected by this work and consideration of how best to support the workforce as they support families The chapters end with Tips for Practice and suggestions for

support families The chapters end with Tips for Practice and suggestions for further reading and learning. We hope this book provides a useful set of tools to help you continue to

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Connecting and Keeping Connected

Relationships Matter

ome visiting is exciting and challenging work. Who else has the opportunity to support young children and their families in such

Han intimate and meaningful way? When families invite us into their

homes, whether in person or virtually, to support them in meeting their children’s needs at such a young age, we have a unique opportunity to engage in and support early relationships that can significantly affect their lives. For more than 40 years and across many different types of services, the focus on relationships has been the foundation of home visiting with infants and young families (Ribaudo et al., 2022; Schafer, 2016; Weatherston & Ribaudo, 2020). During this time much has been learned! In this book we will discuss ways to build your skill as a home visitor. We will also consider challenges to worker physical and emotional well-being while engaged in this often demanding career (Eaves et al., 2022; Sparr et al., 2022). In the field of early intervention, relationships matter, and differ- ent kinds of relationships are connected. Relationships of all kinds matter because relationship is the way we learn best (Guralnick, 2001; Norman- Murch, 1996; Slade et al., 2023; Watson et al., 2014; Weatherston & Ribaudo,

2020). A positive relationship supports learning at any level. Three inter- related relationships must be considered in home visiting and other early intervention fields: caregiver–infant/toddler; caregiver–provider, and provider–supervisor/consultant. Because early intervention professionals are acutely aware of the ben- efits of early relationships, their work is often focused on supporting the caregiver–child relationship. For many of us, our work includes specific Excerpted from "Tackling the Tough Stuff: A Home Visitor's Guide to Supporting Families at Risk, Second Edition" by Angela M. Tomlin, Ph.D., HSPP, IMH-E® and Stephan A. Viehweg, ACSW, LCSW, IECMH-E®, CPC-P

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2 Tomlin and Viehweg

goals centered on improving relationships between caregivers and their young children. The Minding the Baby model, which centers relationship as the foundation for reflection, is a prominent example of home visiting work using this perspective (Sadler et al., 2006; Slade et al., 2023). For others, we attend to relationships less formally. Either way, attention to caregiver– child relationships is critical in early childhood (Jones Harden & Lythcott, 2005; Jeong et al., 2021; Rosenblum et al., 2019). A wealth of evidence stretch- ing back more than 60 years supports the importance of parent–child rela- tionships (Ainsworth, 1979; Ensher & Clark, 2020; Thompson et al., 2022; Weatherson & Ribaudo, 2020) and makes clear that:

• A positive relationship between a young child and their caregiver is necessary for healthy development.
• A positive relationship between caregiver and child can provide long- lasting benefits, including school readiness and better social skills.
• A positive caregiver–child relationship provides support in the face of challenging environments, such as exposure to traumatic events.
• Problems in the caregiver–child relationship may exacerbate difficult experiences and can lead to long-term problems such as behavior dis- orders, unhealthy relationships, and antisocial behaviors.

FIRST RELATIONSHIPS: ATTACHMENT

The first relationship that a baby forms, attachment, is developed over time when caregivers respond to babies’ needs. Although specific caregiving practices clearly vary across cultures, researchers have come to recognize that babies and caregivers can form different kinds of attachments depend- ing on the way that caregiving is delivered. For the most beneficial attach- ment to form, usually called a secure attachment, it is important for one or more primary caregivers to:

Be interested and attentive to the baby’s needs and signals for help.

Be able to read the baby’s signals accurately.

Respond to the signals in an appropriate, timely, and reliable way.

Attachment has been thought to be universal in the sense that all cul- tures need to ensure the safety and development of infants (Ensher & Clark, 2016, 2020; Thompson et al., 2022). However, it is also recognized that both caregiver behaviors and child attachment behaviors may look different across families while still accomplishing the goal of ensuring safety. Much of the original research on attachment was done with Western mother– baby dyads. However, we know that family configurations can vary widely and for many different reasons. For example, in some cultural groups it is typical for extended family members to be involved in daily caregiving

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Connecting and Keeping Connected 3

