[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]

HEARING ON PROPOSALS TO PROVIDE
FEDERAL FUNDING FOR EARLY
CHILDHOOD HOME VISITATION PROGRAMS

=======================================================================

HEARING

before the

SUBCOMMITTEE ON INCOME SECURITY AND FAMILY SUPPORT

of the

COMMITTEE ON WAYS AND MEANS
U.S. HOUSE OF REPRESENTATIVES

ONE HUNDRED ELEVENTH CONGRESS

FIRST SESSION

__________

JUNE 9, 2009

__________

Serial No. 111-24

__________

Printed for the use of the Committee on Ways and Means

----------
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COMMITTEE ON WAYS AND MEANS

CHARLES B. RANGEL, New York, Chairman

FORTNEY PETE STARK, California DAVE CAMP, Michigan
SANDER M. LEVIN, Michigan WALLY HERGER, California
JIM MCDERMOTT, Washington SAM JOHNSON, Texas
JOHN LEWIS, Georgia KEVIN BRADY, Texas
RICHARD E. NEAL, Massachusetts PAUL RYAN, Wisconsin
JOHN S. TANNER, Tennessee ERIC CANTOR, Virginia
XAVIER BECERRA, California JOHN LINDER, Georgia
LLOYD DOGGETT, Texas DEVIN NUNES, California
EARL POMEROY, North Dakota PAT TIBERI, Ohio
MIKE THOMPSON, California GINNY BROWN-WAITE, Florida
JOHN B. LARSON, Connecticut GEOF DAVIS, Kentucky
EARL BLUMENAUER, Oregon DAVE G. REICHERT, Washington
RON KIND, Wisconsin CHARLES W. BOUSTANY JR., Louisiana
BILL PASCRELL JR., New Jersey DEAN HELLER, Nevada
SHELLEY BERKLEY, Nevada PETER J. ROSKAM, Illinois
JOSEPH CROWLEY, New York
CHRIS VAN HOLLEN, Maryland
KENDRICK MEEK, Florida
ALLYSON Y. SCHWARTZ, Pennsylvania
ARTUR DAVIS, Alabama
DANNY K. DAVIS, Illinois
BOB ETHERIDGE, North Carolina
LINDA T. SANCHEZ, California
BRIAN HIGGINS, New York
JOHN A. YARMUTH, Kentucky

Janice Mays, Chief Counsel and Staff Director

Jon Traub, Minority Staff Director

SUBCOMMITTEE ON INCOME SECURITY AND FAMILY SUPPORT

JIM MCDERMOTT, Washington, Chairman

FORTNEY PETE STARK, California JOHN LINDER, Georgia
ARTUR DAVIS, Alabama CHARLES W. BOUSTANY JR., Louisiana
JOHN LEWIS, Georgia DEAN HELLER, Nevada
SHELLEY BERKLEY, Nevada PETER J. ROSKAM, Illinois
CHRIS VAN HOLLEN, Maryland PAT TIBERI, Ohio
KENDRICK MEEK, Florida
SANDER M. LEVIN, Michigan
DANNY K. DAVIS, Illinois

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Ways and Means are also, published
in electronic form. The printed hearing record remains the official
version. Electronic submissions are used to prepare both printed and
electronic versions of the hearing record, the process of converting
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or omissions. Such occurrences are inherent in the current publication
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C O N T E N T S

__________
Page

Advisory of July 02, 2009, announcing the hearing................ 2

WITNESSES

Joan Sharp, Executive Director, Council for Children and Families
of Washington, Seattle, Washington............................. 17
Deborah Daro, Ph.D., Research Fellow, Chapin Hall Center for
Children at the University of Chicago, Chicago, Illinois....... 25
Jeanne Brooks-Gunn, Ph.D., Professor of Child Development at
Teachers College and the College of Physicians and Surgeons,
Columbia University, New York, New York........................ 34
Cheryl D'Aprix, Senior Family Support Worker, Starting Together
Program, Canastota, New York................................... 38
Sharon Sprinkle, RN, Nurse Consultant, Nurse Family Partnership,
Denver, Colorado............................................... 41

SUBMISSIONS FOR THE RECORD

Alice Kitchen, Statement......................................... 76
Children and Family Futures, Statement........................... 77
Children's Defense Fund, Statement............................... 82
Dan Satterberg, Statement........................................ 88
David Mon, Letter................................................ 90
Every Child Succeeds, Statement.................................. 90
Family Violence Prevention Fund, Statement....................... 94
First 5 Alameda County Every Child Counts, Statement............. 95
Gaylord Gieseke, Statement....................................... 98
Gladys Carrion, Letter........................................... 100
Healthy Families Florida, Statement.............................. 101
Howard S. Garval, Statement...................................... 103
Kansas Children's Service League, Statement...................... 104
Kathee Richter, Statement........................................ 105
Lenette Azzi-Lessing, Ph.D., Statement........................... 107
Marcia Slagle, Statement......................................... 109
Matthew Melmed, Letter........................................... 110
Nancy Ashley, Statement.......................................... 114
National Child Abuse Coalition, Statement........................ 115
National Indian Child Welfare Association, Statement............. 119
Oneta Templeton McMann, Statement................................ 120
Ounce of Prevention Fund, Statement.............................. 122
Parents as Teachers, Statement................................... 122
Prevent Child Abuse America, Statement........................... 125
Robin Roberts, Letter............................................ 129
Stephanie Gendell, Statement..................................... 130
The National Conference of State Legislatures, Statement......... 131
The Parent-Child Home Program, Statement......................... 132
The Pew Center on the States, Statement.......................... 137
Voices for America's Children, Statement......................... 140
Child Welfare League of America, Statement....................... 144
Fight Crime, Statement........................................... 152
Sharon Sprinkle, Statement....................................... 154

HEARING ON PROPOSALS TO PROVIDE
FEDERAL FUNDING FOR EARLY
CHILDHOOD HOME VISITATION PROGRAMS

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TUESDAY, JUNE 9, 2009

U.S. House of Representatives,
Committee on Ways and Means,
Subcommittee on Income Security and Family Support,
Washington, DC.

The Subcommittee met, pursuant to call, at 10:03 a.m., in
room B-318, Cannon House Office Building, Hon. Jim McDermott
(Chairman of the Subcommittee) presiding.
[The advisory announcing the hearing follows:]

ADVISORY

FROM THE
COMMITTEE
ON WAYS
AND
MEANS

SUBCOMMITTEE ON INCOME SECURITY AND FAMILY SUPPORT

CONTACT: (202) 225-1025
FOR IMMEDIATE RELEASE
June 02, 2009
IFSF-3

McDermott Announces Hearing on Proposals to Provide Federal Funding for
Early Childhood Home Visitation Programs

Congressman Jim McDermott (D-WA), Chairman of the Subcommittee on
Income Security and Family Support of the Committee on Ways and Means,
today announced that the Subcommittee will hold a hearing to review
proposals to provide funding for grants to States to support early
childhood home visitation programs. The hearing will take place on
Tuesday, June 9, 2009, at 10:00 a.m. in B-318 Rayburn House Office
Building. In view of the limited time available to hear witnesses, oral
testimony at this hearing will be from invited witnesses only. However,
any individual or organization not scheduled to appear may submit a
written statement for consideration by the Subcommittee and for
inclusion in the record of the hearing.

BACKGROUND:

Early childhood home visitation programs provide instruction and
services to families in their homes. These programs are designed to
enhance the well-being and development of young children by providing:
information on child health, development, and care; parental support
and training; referral to other services; or a combination of these
services. Typically visits begin during pregnancy or shortly after a
child's birth and may last until a child is age four. Home visits are
conducted by nurses, social workers, other professionals or
paraprofessionals.

