This book describes the experiences and lessons of a specific nonprofit, Every Child Succeeds (ECS), dedicated to delivery of evidence-based home visiting to support families during pregnancy and the early years of a child’s life. The book uses this as context for understanding the roles and challenges of nonprofit organizations aiming to address social issues. This is a case study of one nonprofit. As traditionally described by Robert K. Yin and others, the case study investigates a contemporary problem within its real-life context (Yin 2014, Yin 2018). Case studies help us understand how or why by exploring, describing, and explaining what happened. Here the questions are about the opportunities and challenges of nonprofit organizations operating in the role of addressing large, complex social issues. This book relies on the author’s direct observation, archival documents, and other information from those who participated in events.

In this case, the issue is related to families with young children and a service approach called home visiting. The specifics are explored in Part 1 of this book. In Part 2, lessons that can be generally applied to other nonprofits (e.g., those working to improve life for child, adolescent, and aging populations) are explored in depth.

As with most nonprofit entities striving to address social issues, ECS grew from a particular problem definition, a predefined remedy based on some evidence of impact, and a commitment of public and philanthropic resources. To understand how ECS came about, and the social and scientific context in which it grew, one must go back to the 1980s and 1990s, and see the changes in thinking that influenced our work.

Learning About the Brains of Young Children

Research on brain development expanded in the 1980s, and by the 1990s was virtually exploding and capturing the public’s interest. Scientists were able to document, in ways not possible before, that early life experiences have an effect well beyond the early childhood years.

In 1994, the Carnegie Corporation of New York released a sentinel report, Starting Points: Meeting the Needs of Our Youngest Children, which described the quiet crisis confronting children from birth to age three (Carnegie Corporation 1994). David Hamburg, MD, a distinguished psychiatrist and longtime president of the Carnegie Corporation, was deeply committed to prevention strategies and the application of research to address social needs. This work underscored the science that pointed to the importance of the first three years of a child’s life for subsequent health and development. To accelerate action, in 1996, Carnegie awarded grants totaling more than $3 million to 16 states and cities. The grants were designed to stimulate reform in policies and programs and, simultaneously, to mobilize community action based on recommendations in the report. The Starting Points initiative brought messages about the importance of early development to policymakers, including governors, state legislators, and city councils.

The next landmark report came from the National Research Council and was aptly titled From Neurons to Neighborhoods (National Research Council, Institute of Medicine 2000). Drawing from the emerging brain research, the report offered important conclusions about the effects of family and community; the influence of politics on programs for children; the costs and benefits of early intervention; and recommendations for action. This report called for health and other early childhood services to be linked, to collaborate at the community level, emphasizing the evidence in support of change. This National Academy of Sciences committee also issued a series of challenges to decision-makers regarding issues of racial and ethnic diversity; the quality of early care and education; the integration of children’s cognitive and emotional development; and the failure of public programs to meet the needs of families with young children. As described by the report, early experiences and the environment affect the development of the brain, and lay the foundation for lifelong health and well-being. And optimal development depends on nurturing early relationships (US Institute of Medicine and National Research Council 2000, 27–31). The work was widely cited and discussed by other researchers, professionals, providers, policymakers, and the media, leading to a shift in public understanding and a groundswell of support for increased emphasis on early childhood programs.

Ron Kotulak, a Pulitzer Prize-winning science editor at the Chicago Tribune, wrote a series of articles for the newspaper that became a book entitled Inside the Brain: Revolutionary Discoveries of How the Mind Works, which detailed for lay audiences what neuroscience was learning about the importance of early brain stimulation for children birth-to-three years old and how that stimulation helped them achieve their maximum potential. Here is how Kotulak described what happens:

By the late 1990s, we were visually able to see with scans what was happening in the brains of our infants and toddlers. Multiple scientific studies, syntheses of research such as From Neurons to Neighborhoods (National Research Council, Institute of Medicine 2000), and books such as Inside the Brain (Kotulak 1998) presented scientific evidence about what was happening neurologically during the first three years of a child’s life. Science firmly indicated that the first three years of life are more important than any three that follow and that optimal development is directly related to changes occurring in the young brain. At the time, we believed the brain had more than 7,000 neural connections being made per second. Today, the Center on the Developing Child at Harvard University, founded and led by Jack B. Shonkoff, MD, reports an estimate of more than one million new neural connections per second (the website for the Center for the Developing Child). These connections become the pathways or neural networks to support the development of cognitive, social, and emotional skills for a lifetime.