(Gopalkrishnan & Babacon, 2015). Lack of representation of families that are diverse in race, ethnicity, configuration, and culture in research means the results may not apply to all families. For example, in early childhood few caregiver assessment tools include consideration of race or ethnicity; this gap limits our understanding of how concepts about caregiving may apply to these various groups (Rodriguez et al., 2023). Experiences that families and providers have related to their identities can have many ramifications for one’s physical, emotional, and social well- being. Specifically in the United States, authors have recently linked histori- cal and current racial trauma to caregiving interactions and have called for more attention to these experiences in attachment research (Coard, 2022). While we do not have a full understanding of how such experiences may impact caregiver beliefs and child-rearing practices, effective home visitors are aware of and make space for conversations about these topics with fami- lies. In home visiting practice, adaptations that make a program more “cul- turally congruent” may improve effectiveness (Luke, 2020, p. 21). Often, the best way to learn what adaptation will be best is to listen to the stories of the caregivers (Charlot-Swilley et al., 2022). When babies have the ongoing experience of caregivers who consis- tently identify and fulfill their needs at the right time and the right level, they feel important and safe, and they learn to trust in relationships. Know- ing that their basic needs will be met helps a baby stay calm or regulated in both an emotional and behavioral sense. In other words, babies come to count on the adults in their lives to help them calm down and learn to trust that the caregivers are there to help them navigate the complexities of life. When babies don’t have to worry that these basics are covered, they are free to learn and develop in all skill areas. In this way, the kind of attach- ment that infants have affects what they learn about themselves, other peo- ple, their families, and their cultures. Over time, this knowledge contributes to a person’s ideas about relationships in general, setting expectations about future relationships and even guiding behavior in future relationships. What happens when babies do not receive sensitive caregiving? For many reasons, adults may not provide the kind of caregiving that creates a sense of safety and security, leading to attachments that are described as insecure. Insecure attachments occur when the caregiving is insensi- tive or inconsistent. A range of caregiver responses are possible, resulting in attachments that vary from mildly maladaptive to those that are highly disturbed or even not present at all (Ainsworth, 1979; Main, 1996; ZERO TO THREE Press, 2021). See Table 1.1 for examples of concerning behaviors requiring attention. This book further explores the kinds of caregiver characteristics and experiences that may challenge early relationships. You may have learned about a range of methods to promote relationships, increase reflection, and improve practice with families. Over the course of this book we present

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4 Tomlin and Viehweg

child is hurt or afraid) Caregiver has trouble thinking about or talking about what the child’s

Source: Zeanah, Berlin, and Boris (2011). our version of these strategies, the PAUSE framework, which providers can use to systematically pause, reflect, and form helpful responses to a variety of situations in home visiting. The steps in PAUSE are Perceive, Ask, Understand, Strategize, and Evaluate. We intend PAUSE to provide a broad framework that can be used alongside other tools, adapted to your needs, and modified to fit a range of communities. Feel free to use these steps individually, as a full sequence, or as anything in between! Using the PAUSE framework, home visitors can integrate relationship and reflective practices with knowledge of child development and behavior. In Chapters 5 through 10, we explore how the PAUSE framework can be applied to a variety of child and family situations that occur in home visiting. We hope you will find this framework flexible for a variety of families and their circumstances

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Connecting and Keeping Connected 5

will develop and work (Shonkoff & Phillips, 2000; Bruer & Greenough, 2001; Bourne et al., 2022). Babies depend on caregivers for protection and for responsive input (Bourne et al., 2022). Simple interactions, including mak- ing eye contact, smiling, and talking to a baby, help the brain form path- ways that will be used for future learning and functioning. In this way, attachment relationships are integrally important to all aspects of develop- ment. Building positive relationships at such a young age may actually help prepare children for later relationships and situations. They develop skills needed for playing with other children, sitting at a desk in school to learn various subjects, working with another person in a job environment, having a relationship with another adult and creating a family, and so forth. Again, experiences that some caregivers have had connected to their own racial or ethnic identities can create differences in how they teach their children to behave in social settings. For example, in one interview study, African American caregivers reported intentionally preparing their toddler sons to respond effectively to negative stereotypes and racism they expected them to encounter in life (Blanchard et al., 2019). Home visitors should be aware of the types of experiences that many families encounter and should be will- ing to learn from caregivers how these experiences affect their caregiving choices. The Early Relational Health-Conversation (ERH-C) intervention (Condon et al., 2022; Charlot-Swilley et al., 2022) is a video-based interven- tion model that provides an example of how providers can partner with caregivers in a way that is strength-based, supports nondominant ways of knowing, and centers the family experience. In ERH-C, caregivers and facil- itators view videos of caregiver–child interactions, and then use reflective prompts to collaboratively observe, interpret, and make meaning of what they see. The facilitator and the caregiver work together to make decisions that are meaningful to the family within their culture and experiences. The authors note that although the ERH-C model was developed for African American families, it may also have utility for other marginalized commu- nities affected by structural racism.