A growing body of research has found strong evidence that early
childhood home visitation programs are effective in reducing the
incidence of child abuse and neglect, and in improving child health and
development, parenting skills, and school readiness. A majority of
States currently provide early childhood home visitation services to a
relatively small number of families. President Obama's FY 2010 budget
includes a proposal to support States in creating and expanding
evidence-based home visitation services. Consistent with the
President's budget proposal, Subcommittee Chairman Jim McDermott (D-WA)
and Representative Danny Davis (D-IL) are introducing legislation
today, The Early Support for Families Act, that would provide mandatory
funding to States to create and expand early childhood home visitation
programs. The McDermott-Davis bill would support rigorously evaluated
programs that utilize nurses, social workers, other professionals and
paraprofessionals to visit families, especially lower-income families,
on a voluntary basis.

In announcing the hearing, Chairman McDermott stated, ``Home
visitation programs have a proven track record of increasing the
chances that a child will have a safer, healthier, and more productive
life. There is considerable interest in expanding these programs to
reach more families. I look forward to working with all of my
colleagues to advance a proposal that will achieve that goal.''

FOCUS OF THE HEARING:

The hearing will focus on proposals to provide mandatory funding
for grants to support State efforts to establish and expand early
childhood home visitation programs.

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Chairman MCDERMOTT. This Subcommittee has a mission of
working on a bipartisan basis to ensure the safety and well-
being of children, and I hope today marks the beginning of our
next step toward that goal.
Last year, we produced major legislation to help relatives
caring for foster children to provide support for tens of
thousands of children who are now aged out of foster care on
their 18th birthday, to improve the oversight of health and
educational needs in children and to increase the support for
adoption assistance.
When we passed that bill, I said at the time our job is far
from done. We still have a child protection system that is
designed primarily as a response program, rather than a
prevention and response program.
Along with Danny Davis and Todd Platts, I put forward
legislation last week to take a more proactive approach to
helping families. The Early Support for Families Act, H.R.
2667, would provide Federal funding for home visitation
programs to reduce child maltreatment as well as to improve
children's health and school readiness. As the Federal
Department of Health and Human Services declared under
President Bush, quote, ``There is a growing body of evidence
that some home visitation programs can be successful as a child
maltreatment prevention strategy.'' I agree and I think we
ought to proceed down that road.
The Early Support for Families Act follows President
Obama's budget recommendation to provide grants to States to
help them establish or expand their voluntary home visitation
programs for families with young children and families
expecting children. Only programs using evidence-based models
that have demonstrated positive effects on important child and
parenting outcomes would be eligible for the funding. Home
visits could start during pregnancy and could be conducted by
nurses or social workers or trained paraprofessionals. The
visits would focus on providing information on child health,
development and care, on parental training and support, and on
referrals to other services.
Many States have home visitation programs funded with State
dollars and/or a hodgepodge of Federal funding. According to
the Pew Center on the States, less than 15 percent of families
needing home visitation are now served. The legislation we put
forward would provide a dedicated funding source to ensure many
more children receive the benefits of home visitation.
Although my colleague, Danny Davis, who is not here yet, I
want--he is at the Congressional Black Caucus Summit on Health.
He authored a home visitation bill in the Education and Labor
Committee during the last Congress, and the principles of that
legislation--are really a guiding force in the bill we put
forward here together. I don't believe home visitation would be
so squarely on our agenda without his efforts.
I also want to add that there is some talk about adding
this provision to the health care reform bill that is presently
being massaged through the Congress. Whether or not that
happens or not remains to be seen.
But I would now like to recognize my Ranking Member, Mr.
Linder.
Mr. LINDER. Thank you, Mr. Chairman.
Today's hearing offers a timely reminder of the differences
between the fantasyland of Washington, D.C., and the reality of
the rest of America. Here in fantasyland, we will discuss
adding one more multibillion dollar entitlement program. This
would be on top of the new higher education entitlement program
created this year, and of course, our current health care and
retirement entitlement programs whose looming insolvency
recently led President Obama to say ``we're broke.''
But we are actually worse than broke. We are massively in
debt, and it is getting deeper every day. USA Today reported
last week that in 2008 the average U.S. household owed almost
$550,000 in Federal debt. That is four times what the same
average household holds in mortgage, car loan, credit card and
other debt combined. And that is before this year's trillion-
dollar orgy of so-called stimulus spending.
Meanwhile, in the real world, the recession is forcing
States to cut current spending. And California, the Governor
proposes eliminating the welfare-to-work program and health
insurance for nearly 1 million low-income kids. After their
2009 budgets passed, 42 States enacted emergency spending cuts
totaling $32 billion.
These are not minor adjustments. Yet the legislation we
will discuss today breezily assumes States will find $3 billion
in new money over the next decade to finance their part of this
new entitlement. Where will that money come from? The tooth
fairy? Being a dentist, I can tell you something about that,
but I won't say it out loud.
I don't often agree with Robert Greenstein, the head of the
liberal Center on Budget and Policy Priorities. But last week
in the New York Times he said, ``A budget tsunami is coming.
That threat should be taken a hell of a lot more seriously than
it is now ''. In the current budget crisis, he called for
``scrapping marginal programs to save the most essential.''
Today we are ignoring that coming tsunami and strolling
along the beach contemplating another program. Several of our
witnesses will discuss how some home visitation programs have
shown some positive effects. We know that from programs already
operating, often with Federal and State program money. But
obviously our colleagues think it is not enough because it is
never enough.
If you added up all the Federal and State funds. States
could spend on home visitation, it is an incredible $244
billion a year. Obviously States don't spend all that money
this way, having other priorities or now needing to cut other
priorities. So we in Washington will create a new program that
forces them to. Not a program that increases child abuse
prevention funds that may be spent on home visitation, but a
program whose funds must be spent on home visitation, and
nothing else.
And if States won't spend this money, or can't come up with
their own share, the Federal cash will be given to another
State. So it is Washington's way or the highway. Except the
children will be the ones who will really pay when the upcoming
budget tsunami washes this and other programs away.
Mr. Chairman, all of us are interested in making sure every
child gets a good start in life. I support reviewing current
home visitation programs that fall under the Committee's
jurisdiction and how they can be improved. However, at this
time of massive and growing Federal and State deficits, I
simply cannot support the creation of a new entitlement that
would send another $8.5 billion in unpaid-for Federal spending
out the door.
To help illustrate the current economic situation, in
closing I ask unanimous consent to insert three documents into
this record at this point.
The first is an Associated Press article from last week
that lists the massive spending cuts under consideration in
California today to bring its budget into balance.
[The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

Mr. LINDER. The second is a Wall Street Journal article
from last week titled States' Budget Woes Are Poised to Worsen.
[The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

Mr. LINDER. And the third is the latest summary of the
Federal budget situation by the Congressional Budget Office
showing that the Federal deficit was $180 billion just in the
month of May.
[The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

Mr. LINDER. Thank you, Mr. Chairman.
[The prepared statement of Mr. Linder follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

Chairman MCDERMOTT. Without objection, those articles will
be entered into the record. Thank you, John.
The first witness will be Joan Sharp, who is the executive
director of the Council for Children & Families of Washington,
my home State, one of the few States that has actually an
organization set up for the specific purpose of trying to
prevent child abuse.
Ms. Sharp.