In a speech, “Acting on What We Know to Be True” for the National Summit on Quality in Home Visiting in February 2011, John Pepper, Jr., then president and CEO of Procter & Gamble (P&G), explained why his commitment to early child development was so strong. He cited Kotulak’s book as one that changed his life. Pepper said:

James Heckman, PhD, Nobel laureate and economist, reinforced the calls for action by letting us know that investing more in proven childhood development, early care, and education programs is the best possible investment for all children—working with the underlying principles that reduction in disparities for children and families is central to success, and that brains are built, not born (Heckman 2012).

Despite many scientific reports and experts describing the urgent need for action, gaining traction for the needs of children ages birth to three has long been a challenge. Children don’t vote, and as Bill Shore stated in his 1999 book The Cathedral Within (1999), when he read the Carnegie Corporation report, Starting Points: Meeting the Needs of Our Youngest Children, he came to understand that the period from prenatal to age three is demonstrably the most formative. Ironically, it is also the most neglected, because there are no clearly defined institutions, such as preschools, to serve it, nor is there a central national child or family policy to support it. Further, Shore wrote:

The Importance of Foundational Early Relationships

Heretofore, we were not aware how much brain stimulation and nurturing parenting mattered for infants and toddlers. Vast and compelling evidence now documents that we cannot begin too early to nurture brain development and early relationships (Willis et al. 2022; Willis et al. 2020; Bethell et al. 2019; National Academies of Sciences, Engineering, and Medicine 2019; Centers for Disease Control and Prevention 2018; National Academies of Sciences, Engineering, and Medicine 2016; Center for the Developing Child 2007). What we had not fully understood was that brain development and early relationships in those first months and years of life was foundational to nearly all child development, as well as an influence on lifelong health and well-being. By carefully listening to the field and research around us, ECS increasingly came to focus itself on the importance of early relationships. Here are some examples of learnings that shaped ECS.

Describing these foundational early relationships for non-professional readers, Kotulak tells us:

The Center on the Developing Child at Harvard University synthesized the scientific evidence this way:

The importance of these relationships was further articulated by the Center on the Developing Child at Harvard, which concluded that:

In 2015, the prestigious Journal of the American Medical Association carried an editorial supporting a focus on the first 1,000 days of life as the path to creating lasting change for children, “Because the brain is the organ from which all cognition and emotion originates, early human brain development represents that foundation of our civilization. Accordingly, there is perhaps nothing more important that a society must do than foster and protect the brain development of our children (Luby 2015, 810).” The American Academy of Pediatrics’ Early Brain Child Development Initiative elevated the importance of the first 1,000 days and the critical importance of early relationships (Garner et al. 2017; Garner et al. 2012; and the website of the American Academy of Pediatrics).

In 2021, the American Academy of Pediatrics reinforced these messages in an important new statement that placed increased emphasis on the importance of focusing on safe, stable, and nurturing relationships that buffer adversity and build resilience. In this updated organizational policy statement, Andrew Garner, MD, and a group of AAP pediatric leaders in early childhood development called for a paradigm shift in thinking about services, research, and advocacy emphasizing the promotion and protection of early relationships between parents and young children. They also called for increased efforts to link families to community-based support such as that provided by home visiting programs. The statement emphasizes that:

Other scientists and thought leaders, including Christina Bethell, PhD, MPH, MBA, at Johns Hopkins University (Bethell et al. 2019) and Robert Sege, MD, at Tufts University (Sege and Harper Browne 2017) have advanced understanding of the role of positive childhood experiences (PCEs) in protecting against toxic stress and the impact of adverse childhood experiences. Adverse childhood experiences (ACEs) endanger health and development, yet early relationships and positive experiences can offset the risks. This emerging body of science helps us to understand how PCEs can promote optimal health and well-being. It also offers new reasons to support parents in their efforts to foster early relationships and positive experiences through programs such as home visiting.