Strategies for Supporting Early Relationships

Home visitors can take actions to help caregivers more frequently demon- strate caregiver behaviors that support their baby’s development (Sama- Miller et al., 2018; Slade et al., 2023). Examples of desired caregiver behav- iors include demonstrating interest in their infant, recognizing infant cues, and acting responsively to promote a positive relationship. Home visitors can help caregivers build these skills by carefully observing, offering feed- back, and providing encouragement around caregiver–child interactions (Roggman et al., 2019). A simple and direct action that home visiting work- ers can take is to notice and name the baby’s social behavior, such as look- ing or smiling at the caregiver. Next the worker can make a statement that gives voice to the baby’s experience, which is often called “speaking for the

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6 Tomlin and Viehweg

together about other ways we can get you that help.”). baby.” When the home visitor highlights the baby’s behavior and connects the behavior to a need, caregivers may be better able to notice and respond more regularly to the behavior in the future (Steele et al., 2015). Table 1.2

the behavior to a need, caregivers may be better able to notice and respond more regularly to the behavior in the future (Steele et al., 2015). Table 1.2 provides some examples. Attention to caregiver strengths is beneficial in promoting relationships and increasing positive caregiver actions (Roggman et al., 2019). A simple but very effective technique is to name a positive caregiver behavior (Dozier & Bernard, 2019). For example, during a home visit Donall’s grandfather sees him bump his head when standing up under a table. He says, “Come here buddy” as he picks Donall up and rubs the hurt spot. Donall stops crying quickly, and his grandfather sets him back down to return to play. Home visitor Leon remarks, “You were quick to help Donall when he got hurt. That hug really helped him feel better.” This technique of frequent “in-the-moment commenting” is one component of the Attachment and Biobehavioral Catchup (ABC) parenting program developed by Mary Dozier and her colleagues. In the intervention, caregivers are coached to provide nurturance, follow the baby’s lead, and avoid interactions that are frightening. The intervention has shown to have long-term benefits to the child, including into middle childhood (Dozier & Bernard, 2019). Ongoing

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Connecting and Keeping Connected 7

the hour-long visits with Carolyn. She often laughs out loud and frequently asks Carolyn if she would like to see a funny video or message. Carolyn notices that Gage watches his mother and sometimes smiles when she smiles or laughs. The next time this happens, Carolyn says, “Deidre, look how Gage is smiling when you laugh. He really likes to see your smile. Maybe he wants you to talk to him too.” Deidre looks surprised. She looks at Gage and smiles. He smiles back and Deidre says, “Well, hello!”

This example illustrates the role of the home visitor as a voice for the baby. In a gentle way, the home visitor states what the baby can’t say. In the case of Deidre and Gage, Carolyn simply noticed how Gage responded to his mother. Carolyn’s quiet observation helps Deidre see her son in a way that supports a feeling of connection. Over time, these small moments can be significant in their relationship. It’s important to note that human beings’ need for supportive relation- ships continues throughout their lives and is one of the ways that people can learn new ideas and behaviors even in adulthood. Research on the relation- ship needs of adults is vast, spanning every possible relationship, including those with romantic partners, friends, co-workers, and even spiritual beings (Thompson et al., 2022). The next section addresses relationships that can form between caregivers and home visitors.

CAREGIVER AND PROVIDER

RELATIONSHIPS: THE WORKING ALLIANCE

Caring for young children is hard work. Home visitors know that the abil- ity to respond to a baby in supportive ways does not come naturally to all caregivers all of the time. For many reasons, even the best caregivers may sometimes struggle to give their babies the emotional support they need. It’s important to recognize that just as young children learn best when sup- ported by positive relationships, adult caregivers need supportive relation- ships themselves to be their best with their babies (Edelman, 2004; Slade et al., 2023). As a result, for all professionals who support families with young children, the work includes the responsibility to develop a positive relationship with the caregivers in addition to a relationship with the child (Gomby et al., 1993; Roggman et al., 2019). The term working alliance (Bordin,

1979. describes the kind of relationship that home visitors hope to form with caregivers: a collaborative partnership. When providers use themselves and their relationship with families to effect change, it is called relationship-based practice. Learning through positive relationships is now a pillar of the work of home visitors and other early intervention providers and is considered the best way to achieve changes in both caregivers and children (Guralnick, 2001; Norman-Murch, 1996; Watson et al., 2014). At times this responsibil- ity to form a positive working relationship is an explicit goal of the home visiting program or practice approach or model. This is often the case for Excerpted from "Tackling the Tough Stuff: A Home Visitor's Guide to Supporting Families at Risk, Second Edition" by Angela M. Tomlin, Ph.D., HSPP, IMH-E® and Stephan A. Viehweg, ACSW, LCSW, IECMH-E®, CPC-P