STATEMENT OF JOAN SHARP, EXECUTIVE DIRECTOR, COUNCIL FOR
CHILDREN & FAMILIES, SEATTLE, WASHINGTON

Ms. SHARP. Thank you, Chairman McDermott, Ranking Member
Linder, honorable Members of the Committee. My name is Joan
Sharp. I am the Executive Director of the Council for Children
& Families in Washington State. We are a small State agency, an
office of the Governor.
We also serve as the Children's Trust Fund of Washington
and the Washington Chapter of Prevent Child Abuse, America. Our
mission is to prevent child abuse and neglect before it occurs.
We strongly support this Committee's efforts to advance home
visiting legislation.
I am here today to share with you our experience and
expertise in funding, monitoring and supporting evidence-based
home visitation programs. From our 27 years of leading child
abuse and neglect prevention in Washington State, this is what
we have come to know with great certainty: Child abuse and
neglect are preventible.
To ensure a better future for Washington's children, we
work to increase public understanding of child abuse in order
to engage individuals, families, communities and systems in
becoming part of the solution. In the last 5 years, we have
increasingly focused on evidence-based home visiting as our
preferred strategy to decrease child maltreatment.
In 2006, the Council for Children & Families proposed to
the Washington State legislature a substantial expansion of
evidence-based home-visiting programs. This request followed a
period of significant preparation.
First, we had quantified the need. Our research suggested
that 50 percent of families under 185 percent of poverty, of
the Federal poverty level, with children birth-to-5, or a total
of about 25,000 families annually in Washington, would be
eligible for appropriate for and would voluntarily participate
in the home visiting program.
We also convened a research advisory Committee of
academicians, providers and other informed stakeholders to set
the criteria that we would use to establish a reasonable yet
rigorous evidentiary threshold. We are then able to identify a
number of home visiting models that met these criteria.
In addition, we conducted statewide outreach. We wanted to
ensure that communities understood evidence-based programs
before they embarked on their own process to determine local
interest, resource availability and which model might best meet
community needs and conditions.
In 2007, the Washington State legislature appropriated $3.5
million over a 2-year period to fund evidence-based home
visiting. We then implemented a request for proposal process,
identified the strongest applicants serving high-need
communities and initiated performance-based contracted to
implement an array of evidence-based home-visiting programs
serving diverse communities across the State.
We have since begun to see the very positive outcomes that
these programs are developing with Washington's vulnerable
children and families. We have also seen that if the strong
benefit of these programs is to be widely felt, State and local
resources alone will not get us to our goal.
The Council for Children & Families supports an array of
evidence-based home visiting models. While we want for our
children and families only the strongest programs, the truth is
that with limited research dollars available, many promising
home-visiting programs have not yet had the opportunity to
conduct the gold standard research.
The multiple randomized control trials and longitudinal
studies necessary to prove their effectiveness. And the fact is
no one size fits all. Families need and want a variety of
supports and services and communities need and want the
strategies that fit best for them.
We also are very concerned about the implementation
challenges that many organizations have in learning to deliver
these evidence-based programs with fidelity to the model. This
is an area that requires the technical assistance and training
that the legislation allows for in the set-aside for those
services. There are many implementation challenges in moving
our field to these goals.
In conclusion, I would like to thank Chairman McDermott,
Ranking Member Linder and the Committee Members for inviting us
to speak with you today. We fully support your efforts to
advance home visiting legislation and are happy to provide more
information as needed to inform your deliberations around House
Resolution 2667.
Thank you again.
[The prepared statement of Ms. Sharp follows:]
Statement of Joan Sharp, Executive Director, Council for Children and
Families of Washington, Seattle, Washington

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

Chairman MCDERMOTT. Thank you for your testimony.

I forgot to say at the start, your entire testimony will be
entered into the record, and we ask you to limit your comments
to 5 minutes. And you were 5 minutes and 6 seconds which is
almost perfect.
So I am not putting anything on anybody that I wouldn't put
on my home State. And I hope that you will all--will try to get
to whatever else is in your testimony through the questioning
period.
Dr. Daro, who is the research fellow at Chapin Hall at the
University of Chicago. Welcome. I trained at the University of
Illinois. So there is a little bit of rivalry, I suppose,
although Chicago is a big city; they have two baseball teams.