And in a more intimate way, Robin Karr-Morse and Meredith S. Wiley in their seminal 1997 book Ghosts from the Nursery: Tracing the Roots of Violence built on a theme first raised in a landmark 1975 paper by esteemed professor of child psychiatry Selma Fraiberg. Karr-Morse and Wiley maintain that in every nursery, there are ghosts from the past haunting many parents, as relational and intergenerational factors, including historical trauma, which may affect their experiences with their infants. They created a remarkable word picture of this phenomena and the newborn brain, writing:

In his role as leader of the Early Relational Health Hub at the Center for the Study of Social Policy, David Willis, MD, emphasizes that foundational early relationships shape the well-being of both the child and the parent/caregiver.

The two-way nature of early relationships affects two-generational health and well-being in the moment and long term. Decades of research from the fields of child development, infant mental health, and neurodevelopment has established the centrality of relationships between caregivers and very young children for optimal health, development, and social-emotional well-being. When we focus on and support these foundational early relationships, children and their caregivers thrive—now and for a lifetime (Personal communication).

The Importance of Community Context

ECS was built upon what was known in the 1990s and adapted as further knowledge emerged, using neuroscience and expert opinion to guide the development of our program. We took action in response to the science about brain development and evidence in support of home visiting as an effective intervention in the period from prenatal to age three. What we did was to create a voluntary home visiting program focused on brain development and early relationships for prenatal to age three, especially for those families facing health, economic, and other social risks.

Along with strong community leadership, ECS had a cadre of personally committed, professional home visitors—heroines all—to partner with families who were willing to accept a frequent and regular schedule of visits, beginning prenatally and continuing until the child reached three years of age. The work of the home visitors was guided by a carefully crafted curriculum allowing parent and child to learn together. They helped parents understand that talking to the baby mattered—really mattered—and that holding the baby and being emotionally present was more important than any high-tech device or complicated activity. Science let us know that it was the relationship that grew between the infant and the parent that grounded brain development to support the child for a lifetime. Lived experience told us all families want the best for their babies. Our program was grounded in efforts to promote these relationships with the coaching and support of a trained, empathic home visitor.

The real-life need for a program devoted to moms and their at-risk infants and young children was made clear to me early in the development of ECS. I received a visit from the co-directors of the Perinatal Institute at Cincinnati Children’s, James Greenberg, MD, and Jeffrey Whitsett, MD. The message they delivered and the poignant concern they expressed was this: “We can do an outstanding job clinically with infants in the hospital, but what happens when they go home? Is there adequate food? Support for breastfeeding? A safe place to sleep? A parent who has the skills and resources to support optimal development?” These were important questions, indeed admonitions, from two fine physician scientists as they asked for coordination and a continuum of care for their youngest patients and their parents.

What we learned was that the larger social and community context left too many parents without the resources they needed to provide safe, stable, and nurturing environments. The environment, and what is now known as the social determinants of health, were crucially important to the safe, stable, and nurturing relationships between parents and young children. Parents often experienced stressors related to racism, poverty, community disinvestment, and fragmented services. How unstable is the family’s economic situation? Are they about to be evicted? Are the home and neighborhood safe? Is the child or parent the victim of violent behavior? Does it occur around them? Is there enough to eat? Is there enough money to pay rent and keep the utilities on? Is there a safe and nurturing childcare arrangement when parents have to go to work? Understanding of these community characteristics has been growing (Acevedo-Garcia et al. 2020; Sandel et al. 2016; Acevedo-Garcia et al. 2014; Tandon et al. 2007; Schorr 1997).