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8 Tomlin and Viehweg

home visitors who work with highly vulnerable families, including those in underserved and under-resourced communities and those at risk for child abuse and neglect. However, even when an intervention is focused on infant development, the caregiver–parent relationship is frequently a central piece of the work. In early intervention practice, it has been established that caregiv- ers who trust and feel supported by the interventionist are more likely to become engaged and continue in the work that is needed to make changes for their children (Daro & Harding, 1999). Home visitors who act in ways that are described as empathetic, warm, understanding, and responsive toward caregivers facilitate positive changes in both parent and child behaviors (Popp & Wilcox, 2012). Furthermore, “the way that expertise is delivered becomes an essential aspect of the work” (Edelman, 2004, p. 5). This point has been succinctly stated by Jeree Pawl as “how you are is more important than who you are” (Pawl & St. John, 1998). The COVID-19 emergency resulted in a unique set of challenges for most human service fields, including home visiting. Overnight, agencies had to make decisions about how to continue to offer services, or even whether to continue them at all. Many programs that serve young fami- lies, including a significant number of early care and education programs, closed their doors and have yet to reopen, creating a range of problems (Jessen-Howard & Workman, 2020; Mongeau, 2020). In home visiting, work- ers attempted “social distancing,” carried on with protective equipment in place or they shifted their work to the family’s porches and yards. Others converted to a virtual service delivery model, often with little warning and less experience. Challenges to virtual home visiting range from issues such as family access to Wi-Fi and appropriate devices to the reality of trying to get an infant or toddler to participate with a provider on screen. In many virtual formats, the provider’s role becomes more that of a coach to the care- giver, who will deliver the intervention to the child. Forming and main- taining relationships under these strange circumstances was new to both families and workers. In one study, home visitors and supervisors in a large urban area reported on their experiences with transitioning to virtual home visiting (Traube et al., 2022). Both home visitors and supervisors reported needs for funding, technology, supervision, and guidance, including from funders and program leadership, in this transition. Supervisors viewed home visitors as having more issues with the transition than did the home visitors themselves, who reported concerns about family engage- ment. In other studies, home visitors sought practical help for how to conduct virtual assessments and self-care (Marshall et al., 2020). Lessons learned from the pandemic experience continue to be used, as virtual means for connecting have become an important way that some families access our services.

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Connecting and Keeping Connected

Strategies to Support the Caregiver–Professional Relationship What home visitor actions help caregivers feel supported? How do these actions build good relationships with caregivers? It is helpful to think about

actions build good relationships with caregivers? It is helpful to think about the caregiver behaviors that help a baby feel safe and supported:

the caregiver behaviors that help a baby feel safe and supported: Showing interest and attention

Showing interest and attention Accurately reading signals about needs

Accurately reading signals about needs Responding to needs in a timely and sensitive way Consider how these kinds of behaviors can be applied to caregiver– parent relationships. Paralleling the parent’s actions toward babies, home visitors build relationships with caregivers when they demonstrate an active interest in the caregiver and their needs. Next, home visitors will need to work to accurately understand what caregivers are saying and showing what they need from the relationship. Extra time and effort may be needed when the home visitor and the family do not share cultural or other similarities that inform child-rearing beliefs and practices. Language differences that require interpreters can add another layer of complexity. Open discussion and exploration about these issues can be helpful. Finally, home visitors make efforts to respond in consistent and reliable ways to meet those needs. In this way, the home visitor’s relationship with the caregiver can become part of the caregiver’s own attachment network (Thompson, 2022). See Table 1.3 for some

examples of how a home visitor might respond to child actions. t the next visit, Deidre comments that since Gage has started to walk, he Acan now get into everything. She shares that he got into her purse and scattered her things all around the house; now she can’t find her phone charger. Carolyn considers explaining that curiosity is a good thing and suggesting that Deidre make a plan to keep her purse out of Gage’s reach. If Carolyn

wanted to show interest in Deidre’s experience, what could she say instead?