STATEMENT OF DEBORAH DARO, PH.D., RESEARCH FELLOW, CHAPIN HALL
AT THE UNIVERSITY OF CHICAGO, CHICAGO, ILLINOIS

Ms. DARO. You also grew up very close to where I live.
I want to thank you, Chairman McDermott and the Committee,
for inviting me this morning to have this opportunity to
discuss with you about what this important legislation.
The President's decision to invest in home visitation for
newborns and the Congress' willingness to act on this decision
demonstrates a commitment to an evidence-informed public
policy, a commitment essential if we are to successfully
confront complex problems such as child maltreatment. Although
no legislation comes with absolute guarantees, the Early
Support for Families Act builds on an impressive array of
empirical evidence and creates an implementation culture that
emphasizes quality and continuous program improvement.
In my time this morning I want to briefly summarize this
evidence base, talk about the program elements associated with
more positive outcomes, and underscore the importance of using
this legislation not simply to deliver a product, but also to
enhance learning.
With respect to the evidence, confidence in the efficacy of
early, home-based interventions rests on a diverse and
expanding number of high-quality program evaluations. This
includes the seminal work of David Olds and his colleagues,
showing initial and long-term benefits from early nurse home
visitation when provided to first time moms early in their
pregnancy, the expanding research including both randomized
clinical trials and other strong research designs that support
the efficacy and efficiency of several national home visitation
models serving more diverse populations and the ongoing
investment and experimentation at the State and local level
across this country to create the infrastructure necessary to
ensure such services are sustainable and integrated into
existing health and early education systems.
The consistent message from this large and growing body of
research is that the chances of success, regardless of the
model, are improved when programs have certain features. It is
improved when programs have:
Solid internal consistency that links specific program
elements to specific outcomes;
Strong provider/participant relationships that extend for a
significant period of time to accomplish meaningful change in a
parent's knowledge levels, skills and an ability to establish a
positive attachment with her infant;
Well-trained and competent staff;
High-quality supervision that includes observation of the
home visitor interacting with the parent;
Solid organizational capacity among those community
agencies delivering this service; and
Appropriate linkages to other community resources and
supports.
As Congress moves forward toward developing this
legislation, these parameters, rather than the utility of a
given model or research design, should guide your thinking.
Unless all of the interventions supported by this initiative
are structured around these types of core practice principles,
the odds of success, regardless of the model you use, are
greatly diminished.
Second, defining the evidentiary base necessary for
estimating the potential impacts of a given intervention is
complex. As noted in a recent memo to OMB by the American
Evaluation Association, ``There are no simple answers to
questions about how well programs work, and there is no single
analytic approach or method that can decipher the complexities
that are inherent within the program environment and assess the
ultimate value of public programs.'' Given this reality, this
legislation should direct States to consider a model's full
research portfolio, not simply count the number of randomized
clinical trials that have been done. Knowing a program can be
implemented under ideal circumstances is not the same as
knowing a program will achieve comparable effects when broadly
implemented with a more challenged population and in
communities that are more poorly resourced.
Fortunately, the research base on which this legislation
draws is much wider and more nuanced than a handful of clinical
trials. State planners should be directed to consider all
facets of this database in identifying those evidence-based
programs best suited to their service delivery context, their
community challenges and their at-risk populations.
Finally, the act's emphasis on evaluation and data
documentation is perhaps its most important feature. Home
visitation, while promising, does not produce consistent
impacts in all cases. Not all families are equally well served
by the model. Retention in long-term interventions can be
difficult. Identifying, training and retaining competent
service providers is challenging, particularly when the
strategy is made widely available to diverse populations.
Addressing these and similar questions requires that
evidence-based interventions be implemented not only in light
of what we know, but also in humble recognition of our
obligation to do better. Improving our ability to identify,
engage and effectively serve new parents facing the most
challenging circumstances requires more than implementing a
program. Doing better requires a research and policy agenda
that recognizes the importance of linking learning and
practice. Initiatives must be implemented and assessed in a
manner that maximizes both the ability of researchers to
determine the efforts efficacy and the ability of program
managers to draw on these data to shape their practice and
policy decisions.
The Early Support for Families Act encourages and rewards
innovation by providing State planners important incentives to
expand the pool of evidence-based programs in ways that will
strengthen outcomes for family, improve service efficiencies
and maximize social savings.
Thank you.
Chairman MCDERMOTT. Thank you very much for your testimony.
[The prepared statement of Ms. Daro follows:]
Statement of Deborah Daro, Ph.D., Research Fellow, Chapin Hall Center
for Children at the University of Chicago, Chicago, Illinois
Early intervention efforts to promote healthy child development
have long been a central feature of social service and public health
reforms. Today, prenatal care, well-baby visits, and assessments to
detect possible developmental delays are commonplace in most
communities. The concept that learning begins at birth, not when a
child enrolls in kindergarten, has permeated efforts to improve school
readiness and academic achievement (Kauffman Foundation, 2002).
Recently, child abuse prevention advocates have applied a developmental
perspective to the structure of prevention systems, placing particular
emphasis on efforts to support parents at the time a woman becomes
pregnant or when she gives birth (Daro & Cohn-Donnelly, 2002).
Although a plethora of options exist for providing assistance to
parents around the time their child is born, home visitation is the
flagship program through which many states and local communities are
reaching out to new parents. Based on data from the large, national
home visitation models (e.g., Parents as Teachers, Healthy Families
America, Early Head Start, Parent Child Home Program, HIPPY, and the
Nurse Family Partnership), it is estimated that somewhere between
400,000 and 500,000 young children and their families receive home
visitation services each year (Gomby, 2005). Although the majority of
these programs target newborns, it is not uncommon for families to
begin receiving home visitation services during pregnancy, to remain
enrolled until their child is 3 to 5 years of age, or to begin home
visits when their child is a toddler. Given that there are about 23
million children aged 0-5 in the U.S. (and about 4 million births every
year), the proportion of children with access to these services is
modest but growing.
This expansion of home visitation services has been fueled by
extensive work on the part of several national models to both
strengthen their research base and improve their capacity to provide
ongoing technical assistance and monitoring to local agencies adopting
their approach. Equally important has been the work in over 40 states
that have invested not only in home visitation but also in the
infrastructure necessary to insure services are implemented with high
quality and integrated into a broader system of early intervention and
support (Johnson, 2009). Until now, this expansion has been largely
supported through innovative state funding mechanisms and private
investment.
The Early Support for Families Act dramatically increases federal
investment in home-based services. The President's decision to invest
in home visitation for newborns and the Congress's willingness to act
on his decision demonstrate a new and important commitment to
prevention and to the type of evidence-informed public policy essential
for maximizing impacts on important child and family outcomes. Although
no legislation comes with absolute guarantees, the Early Support for
Families Act builds on an impressive array of knowledge regarding the
efficacy of home visitation programs and creates an implementation
culture that emphasizes quality and continuous program improvement.
Among the bill's most important features are the following: mandatory
funding to the states to strengthen the strategy's sustainability;
channeling these dollars to programs demonstrating strong evidence of
effectiveness; requiring states to identify how these programs will
complement and draw upon existing community efforts; and requiring the
collection and use of information to enhance practice and policy.
In my time this morning I want to summarize the evidence supporting
the expansion of home visitation programs for newborns, identify those
program elements associated with more positive outcomes, and underscore
the importance of using this legislation not simply to deliver a
service but also to enhance learning.
The Broader context of Early Learning
The rapid expansion of home visitation over the past 20 years has
been fueled by a broad body of research that highlights the first 3
years of life as an important intervention period for influencing a
child's trajectory and the nature of the parent-child relationship