Local data indicated that too many families lacked the resources to provide a safe, stable, and nurturing environment. Hamilton County, Ohio, where ECS and Cincinnati Children’s are located, was then ranked among the bottom (worst) 10% of counties across the nation for infant mortality rates. Cincinnati child poverty rates are among the highest for cities across the country for Black, White, and Hispanic children. Tensions related to racial disparities in poverty, infant mortality, and other factors have been high at various points, and community leaders have sought remedies. A Child Opportunity Map from Brandeis University shown on the next page illustrates the fact that many census tracts in greater Cincinnati have low Child Opportunity Index scores, particularly for Black children (note the Avondale neighborhood highlighted in red in the center of the map is the location of Cincinnati Children’s and some of the ECS’s intensive community engagement initiatives, as well as the site of ongoing disparities and occasional civil unrest). Certainly, recognition of the situation for Black children in greater Cincinnati was one important reason that civic leaders and social activists supported the development of ECS.

Source: diversitydatakids.org 2023. Waltham, MA: Institute for Child, Youth and Family Policy, Heller School for Social Policy and Management, Brandeis University.

We learned a lot from our journey with ECS, while the larger research community continued to inform us, and expand our understandings. The Center for Community Resilience, led by Wendy Ellis, DrPH, MPH, at George Washington University, has articulated the Pair of ACEs Tree which depicts the interconnectedness of adverse community environments—the soil in which some children’s lives are rooted—and adverse childhood experiences. Factors such as poverty, discrimination, lack of economic opportunity, inadequate housing, and community violence can contribute to—and are the socioeconomic roots of—many adverse experiences in childhood. The Pair of ACEs Tree model encourages thinking and action beyond addressing individual family-level challenges, toward enriching the community context and opportunity (Ellis and Dietz 2017).

The importance of community context, the “village” that raises children, has been widely discussed. Too often, for too many children, geography becomes destiny, with lack of opportunity in the village and community context in which they grow and develop. What the child experiences and learns there will guide and shape the remainder of life. A poem, “Celebrating Childhood,” by Adonis (2006), translated from the Arabic by Khaled Mattawa and printed in The New Yorker magazine included the following line: “Your childhood is a village. You will never cross its boundaries no matter how far you go.”

In April 2000, at a workshop for the American Society of Newspaper Editors, David Lawrence, Jr., formerly publisher of the Miami Herald, president of the Early Childhood Initiative Foundation in Florida, and self-described as a “recovering journalist” said this:

Science to Action through Home Visiting

Grounding in science and evidence-based practices is considered important in today’s world for nonprofit organizational missions and work, particularly those tackling large social issues with public funding. On the surface, the concept of turning science into action seemed straightforward and yet, determining how to translate knowledge into programs can be complex. In the vernacular of Cincinnati Children’s, the challenge for ECS was: How could we move from emerging research findings to a strategy that would turn the science into actions to help children receive the optimal start in life that they deserve?

Because science was telling us that the first 1,000 days of a child’s life are more important for development than any that follow, our community came together. While knowledge has expanded dramatically since the late 1990s, when ECS was launched, we applied what was known then. The evidence was clear that children exposed to safe, stable, nurturing environments early in life make more synaptic connections in the brain and that the more of these connections are made, the greater the positive impact for all domains of child development—cognitive, physical, and emotional-relational. In other words, waiting until kindergarten or even pre-kindergarten to begin educating and nurturing the brain was far too late. When earlier brain stimulation and learning has been deficient, essential time has been lost. Thus, the concepts that became embedded in our work were: a focus on the prenatal period to age three, brain development, early relationships, nurturing parenting, safe environments, and prevention.

Acknowledging the importance of early brain development, the Ohio Business Roundtable emphasized that the case for investing in young children had clearly been made:

On a parallel track, researchers were conducting studies to examine how the home visiting services approach from the early 1900s could be modernized, with professionals visiting families to provide support, connect them to resources, and help them fulfill their life goals. The published results of the first-rate studies from David Olds, PhD, and his colleagues who founded the Nurse-Family Partnership™ (NFP) model showed strong positive and long-term impact on an array of family issues, such as optimal use of health care, improved parent-child relationships, and family economic self-sufficiency (Olds et al. 1988; Olds and Kitzman 1990; Olds et al. 1997; Olds et al. 2019). Other models such as Healthy Families America (HFA) and Parents As Teachers (PAT) also had published positive results from their home visiting evaluation studies (National Home Visiting Resource Center 2021; Ammerman et al. 2021; Goyal et al. 2020; Green et al. 2020; Finello et al. 2016; Minkovitz et al. 2016; Goyal et al. 2014; Goyal et al. 2013; Avellar and Supplee 2013). Researchers such as Anne Duggan, ScD, at Johns Hopkins University, helped to advance a larger body of research about the effectiveness and characteristics of home visiting (Duggan 2022; Duggan et al. 2013; Duggan et al. 2007; Duggan et al. 2004). Notably, the NFP studies were done in randomized trial studies, where many external factors were controlled. The HFA and PAT models were more likely to be launched by state health departments and evaluated in real-world contexts. Results of implementation in some states showed mixed but generally positive results. In response to this growing body of research, states and communities began to use these evidence-based home visiting models and similar programs with the promise of improving maternal, young child, and family outcomes. By 1999, 37 states were operating 49 state-based home visiting programs. The most frequent reasons for launching these efforts were to improve parenting skills, enhance child development, and prevent child abuse (Johnson 2001).

The logical question was: Science is clearly telling us what to do, but how are we going to put into practice what we know? Pepper argued that we must overcome the inequality by creating high-quality early childhood programs, beginning as early as possible, to ensure that all children get the best possible start. There are, Pepper told us, no magic bullets, but there are programs that make a difference. He captured the essence of the path ahead—use science to guide program development and funding, to build upon what works, and to ground collaboration and cooperation. And, as he says quite often, “Never give up.” Focusing in, Pepper said:

When the time came for the United Way, Cincinnati Children’s, and the Cincinnati-Hamilton County Community Action Agency (CAA) to agree on a program strategy to ensure all children had the best possible start, two evidence-based home visiting models (NFP and HFA) were initially chosen as the pathway. Over time, we were able to use what we drew from research and evaluation to enhance our original program offerings. ECS grew into a robust regional Cincinnati initiative with home visiting services provided through a network of contracted community-based agencies. However, none of this would have been possible if the community leaders had not accepted the challenge to act upon the science and to commit themselves to changing opportunities for children and families.

Lessons

For nonprofit organizations charged with addressing large, complex social problems, many opportunities and obstacles exist. Building on the best evidence may be in some ways the easiest step. Overcoming the challenges that solo nonprofits face may be the toughest. The conundrum we all live with—resources are finite, needs are infinite—is reality for nonprofit organizations designed to address social problems. How then can we do the best job with what we are given, and in the situations we find ourselves? Knowing that simply looking at the size of the problem can lead to paralysis, yet maintaining one’s vision, is important. In a pragmatic approach, one must start with something that is manageable; stay focused; be creative and determined; do what our quality improvement friends call “small tests of change;” and create a strong case for support for a solution that has the potential to expand and grow.

Pepper’s challenge was—and continues to be—real and immediate. An infinite number of worthy causes and effective responses to social problems exist. How do we as a society address those issues in the best possible way, using resources most effectively and documenting that what we are doing produces the results we seek? How can nonprofits be better supported in fulfilling their mission, their social-change assignment? Our society must confront the uncomfortable truth that there are, at a minimum, dual expectations for nonprofits—high-quality program delivery and outcomes, but with the lowest budgets and often-ambiguous funding incentives.

In 2011, as part of a national address to people involved in the home visiting field, P&G’s Pepper asked himself, “Having been involved in this effort now for 15 years, what have I learned?” His answers continue to inform ECS’s work and have value for other community nonprofits.

1. I have learned that this is a hard, difficult undertaking. Yet, as hard as it is, we can never give up on the objective of doing what it takes to support the development of not just some children but all children who need this support.
2. I have learned that early childhood is one area where we do need more money to get the job done, and we need to make better choices on how we allocate funds.
3. I have learned that the only way to succeed is through public/private partnerships.
4. I have learned that quality standards can and must be improved . . . establishing transparent, minimal quality standards for these programs based on research and a high level of accountability is essential to delivering better-quality outcomes, ones that deserve funding.
5. I have learned that continual learning and innovation are just as vital here in the nonprofit world as in business.
6. I have learned that while effective programs are essential, in the end, like everything else, it all gets down to people.