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10 Tomlin and Viehweg Home visitors may wonder about this emphasis on forming a relationship with the family members and our concern about their experiences. After all, we are infant and toddler specialists, so doesn’t that mean we need to keep our focus on the babies? The term parallel process can help us understand what happens when we support caregivers and why these caregiver– provider relationships are an important part of the work. Parallel process conveys the concept that one relationship affects other relationships. Events and experiences in one relationship may affect another relationship, either in the present or at a later time. This can occur in many ways. Any time you have a hard workday and then are irritable at home with your family, parallel process may be at work. On the other hand, you could feel your mood lightened after talking with a close friend over dinner and then find yourself giving your server a big tip! Table 1.4 provides a couple of examples of parallel process in action. The concept of parallel process helps home visitors understand how their actions that support caregivers will in turn

Table 1.4. Parallel process in action

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Connecting and Keeping Connected 11

Table 1.5. Filling up the family’s emotional tank

At the beginning Geneel, the home visitor, began the session by saying, “Emma, I was think- of a visit ing about you this week. I remembered how excited you were last time with Evelyn’s progress and her interest in looking at pictures, pretending to eat the food in the pictures. You were going to practice ‘reading’ to her again this week. Tell me how it went.” During the visit Bryan works with Evan’s father, William, on interacting more with his baby. During a diaper change, William begins to play a game with Evan to keep him distracted. He flips him over from side to side in between caring for Evan. Evan squeals in delight. Bryan notes afterwards, “Evan really likes to play with you and you found a way to help him learn how to roll over at the same time you did a diaper change. That makes changing a diaper a pretty fun activity. Great idea!” Summarizing the At the end of the home visit, Susan summarizes what was discussed with visit Carol by saying, “You asked about finding a different place to live today. We talked about the different options and you decided to talk with your current landlord about changing apartments. We practiced what you might say, and you sounded pretty confident about how to ask for what you need. You really know what’s best for your family and how to get that in a respectful way.” In between visits Samantha sees her home visitor, Rebecca, in the hallway at the agency where the home visiting program is co-located with other agencies. Samantha has come for a WIC appointment and is early. She tells Rebecca in a quiet voice that she realized during the last visit that she could take Anthony to the local library to check out some books, since he seemed to have so much fun with the hard-paged picture books they used in the home visit. She had just gone to the library prior to the WIC appointment; she pulled out a canvas bag to show Rebecca the books they found. Rebecca comments, “What a great idea you had to get more books from the library so you and Anthony can read together!”

The support that caregivers receive from a home visitor can be thought of as energy that can be used to fuel the caregiver’s positive actions toward their children (Webster-Stratton, 2019). We encourage caregivers to fill up their emotional fuel tanks so that they have the emotional energy to then respond to their child’s needs. See Table 1.5 for some examples of home visi- tors supporting caregivers in this way.

REFLECT: RECOGNIZING AND

REPAIRING MISSTEPS IN HOME VISITING PRACTICE

Carolyn visits Deidre and Gage again after a few missed sessions. She is wondering about what led to the canceled sessions and whether she should mention this during the visit. When Deidre answers the door, she is unusu- ally quiet and appears sad. Carolyn notices that Gage is in need of a new diaper and seems fussy. She is unsure if she should start by addressing Deidre’s apparent distress, alert her to Gage’s immediate need, or ask about the canceled visits. Despite best efforts, home visitors and other early intervention pro- fessionals may find it very difficult to establish a positive and productive relationship with some families. The block to forming a good relationship can come from the caregiver, the home visitor, or a combination of both.

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12 Tomlin and Viehweg

Barriers for caregivers might include a mental health problem or just having so many competing demands that make this particular relationship not a priority. Sometimes caregivers’ own backgrounds and histories include so many relationship challenges that they are unfamiliar with the kind of rela- tionship that the home visitor is seeking to form. Box 1.1 lists some examples of experiences that could block relationships between caregivers and home visitors. In fact, some people may never have experienced the kind of sup- port home visitors offer and cannot understand or even recognize what is being offered. For these families, the home visitor’s persistence and consis- tency can help. It may take a very long time for the caregiver to have enough experiences with the home visitor to begin to trust and listen to the home v i sitor ’s g u ida nc e. When establishing trust is an issue, a home visitor may want to create opportunities for the caregiver to learn that the home visitor can be counted on. For example, the home visitor can make plans to bring information or