(Shonkoff & Phillips, 2000). A child who can avoid trauma and
experience consistent and nurturing caregiving in their early years has
a better chance of successfully transitioning to adulthood (i.e., will
more likely be physically and emotionally healthy, well educated,
employable, and engaged in positive social exchange and civic life)
than one whose early years are filled with violence and turmoil.
In addition, longitudinal studies on early intervention efforts
implemented in the 1960s and 1970s found marked improvements in
educational outcomes and adult earnings among children exposed to high-
quality early intervention programs (Campbell, et al., 2002; McCormick,
et al., 2006; Reynolds, et al., 2001; Schweinhar, 2004; Seitz, et al.,
1985). These data also confirm what child abuse prevention advocates
had long believed--getting parents off to a good start in their
relationship with their infant is important for both the infant's
development and for their relationship with parents and caretakers
(Cohn, 1983; Elmer, 1977; Kempe, 1976).
The key policy messages from this body of research are that
learning begins at birth, and that to maximize a child's developmental
potential requires comprehensive methods to reach newborns and their
parents. Individuals may debate how best to reach young children; few
dispute the fact that such outreach is essential for insuring children
will have safer, healthier, and more productive lives. Over time, these
individual benefits translate into substantial societal savings on
health care, education, and welfare expenditures (Heckman, 2000).
Why Home Visitation?
A central feature of this emerging developmental approach to
addressing child abuse and other negative outcomes for children is an
increased focus on expanding the availability of home visitation
services to newborns and their parents. Drawing on the experiences of
western democracies with a long history of providing universal home
visitation systems and emerging evidence of the model's utility in the
United States, the U.S. Advisory Board on Child Abuse and Neglect
concluded that ``no other single intervention has the promise of home
visitation'' (U.S. Advisory Board, 1991: 145). The seminal work of
David Olds and his colleagues showing initial and long-term benefits
from regular nurse visiting during pregnancy and a child's first 2
years of life provided the most robust evidence for this intervention
(Olds, Sadler & Kitzman, 2007).
Equally important, however, were the growing number of home
visitation models being developed and successfully implemented within
the public and community-based service sectors. Although initially less
rigorous in their evaluation methodologies, these models demonstrated
significant gains in parent-child attachment, access to preventive
medical care, parental capacity and functioning, and early
identification of developmental delays (Daro, 2000). This pattern of
findings, coupled with Hawaii's success in establishing the first
statewide home visitation system, provided a compelling empirical and
political base for the initial promotion of more extensive and
coordinated home visitation services.
The Evidence of Success
Over the past 15 years, numerous researchers have examined the
effects of home visitation programs on parent-child relationships,
maternal functioning, and child development. These evaluations also
have addressed such important issues as costs, program intensity, staff
requirements, training and supervision, and the variation in design
necessary to meet the differential needs of the nation's very diverse
new-parent population.
Attempts to summarize this research have drawn different
conclusions. In some cases, the authors conclude that the strategy,
when well implemented, does produce significant and meaningful
reduction in child-abuse risk and improves child and family functioning
(AAP Council on Child and Adolescent Health, 1998; Coalition for
Evidence-Based Policy, 2009; Geeraert, et al., 2004; Guterman, 2001;
Hahn, et al., 2003). Other reviews disagree Chaffin, 2004; Gomby,
2005). In some instances, these disparate conclusions reflect different
expectations regarding what constitutes ``meaningful'' change; in other
cases, the difference stems from the fact the reviews include different
studies or place greater emphasis on certain methodological approaches.
It should not be surprising to find more promising outcomes over
time. The database used to assess program effects is continually
expanding, with a greater proportion of these evaluations capturing
post-termination assessments of models that are better specified and
better implemented. In their examination of 60 home visiting programs,
Sweet and Appelbaum (2004) documented a significant reduction in
potential abuse and neglect as measured by emergency room visits and
treated injuries, ingestions or accidents (ES = .239, p < .001). The
effect of home visitation on reported or suspected maltreatment was
moderate but insignificant (ES = .318, ns), though failure to find
significance may be due to the limited number of effects sizes
available for analysis of this outcome (k = 7).
Geeraert, et al. (2004) focused their meta-analysis on 43 programs
with an explicit focus on preventing child abuse and neglect for
families with children under 3 years of age. Though programs varied in
structure and content, 88 percent (n = 38) utilized home visitation as
a component of the intervention. This meta-analysis, which included 18
post-2000 evaluations not included in the Sweet and Appelbaum (2004)
summary, notes a significant, positive overall treatment effect on
reports of abuse and neglect, and on injury data (ES = .26, p < .001),
somewhat larger than the effect sizes documented by Sweet and
Appelbaum.
Stronger impacts over time also are noted in the effects of home
visitation on other aspects of child and family functioning. Sweet and
Appelbaum (2004) note that home visitation produced significant but
relatively small effects on the mother's behavior, attitudes, and
educational attainment (ES .18). In contrast, Geeraert et al. (2004)
find stronger effects on indicators of child and parent functioning,
ranging from .23 to .38.
Similar patterns are emerging from recent evaluations conducted on
the types of home visitation models frequently included within state
service systems for children aged 0 to 5. Such evaluations are not only
more plentiful, but also are increasingly sophisticated, utilizing
larger samples, more rigorous designs, and stronger measures. Although
positive outcomes continue to be far from universal, families enrolled
in these home visitation programs, as compared to participants in a
formal control group or relevant comparison population report fewer
acts of abuse or neglect toward their children over time (Fergusson, et
al., 2005; LeCroy & Milligan, 2005; DuMont et al., 2008; Old, et. al.,
1995; William, Stern & Associates, 2005); engage in parenting practices
that support a child's positive development (Love, et al., 2009;
Zigler, et al., 2008); and make life choices that create more stable
and nurturing environments for their children (Anisfeld, et al., 2004;
LeCroy & Milligan, 2005; Wagner, et al., 2001). Home visitation
participants also report more positive and satisfying interactions with
their infants (Klagholz, 2005) and more positive health outcomes for
themselves and their infants (Fergusson, et al., 2005; Kitzman, et al.,
1997). One home visitation model that initiates services during
pregnancy has found that by age 15 the children who received these
visits as infants reported significantly fewer negative events (e.g.,
running away, juvenile offenses and substance abuse) (Olds, et al.,
1998).
Home visits begun later in a child's development also have produced
positive outcomes. Toddlers who have participated in home visitation
programs specifically designed to prepare them for school are entering
kindergarten demonstrating at least three factors correlated with later
academic success--social competency, parental involvement, and early
literacy skills (Levenstein, et al., 2002; Allen & Sethi, 2003;
Pfannenstiel, et al., 2002). Longitudinal studies of home visitation
services that begin at this developmental stage have found positive
effects on school performance and behaviors through sixth grade
(Bradley & Gilkey, 2002) as well as lower high school dropout and
higher graduation rates (Levenstein, et al., 1998).
A prime consideration for the unique emphasis on nurse home
visitation within the President's proposal is the long-term cost
savings found in Nurse Family Partnership's (NFP) initial trials. These
savings were primarily realized through a reduction in the subsequent
use of Medicaid and other entitlement programs as a result of women
receiving the intervention entering and remaining in the workforce.
Although comparable data have not been collected on the other home
visitation models, the range of outcomes achieved by many of them
suggests similar savings could accrue from them as well. Additional
areas for potential savings include stronger birth outcomes among
families enrolled prenatally in a sample of Health Families New York
programs (Mitchel-Herzfeld, et al., 2005), higher monthly household
earnings among those who access Early Head Start services (Love, et
al., 2009), and better school readiness and a reduced need for special
education classes among children enrolled in PAT or Parent Child Home
Program (Ziegler et al., 2008; Levenstein, et al., 2002).
In short, confidence in the efficacy of early home-based
interventions with newborns and their parents rests with numerous
randomized control trials, quasi-experimental evaluations with strong
counterfactuals, and detailed implementation studies that have
demonstrated both the efficacy and efficiency of this approach. Perhaps
the most compelling use of these data is not to simply highlight a
given model's efficacy but rather to underscore the importance of high-
quality implementation and service integration. The full volume of
research data across various models clearly shows that the chances of
success are improved when any program embraces certain features such
as:

Solid internal consistency that links specific program
elements to specific outcomes
Forming an established relationship with a family that
extends for a sufficient period of time to accomplish meaningful change
in a parent's knowledge levels, skills, and ability to form a strong
positive attachment to the infant
Well-trained and competent staff
High-quality supervision that includes observation of the
provider and participant
Solid organizational capacity
Linkages to other community resources and supports

As Congress moves toward developing legislation to act on the
President's promise to provide early intervention services to those
children facing the most significant obstacles, these parameters--
rather than the utility of a given model or given workforce structure--
should guide policy development. Unless all of the interventions
supported by this initiative are structured around core practice
principles, the odds of success, regardless of the model implemented,
are greatly diminished.
Defining Standards for Evidence-Based
Defining the evidentiary base necessary for estimating the
potential impacts of a given intervention is complex. In general, two
lines of inquiry guide the development of program evaluations: Does the
program make a measurable difference with participants (efficacy)? And,
does a given strategy represent the best course of action within a
given context (effectiveness)? Randomized control trials are often
viewed as the best and most reliable method for determining if the
changes observed in program participants over time are due primarily to
the intervention rather than to other factors. Maximizing the utility
of program evaluation efforts, however, requires more than just
randomized clinical trials. As noted by the American Evaluation
Association in a February, 2009 memo to OMB Director Peter Orszag:
There are no simple answers to questions about how well programs
work, and there is no single analytic approach or method that can
decipher the complexities that are inherent within the program
environment and assess the ultimate value of public programs. (AEA
Evaluation Policy Task Force, 2009).
Well-designed effectiveness evaluations are needed to improve the
quality of home visitation programs and their successful replication.
However, knowing that a program is capable of achieving effects under
ideal conditions is not the same as knowing it will achieve effects
when broadly implemented with more challenged populations or in more
poorly resourced communities. In the real world, the success of a home
visitation program will depend on how local parents from all points on
the risk continuum view early intervention services, on what service
and provider characteristics will attract new parents into these
programs, and on the relation between these efforts and other elements
within a community's existing service continuum.
In many respects, the core features of a well-done randomized
trial--a highly specified intervention, consistent implementation, and
a specific target population--limit the ability to generalize its
findings to diverse populations and diverse contexts. In determining
which programs constitute the highest level of evidence, states should
examine a model's full research portfolio. Although randomized clinical
trials are excellent for assessing impacts, they offer little guidance
in terms of how to integrate such efforts into existing healthcare and
educational systems, the vehicles through which a truly comprehensive
national effort to support new parents needs to be based. The knowledge
and assurances needed to build this type of integrated system for at-
risk children and their parents will be found in the evidence being
generated by diverse analytic and research methods such as those that
have been and are being incorporated by a number of home visitation
efforts throughout the country.
Assuring Continuous Program Improvement
The emphasis it places on evaluation and program monitoring is an
important feature of the Early Support for Families Act. Under this
legislation, states will be required to provide annual reports
outlining, among other things, the specific services provided under the
grant; the characteristics of each funded program, including
descriptions of its home visitors and participants; the degree to which
services have been delivered as designed; and the extent to which the
identified outcomes have been achieved. This type of systematic data
collection and monitoring is particularly critical as home visitation
programs become more widely available. Home visitation, while
promising, does not produce consistent impacts in all cases. Not all
families are equally well served by the model; retention in long-term
interventions can be difficult; identifying, training, and retaining
competent service providers is challenging, particularly when the
strategy is designed to be offered widely and integrated into existing
early intervention systems. Finally, although home visitation programs
are substantial in both dosage and duration, even intensive
interventions cannot fully address the needs of the most challenged
populations--those struggling with serious mental illness, domestic
violence, and substance abuse as well as those rearing children in
violence and chaotic neighborhoods. Addressing these and similar
questions requires that evidence-based interventions be implemented in
light of what we know along with a determination to do better.
Identifying the appropriate investments in home visitation programs
will require a research and policy agenda that recognizes the
importance of linking learning and practice. It is not enough for
scholars and program evaluators, on the one hand, to learn how
maltreatment develops and what interventions are effective and for
practitioners, on the other, to implement innovative interventions in
their work with families. Instead, initiatives must be implemented and
assessed in a manner that maximizes both the ability of researchers to
determine the effort's efficacy and the ability of program managers and
policymakers to draw on these data to shape their practice and policy
decisions. Most of the major national home visitation models recognize
this objective and have engaged in a series of self-evaluation efforts
designed to better articulate those factors associated with stronger
impacts and to better monitor their replication efforts. For example,
the Nurse Family Partnership maintains rigorous standards with respect
to program site selection. Data collected by nurse home visitors at
local sites is reported through the NFP's web-based Clinical
Information System (CIS), and the NFP national office manages the CIS
and provides technical support for data entry and report delivery.
Since 1997, Healthy Families America's (HFA) credentialing system has
monitored program adherence to a set of research-based critical
elements covering various service delivery aspects, program content,
and staffing. And, after 3 years of extensive pilot testing and review,
Parents as Teachers (PAT) released its Standards and Self-Assessment
Guide in 2004.
In fulfilling their reporting obligations under the Early Support
and Education Act, state planners should be encouraged to draw on these
systems in developing a coordinated database that will allow them to
look across the models they are implementing. This integrated data
system can be used to determine the constellation of models and
collaborative efforts needed to better identify, engage, and
effectively serve the communities and families in facing their greatest
challenges.
Achieving Broader Outcomes
Home visitation is not the singular solution for preventing child
abuse, improving a child's developmental trajectory, or establishing a
strong and nurturing parent-child relationship. However, the empirical
evidence generated so far does support the efficacy of the model and
its growing capacity to achieve its stated objectives with an
increasing proportion of new parents. Maintaining this upward trend
will require continued vigilance to the issues of quality, including
staff training, supervision, and content development. It also requires
that home visitation be augmented by other interventions that provide
deeper, more focused support for young children and foster the type of
contextual change necessary to provide parents adequate support. These
additions are particularly important in assisting families facing the
significant challenges as a result of extreme poverty, domestic
violence, substance abuse, or mental health concerns.
All journeys begin with a single step. The Early Support for
Families Act provides states an important vehicle for identifying the
best way to introduce home visitation into its existing system of early
intervention services. Chapin Hall's review of this process suggests
states are already responding to this challenge by requiring that any
model being replicated reflect best practice standards, embrace the
empirical process, and be sustainable over time through strong public-
private partnerships (Wasserman, 2006). The ultimate success of this
legislation will hinge on the willingness of state leaders to continue
to support data collection and careful planning and on the willingness
of program advocates to carefully monitor their implementation process
and to modify their efforts in light of emerging findings with respect
to impacts.
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Chairman MCDERMOTT. Our next witness is Dr. Brooks-Gunn,
who is a graduate of Connecticut and Harvard and the University
of Pennsylvania. She has written four books.
And, Dr. Gunn, we appreciate your testimony.