Box 1.1. Caregiver and Family Experiences That May Block Relationships

With Home Visitors

• Home visitor reminds caregiver of someone in the caregiver’s life who was difficult
• Losses in early childhood (e.g., caregiver’s own parent died or left the family)
• Separation, divorce (e.g., of child’s caregivers, grandparents)
• Domestic violence or other trauma
• Medical illness or disability
• Mental illness, including depression, personality disorder, or bipolar disorder
• Incarceration of parent or other family members
• Past or current alcohol and/or drug use or abuse
• Past experience with systems such as child welfare and other social programs
• Current worries about housing, food, health care, education, and other basic life needs
• Challenging immigration experiences or difficulties in acculturation
• Current and/or historical experiences of discrimination based on race, ethnicity, religion, and language Excerpted from "Tackling the Tough Stuff: A Home Visitor's Guide to Supporting Families at Risk, Second Edition" by Angela M. Tomlin, Ph.D., HSPP, IMH-E® and Stephan A. Viehweg, ACSW, LCSW, IECMH-E®, CPC-P

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Connecting and Keeping Connected 13

activities to the next session so that the caregiver experiences the home visi- tor as someone who follows through. The home visitor can make a point of bringing up something that happened during previous sessions to demon- strate their attention and memory about the family. Statements that indi- cate that the home visitor is thinking about the child and family outside of sessions can be powerful indicators that the home visitor is holding the caregiver in mind, even when not with the family. In Chapters 5 through 10, we explore these concepts more specifically using the PAUSE framework to think about caregiver experiences that may get in the way of forming posi- tive relationships with home visitors, and we suggest practical responses and actions.

arolyn brings a recipe for modeling dough to her visit with Deidre and

CGage. She says, “I found this recipe for you. I remembered that you and

Gage had a lot of fun with the play doh I brought last week, so I thought you might like to make some yourself.” Deidre smiles and says, “Thanks! I bet my mom will like this. We used to make modeling dough when I was little.” She puts the recipe in a folder on the table and sits with Carolyn to start the session.

Home visitors can also experience blocks in their own ability to see or do what the caregiver needs. These blocks may come from unconscious biases and have the potential to lead to behaviors that contribute to dis- parities or to do other harm (Parker, 2021). Home visitors may find the care- giver reminds them of another client who was hard to work with or perhaps someone else from their own past. The caregiver may display behaviors that the home visitor has trouble understanding (e.g., discipline or housekeeping practices that make the home visitor feel uncomfortable). The home visitor may find it difficult to maintain a balance between attending to the care- giver’s needs and those of the baby. At other times, a home visitor may sim- ply feel worn out from all the needs that families have. In some cases, the caregiver and the home visitor may just not be a good match. For whatever reason, the practitioner won’t always get it right. When mistakes or mis- matches occur, the practitioner should acknowledge them and take steps to repair the relationship as needed. (These issues are discussed in more detail in Chapter 10.)

arolyn is aware that Deidre once again canceled two sessions in a row and Cthat she has not returned several phone calls. She sends a text to ask if they can meet the following week and Deidre agrees to the appointment. However, when Carolyn arrives, the grandmother is at home with Gage and Deidre is not there. Carolyn wonders what could be happening. She decides to keep trying, and the following week Deidre is present for the appointment. Carolyn says, “It’s been a while since I saw you. I was wondering if everything is okay with

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14 Tomlin and Viehweg

you.” Deidre says she is fine, but Carolyn still feels like something is not right. She says, “I am concerned that I might have done something to upset you. Is there anything we should talk about?” Deidre crosses her arms and says, “Well, I am kinda mad at you. You told my mom I am not feeding Gage right.” Carolyn is surprised. She doesn’t think she said that, but she says, “Wow. I am sorry; I really don’t remember saying that. You and I have been talking a lot about how you are enjoying feeding Gage and watching him grow. Maybe we can fig- ure out what happened.” Deidre’s shoulders relax and she seems calmer. She snuggles a little closer to Gage on the couch and helps him reach for a toy.

SUPPORTS TO HOME VISITORS:

MENTORING, COACHING, AND SUPERVISION

One of the best ways for home visitors to gain perspective on their work with families, including their own responses, is to regularly seek support from someone more experienced in the work. This brings us to the third important relationship in home visiting or other early intervention work— the relation- ship between the home visitor and a supervisor. Whether it is called supervi- sion, mentoring, consultation, facilitation, or coaching, consensus is growing that infant and family workers benefit from ongoing professional develop- ment experiences that come from this kind of relationship (Watson et al., 2014; Watson, 2022). Home visitors who regularly receive this kind of guidance feel supported, recognized, and better able to identify their own strengths and needs (Watson & Gatti, 2012). Supervision that includes reflection has been used for years in many settings, but research on the approach is relatively new (Tomlin et al., 2014). There is growing interest in research showing how supporting the workforce will ultimately improve outcomes for parents and children (Huffhines et al., 2023; Watson et al., 2014; Stacks et al., 2021). There are many types of supervision and styles of supervisors (Hef- fron & Murch, 2010). Home visitors who have received supervision in the past that did not feel supportive may be skeptical about how reflective supervision might be different and more helpful. Recent work is helping the field understand what is most important to supervisees (Barron et al., 2022a, 2022b). Some preferences include having access to a supervisor who has done the same work, speaks the same language, and is similar in race or ethnicity. These studies are highlighting the challenges of representation in home visiting fields and give impetus to reducing barriers to advancement for historically minoritized members of the workforce. Supervisors should take a lead in discussing any differences such as gender, race, or language between themselves and the supervisee that might present a barrier to forming a collaborative relationship. Good ways to begin are for the super- visor to self-identify and broach discussion of similarities and differences between the supervisor and the supervisee (Hardy, 2016; Stroud, 2010). Supervision that follows a reflective model has been described as a relationship for learning (Shamoon-Shanok, 2006). Just as consistency and

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Connecting and Keeping Connected 15

reliability build trust in caregiver–child and caregiver–provider relation- ships, these attributes are required in the provider–supervisor relationship as well. Therefore, it’s important that reflective supervision occurs regularly. This allows the home visitor to come to see the supervisor as a consistent source of support. It is also important in this model that supervisors work to form a rela- tionship with the supervisee that feels more collaborative and less hierarchi- cal. This may look different to different people. One way of demonstrat- ing collaboration is avoiding an “expert” stance (i.e., the supervisor should not just tell the supervisee what to do). Using reflective supervision as a method for building skills, the supervisor guides the supervisee to consider many possibilities and to figure out their own solutions. The supervisor will accomplish this goal by using their own reflective skills and by pro- moting reflection by the supervisee. Use of reflective skills that encourage the supervisee to consider their own responses to the work is the third hallmark characteristic of this type of supervision. Such consideration will often include attention to feelings that arise within the work (Alliance for the Advancement of Infant Mental Health, 2018; Fenichel, 1992).

arolyn keeps thinking about her last few meetings with Deidre and Gage.

CWhen she prepares for her supervision time with Toby, she puts talking

about this family at the top of her list. During the session, Carolyn shares the story about Deidre canceling sessions and the discussion they had. She tells Toby, “I know I did not say what Deidre thinks I said!” Toby listens carefully and says, “It’s pretty upsetting to have someone say something about you that isn’t true.” “It sure is!” Carolyn replies. “I think I am doing the best I can with them. Deidre is really hard to read. I am never sure if she is really taking in what I say about Gage. Some days I wonder if I am wasting my time.” Toby says, “It’s hard to feel successful when you don’t get a response or the response you get is negative.” They continue to discuss this issue for several minutes. Then Toby says, “I was remembering that you said that Gage is kind of a quiet baby. You had mentioned that it’s been hard for Deidre and Gage to connect. I wonder what it is like for you to see that struggle.” Carolyn responds, “It’s frustrating. Last month I even tried to get Deidre’s mother to help prompt her a little with him. I asked her to praise Deidre whenever she sees her do something well.” Carolyn stops suddenly. She looks thoughtful and says, “I guess that could explain why Deidre thinks I told her mom she wasn’t feeding Gage right. She does try very hard and I guess that her being upset was really showing that she does listen and try things we talk about. She must feel bad when she tries but Gage doesn’t respond right away.”

In the past, evidence for reflective supervision came primarily from clinical thinking and practical experiences (Huffhines et al., 2023; Tom- lin et al., 2014). More recently, a surge of attention to the practice has been supporting more empirical evidence (see Hause & LeMoine, 2022). It is

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16 Tomlin and Viehweg

becoming clearer that reflective supervision or consultation, while not suf- ficient by itself, provides many benefits to agencies, providers, and families (Barron et al., 2022a, 2022b; Norman-Murch, 2005; Weatherston, Kaplan- Estrin, & Goldberg, 2009). Reflective supervision is increasingly seen as a form of professional development that improves the participant’s skill and increases capacities for insightfulness and reflection (Hause & LeMoine, 2022; Watson, 2022). Agencies benefit when providers benefit. For exam- ple, when professionals feel supported, they may be more likely to stay on the job, reducing turnover. Less frequent turnover is a benefit for agencies because it reduces hiring and training expenses. Participation in reflective supervision can also result in home visitors who can deliver better services, leading to better attainment of family goals and higher family satisfaction with services (Stacks et al., 2021). For more about reflective supervision and its connection to worker well-being, see this book’s supplement, “Reflective Supervision and Consultation: What Is It, Why Do I Need It, and How Can I Use It Most Effectively?”