STATEMENT OF JEANNE BROOKS, PH.D., PROFESSOR OF CHILD
DEVELOPMENT AT TEACHERS COLLEGE AND THE COLLEGE OF PHYSICIANS
AND SURGEONS, COLUMBIA UNIVERSITY, NEW YORK, NEW YORK

Ms. BROOKS-GUNN. Thank you very much. It is a pleasure to
be here addressing the Members of this Committee. Thank you,
Chairman McDermott and Ranking Member Linder.
I am a developmental psychologist by training. I have been
spending 30 years following families over time to see what
circumstances help them do better and what circumstances impede
success for both parents and children. I have also been
involved in the evaluation and design of three different
programs that are relevant to this hearing today: the Infant
Child and Development Program, the Early Head Start National
Evaluation and the Home Instruction For Parents of Preschool
Youngsters, affectionately known as HIPPY.
For understanding the review of literature, what we know
about how home visiting works, I would suggest that all of you
turn to The Future of Children. This is a particular set of
volumes that has been looking at what programs are effective
for children and families. The Future of Children has an issue
on home visiting in 1993, 1999, 2005 and 2009. I was involved
in coauthoring the articles in 2005 and 2009. But it gives you
a really great history over time of what we found.
What I want to do today is talk about the different
strategies that we have for enhancing young families' lives. I
am particularly interested in young, first-time mothers. They
are the most vulnerable, as are their children, for later
problems in life. I would like you to consider also several
different kinds of outcomes that programs can have.
What we are concerned about for what I will just call
first-time young mothers and their education success. Clearly,
we have to be worried about if we can enhance their education,
if we want long-term impact on them or on their children.
The second is their parenting capabilities and capacities,
and home-visiting programs do address this. Part of this is
child abuse and neglect, but there are other aspects of
parenting capabilities that we are interested in.
And, of course, the third is children's school readiness.
So how do these strategies that we all have been looking at
over the years stack up in terms of the outcomes that we think
are important? First, home-visiting programs that offer--are in
conjunction with center-based care do seem to have the ability
to increase these young mother's education. That is very
important. Programs that are just home-visiting programs alone,
in general, do not increase parents' education; the nurse home
visiting program is an exception to this.
Almost all the programs that you will hear about do seem to
influence parenting capabilities and capacities. This is very
important when you look at the range of programs that exist.
These programs--these effects are modest, but they are
consistent across programs.
Very few programs actually reduce the incidence of child
abuse and neglect, and there are a variety of reasons for that
that we can talk about later.
In terms of school readiness for the children, when we are
focusing on the children, some, but not all, home-visiting
programs have shown that they can change the school readiness
of children. Home-visiting programs often also target child and
health safety and seem to do a good job of targeting this.
Some programs are able to change maternal mental health,
although that is very, very difficult to change in general. So
I also focus on the effectiveness factors in programs to try to
get the outcomes that we want, the effectiveness factors that I
think are important from my review of the literature. Specific
curriculum, very intensive services, home-visiting programs
that provide services less than weekly in general are not
likely to be effective. There are a couple of exceptions to
that. But, in general, if it is not intensive, it is probably
not going to have an effect.
We need well-trained staff. This includes ongoing
evaluation during the home visits themselves. This is typically
not done. We need well-educated staff. My read of the
literature is, the programs using paraprofessionals are, in
general, not likely to be effective when we compare these to
programs that use professionals and more educated staff.
And the services provided is very important. Even in
programs that are designed to be intensive, we have to make
sure that people receive the expected number of home visits.
So, in summary, we can make differences.
What kinds of programs should we be putting in place? There
are some home-visiting programs that look like they will do
what we want them to do. I also would urge the Committee to
allow States to do some sort of demonstrations to see what
happens when you combine home visiting with programs that offer
these young mothers educational supports so that we can get the
mothers to increase their education. Since this is a poorly
educated group, these first-time, young mothers.
States could also try combination programs, if possible,
that combine the best of home visiting with child care.
Otherwise, if we don't try both to keep the effectiveness
factors in place, we will not be able to impact the families
that are being served.
Thank you.
Chairman MCDERMOTT. Thank you very much for your testimony.
[The prepared statement of Ms. Brooks-Gunn follows:]
Statement of Jeanne Brooks-Gunn, Ph.D., Professor of Child Development
at Teachers College and the College of Physicians and Surgeons,
Columbia University, New York, New York
It is a pleasure to be here today, addressing the members of the
House Ways and Means Subcommittee on Income Security and Family
Support. I will be considering the evidence for the effectiveness of
programs for young, first-time mothers, both in terms of their impacts
on the mothers themselves and their infants, toddlers and preschoolers.
A developmental psychologist, I have spent the last 30 years examining
the life courses of families, both parents and their children, with a
special focus on what might be termed vulnerable families. These would
include families whose parents are young, are poor, are unmarried, and/
or have low educational levels. I am interested in identifying what
conditions are likely to enhance the success of parents who are rearing
their children under the often difficult circumstances. I have also
designed and evaluated a set of programs which aim to enhance the well-
being of parents and children. These include the Infant Health and
Development Program, the Early Head Start National Evaluation, and the
Home Instruction for Parents of Preschool Youngsters (HIPPY).
References and documentation of the comments made in this testimony
may be found in articles in The Future of Children
(www.futureofchildren.org) from Issue 15 (2005, on Racial and Ethnic
Gaps in School Readiness, edited by C. Rouse, S. McLanahan and J.
Brooks-Gunn), Issue 9 (1999, on Effectiveness of Home Visiting, edited
by D. S. Gomby), and Issue 19 (2009, article by K. S. Howard and J.
Brooks-Gunn on The Role of Home-Visiting Programs in Preventing Abuse
and Neglect). A list of publications by Brooks-Gunn is available at
www.policyforchildren.org.
The Problem
The families being considered today are those with young, first-
time mothers. Each year, almost one-half of a million children are born
into these families. Young, first-time mothers, as a group, have
relatively low levels of education, which limits their access to
stable, well paid employment. These mothers, often living in precarious
economic circumstances, are also more likely to exhibit harsh
parenting, inconsistent parenting, and insensitive parenting, all of
which are associated with lower cognitive and emotional capacities of
their children than mothers who are older and have more education. The
children of young mothers are also more likely to experience child
abuse or neglect than those born to older, more educated parents. In
brief, young, first-time mothers are likely to have low levels of
education and more financial hardship as well as to exhibit less
optimal parenting. Their children, in turn, are less likely to develop
the capacities necessary for success in school and in later life. All
three outcomes (maternal education, parenting behavior, and child
capabilities) have been, and should be, targets of intervention.
Enhancing the Lives of Young Mothers and Their Children
Is it possible to help young mothers improve their educational
status and/or their parenting capabilities? The answer, from both
longitudinal studies and intervention programs, is yes.
Is it possible to improve directly the educational success of their
children (most often measured by how well prepared their children are
for entry into school)? The answer is yes. Well-developed early
childhood education programs do so.
Is it possible to enhance school readiness of young children by
improving maternal education and/or parenting capabilities of young
mothers? The answer is yes. It is most likely that such enhancements
will occur if both the young mothers and the children are both provided
intervention services.
Strategies for Enhancing Young Family's Lives
Several different types of programs have been developed for
improving young mothers' education and parenting capabilities as well
as their children's school readiness. Each has demonstrated
effectiveness, although not every program has been effective.
Maternal education programs provide supports and incentives for the
continued education of young mothers. Welfare demonstration programs
focusing on maternal education report small to modest impacts on
education, as have some home visiting programs and some programs
offering home-visiting services to the parents and center-based
educational services to the children.
A variety of programs, usually home-based, demonstrate modest
consistent effects on parenting capabilities (reductions in harsh
parenting and increases in sensitive parenting). Many but not all
programs provide such evidence.
Some programs also have, as their aim, preventing child abuse and
neglect. Of those programs that look at child abuse and neglect
directly (i.e., substantiated cases), only a few have reduced child
abuse and neglect. However, given the incidence of child abuse and
neglect, program evaluations often do not have the power to detect such
differences (while they do have the power to detect differences in
parenting capabilities).
Home-visiting programs often target child health and safety, child
cognitive development, and maternal mental health. Child health and
safety have been enhanced by several programs. Fewer home-visiting
programs have altered child cognitive development (unless they are
coupled with center-based child care; but see, for exceptions, the
Nurse Family Partnership in Denver and Memphis and Early Head Start and
one Healthy Families evaluation).
Effectiveness Factors
Effective programs for families with young children (indeed, for
programs generally) have the following characteristics----
Specific curricula with clearly defined goals and educational
methods to achieve such goals
Intensive services (home-visiting programs that provide services
less than weekly in general are not effective; although see Early Start
as an exception)
Well-trained staff (training prior to implementation as well as on-
going training including evaluation during home visits themselves)
Well-educated staff (programs using paraprofessionals are less
likely to be effective than those using professionals and more educated
staff)
Services provided (some programs are designed to be intensive, even
though most families do not receive the expected number of home visits;
programs in which the delivered dose is low are likely not to be
effective)
Best Bets for Investments
Based on the current literature, young first-time mothers seem to
benefit most from home-visiting programs. Thus, targeting this group is
a good bet.
Also, home-visiting programs (if well-developed) are most likely to
alter parenting practices than child abuse and neglect. Several of the
programs also have the potential to enhance school readiness.
It is likely that two-generation programs, that combine home-
visiting programs with child care, will be necessary to alter maternal
education. Programs might also need to provide other specific
educational supports (help in the navigation of post-secondary
education institutions in a specific community, tuition assistance or
conditional tuition assistance).
It would be ideal if states were allowed to mount demonstration
programs that combine educational and parenting supports to see if
combinations of services provide greater impacts on parents and
children than just parenting support alone. The same might be true if
parenting capabilities were enhanced via home-visiting and, at the same
time, child care assistance were provided.
In general, any programs that are implemented must be able to
document and continue documenting, fidelity to the effectiveness
factors outlined above. Otherwise, the investments are unlikely to
impact the families which are being served.
National Center for Children and Families
(www.policyforchildren.org)

Chairman MCDERMOTT. Our next witness is Cheryl D'Aprix, who
brings a combination of having been a recipient of some
visitation as well as now being a home visitor herself.
Ms. D'Aprix.