WHAT’S NEXT?

In Chapter 2 we talk more about reflective skills, why they are important in early childhood work, and how they can be enhanced in ourselves and families.

TIPS FOR PRACTICE

• Attend and respond to caregiver needs to build relationships and increase caregiver sensitivity to their children.
• Monitor your own feelings about children, caregivers, and family situa- tions. Purposefully attend to your own biases. Awareness of your biases and feelings can provide information about what is happening. Plus, when you are aware of feelings, you can better manage them in order to respond more effectively.
• Regularly seek supports such as supervision, consultation, or coaching, which include reflection to build skills and to obtain support for the challenging feelings that home visiting brings.

KEY POINTS TO REMEMBER

• Early experiences have the potential for lifelong consequences, both positive and negative. Evidence for the long reach of these early experi- ences includes changes to brain structure and functioning. Excerpted from "Tackling the Tough Stuff: A Home Visitor's Guide to Supporting Families at Risk, Second Edition" by Angela M. Tomlin, Ph.D., HSPP, IMH-E® and Stephan A. Viehweg, ACSW, LCSW, IECMH-E®, CPC-P

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Connecting and Keeping Connected • Effective home visitation services attend to the formation of positive relationships between caregivers and their young children (attachments), caregivers and home visitors (working alliance), and home visitors and supervisor/consultants (reflective supervision/consultation

visitors and supervisor/consultants (reflective supervision/consultation relationships). • Current and past relationships and experiences within relationships are

interconnected and have reciprocal effects through parallel process.

SUGGESTED FURTHER READING Ensher, G. L., & Clark, D. A. (2016). Foundations for best practice with special children and their families. ZERO TO THREE Press. To stay up to date about important home visiting models such as Healthy Families America and others, bookmark the National Home Visiting

“A vital tool for translating research-based strategies into comprehensive, actionable guidance for home visitors. Home visitors who practice from this relational and reflective approach will find that they are better able to support families navigating personal and structural challenges.” —Dorian Traube, Ph.D., LCSW, Neidorff Family and Centene Corporation Dean of the Brown School and

—Dorian Traube, Ph.D., LCSW, Neidorff Family and Centene Corporation Dean of the Brown School and Professor, Brown School at Washington University in St. Louis
“Destined to become a foundational reference in the field of early childhood home visiting . . . the authors’ conversational tone and practical guidance regarding many challenging situations will make this book a

conversational tone and practical guidance regarding many challenging situations will make this book a go-to resource for home visitors experiencing uncertainty in their work.” —Elizabeth B. Frisbie, M.A., MS.Ed., I/ECMH-C, CCP, Early Childhood Mental Health Consultant/Reflective Supervisor,

ow more than ever, today’s at-risk families need home visitors who can address their complex challenges with skill and sensitivity. This second edition will help home visitors manage even the Ntoughest situations they encounter on the job—and support and empower vulnerable families of

children birth to 3. The authors present their highly effective PAUSE framework (Perceive, Ask, Understand, Strategize, and Evaluate), a blend of relationship-based practice, reflective skills, and recommended strategies for supporting at-risk families. Readers will learn how to develop positive partnerships with parents and caregivers, address specific challenges in skillful and culturally sensitive ways, and give families the tools and knowledge they need to generate their own solutions. Vignettes, sample dialogues, and fillable PDF forms help home visitors

translate evidence-based strategies into everyday action.

WHATíS NEW • Coverage of contemporary topics such as virtual home visiting,

• Coverage of contemporary topics such as virtual home visiting, reflective supervision, and diversity, equity, inclusion, and justice (DEIJ)

• Updates to reflect the ongoing impact of COVID-19 • More on the PAUSE framework’s compatibility with home visiting programs such as Parents as Teachers, Early

ABOUT THE AUTHORS: Angela M. Tomlin, Ph.D., HSPP, IMH-E®, is Professor of Clinical Pediatrics, Co-Chief of the Division of Developmental Medicine, and Director of the Indiana LEND Program at Indiana University School of Medicine (IUSM). Stephan A. Viehweg, ACSW, LCSW, IECMH-E®, CPC-P, is Assistant Research Professor of Pediatrics and Associate Director of the Indiana LEND Program at the Indiana University School of Medicine, Department of Pediatrics, Division of Developmen-

visiting programs such as Parents as Teachers, Early Head Start, and Healthy Families America