STATEMENT OF CHERYL D'APRIX, SENIOR FAMILY SUPPORT WORKER,
STARTING TOGETHER PROGRAM, CANASTOTA, NEW YORK

Ms. D'APRIX. Thank you and good morning, Mr. Chairman and
distinguished Members of the Committee. My name is Cheryl
D'Aprix and I am a family support worker in the Healthy
Families America program serving Madison County in New York. It
is an honor and a privilege to be here today to share my
experience, first as a participant in Healthy Families America
and now as a home visitor for the program.
In 1993, my husband, Jeff, my 3-year-old daughter, and I
were presented with a new challenge. I received the news that
we would be expecting another baby and could welcome him in
about 7\1/2\ months. I gently broke the news to my husband and
together we sat in silence, each struggling with our own fears
and thoughts.
Jeff had his mind on the already-insufficient funds and how
we were going to replace all the baby furniture we had just
given away because we were convinced that we were already
blessed and would not have any more children. I was busy
thinking about having to go through postpartum depression with
another baby.
I had suffered with PPD for more than a year after the
birth of my daughter. I had no clue what was happening to me,
but I made it through that year with the patience of my husband
and kind words from my family. I was petrified of going through
it again and the possibility of it worsening. I had heard the
horror stories in the news, and I prayed that I could remain
well enough to take care of our children and hold things
together at home.
Visiting with a friend, I expressed some of my concerns,
and she recommended I check into a home visiting program that
was available in our county through the Community Action
agency. The program is called Starting Together, which is part
of Healthy Families America, New York. The program partners
with families who have children, prenatal to 3 to 5 years of
age.
During my pregnancy, she would meet with me weekly, and
Jeff would join us whenever he got the chance. She listened to
me and she shared information with me. She gave us the support
I needed to not only feel like a competent parent to the child
I already had, but she helped me gain the confidence I needed
to talk with my doctor about the postpartum depression. I was
afraid that whichever doctor happened to be on call that day
would either just dismiss my concern or tell me it is normal to
have the baby blues after a baby comes.
Through the information she brought me, I knew it was much
more than the baby blues; and I was able to get the help I
needed with medication and strong shoulders, and I was on my
way to a healthier life and a more secure attachment with my
son.
Once Damian was born, our home visitor brought us
curriculum on the stages of development, books and videos on
basic care and information on community resources that helped
our family stay afloat. She left information on fatherhood for
Jeff so he could feel more confident and strong in the vital
role that he played in our lives. Throughout the course of 3
years, we spent time together doing activities with the kids,
setting attainable goals for my family and spending countless
hours just talking. We talked about everyday stresses, and at
that point there were plenty of those.
We also spent time about talking my life and what it was
like growing up. She gave me the opportunity to tell my story,
and I came to see that I too was worth listening to. She
laughed with me on the good days and she let me cry on the bad
days that were so overwhelming that I could barely get one foot
on the floor. But I put that foot on the floor because I knew
she was coming to visit. It meant so much to me that she
understood the importance of nurturing the parent as well as
the child.
When Damian turned 3, my family graduated out of the
program. Jeff was working two jobs, I was now working full time
and our daughter was honing the skill of bossing her baby
brother around. The job I was doing was unfulfilling, but it
helped pay the bills.
On our last home visit, our support worker encouraged me to
apply for an open position at the program as a home visitor.
After all she had taught me and all the ways our family had
benefited from the program, I was excited about applying for
the job. I was anxious to start lending a helping hand and a
supportive ear to other parents. One of the greatest gifts she
gave me was the belief in myself, and I was lucky enough to
have the program see my strengths, as well, and I was offered
the position.
My home visiting career started out with many, many months
of training and researching community resources so that I could
be equipped to meet the diverse needs of each family. The very
heart of Healthy Families America is promoting healthy parent-
child interaction and child development. While on the floor
doing activities together, we also discussed life challenges
such as housing, employment, accessing medical care or
transportation.
Offering referrals and brainstorming ways to remove the
barriers that families feel interfere with their success is the
key part of our visits. One recent example is, I visited a
young, single mother with relationship challenges and
insufficient income. I referred her to a child care center
which she enrolled her child in, enabling her to go to work.
Once she had a stable income, we were able to connect her to a
first-time home buyers program, which provided her with a
financial education to make sure homeownership was appropriate
for her.
I am happy to report that she is still successfully
employed and does own her own home. Outcomes can be amazing
when supports are identified and goals are attainable.
So, here I am 8 years and a few home visits later, and I am
still learning about the benefits and the power of preventive
programs, and my passion to partner with families is as strong
as ever. I home visit with low-income families, no-income
families and middle-class families who are now finding
themselves in positions they have never been in before. They
all had a multitude of stresses and some just need another
adult to talk to, each having their own story worth listening
to, each craving the opportunity to learn and grow and each
deserving to be nurtured.
The common bond with each and every one of these families,
including myself, is their child. We all want the best for them
and we want more than anything in the world to be the ones to
give it to them.
I have seen both sides of what a home visiting program can
accomplish, and it is so much more than life changing. It is
life enhancing. So I thank you today from the bottom of my
heart for your time and your own supportive ears.
Thank you.
Chairman MCDERMOTT. Thank you very much for telling your
story to us. It is tough.
[The prepared statement of Ms. D'Aprix follows:]
Statement of Cheryl D'Aprix, Senior Family Support Worker, Starting
Together Program, Canastota, New York
Good morning Mr. Chairman and distinguished members of the
committee. My name is Cheryl D'Aprix, and I am a Senior Family Support
Worker with the Healthy Families America program serving Canastota, New
York. It is an honor and a privilege to be here today to share my
experience, first as a participant in the Healthy Families America
program, and now as a home visitor for the program.
In 1993, my husband Jeff, our 3-year-old daughter and I were
presented with a new challenge. I received the news that we would be
expecting another baby and could welcome him into our world in about
7\1/2\ months. I very gently broke the news to my husband and together
we sat in silence each struggling with our own fears and thoughts. Jeff
had his mind on the already insufficient funds and how we were going to
replace all the baby furniture we had just given away because we were
convinced we were already blessed and would not have any more children.
I was busy thinking about having to go through post partum depression
with another baby. I had suffered with PPD for more than a year after
the birth of our daughter. I had no clue what was happening to me but I
made it through that year with the patience of my husband and kind
words from my family. Now I was petrified of going through it again and
the possibility of it worsening. I had heard the horror stories in the
news and I prayed that I could remain well enough to take care of our
children and hold things together.
While visiting with a friend, I expressed some of my concerns and
she recommended that I check into a home-visiting program that was
available in our county through our Community Action agency. The
program was called Starting Together, which is part of Healthy Families
America, NY. The program partners with families who have children
prenatal to three to five years of age. After much thought and a
lengthy conversation with Jeff I reluctantly gave the program a call. I
have to say that it was really scary and unnatural to invite a stranger
into my home but after just a few minutes of meeting with our home
visitor I knew that we had made the right decision for our family.
During my pregnancy she would meet with me weekly and Jeff would
join us whenever he got the chance. She listened to me and shared
information with me. She gave me the support I needed to not only feel
like a competent parent to the child I already had but she helped me
gain the confidence I needed to talk with my doctor about the post
partum depression. I was afraid that whichever doctor happened to be on
call that day would either just dismiss my concern or tell me it's
normal to have the blues after a baby comes. Through the information
she brought me I knew that it was much more than the baby blues. I was
now able to get the help I needed and with medication and strong
shoulders, I was on my way to a healthier life and a more secure
attachment with my son.
Once Damian was born, our home visitor brought us curriculum on the
stages of development; books and videos on basic care and information
on the community resources that helped our family stay afloat. She left
information on fatherhood for Jeff so that he could also feel competent
and strong in the vital role he played in our lives. Throughout the
course of three years, we spent time together doing activities with the
kids, setting attainable goals for my family and spending countless
hours of just talking. We talked about everyday stresses and there were
plenty of those. We also spent time talking about my life and what it
was like growing up. She gave me the opportunity to tell my life story
and I came to see that I too, was worth listening to. She laughed with
me on the good days, and she let me cry on the bad days that were so
overwhelming I could barely get one foot on the floor. But I put that
foot on the floor because I knew she was coming to visit. It meant so
much to me that she understood the importance of nurturing the parent
as well as the child.
When Damian turned three, my family graduated out of the program.
Jeff was working 2 jobs, I was now working full time, and our daughter
was honing the skill of bossing her baby brother around. The job I was
doing was unfulfilling but it helped pay the bills. On our last home
visit our support worker encouraged me to apply for an open position in
the Starting Together program as a home visitor. I jumped at the
chance. After all she had taught me, and with all the ways our family
had benefited from the program I was excited about applying for the
job. I was anxious to start lending a helping hand and a supportive ear
to other parents. One of the greatest gifts our home visitor left with
me was the belief in myself and I was lucky enough to have the program
see my strengths as well and I was offered the position.
My home visiting career started out with months of training and
researching community resources so that I could be equipped to meet the
diverse needs of each family. The very heart of Healthy Families
America is promoting healthy parent/child interaction and child
development. While on the floor doing an activity together we will also
discuss life challenges such as housing, employment, accessing medical
care or transportation. Offering referrals and brainstorming ways to
remove barriers that the family feels may interfere with their success
is a key part of our visits. As one recent example, I visited with a
single mother with relationship challenges and insufficient income. I
referred her to a child care center, which she enrolled her child in,
enabling her to go to work. Once she had a stable income, we were able
to connect her to a first-time homebuyers program, which provided her
with financial education to make sure home ownership was appropriate
for her. I am happy to report that she is still successfully employed
and owns her own home. Outcomes can be amazing when supports are
identified and goals are attainable.
So here I am eight years and a few home visits later. I am still
learning about the benefits and the power of preventative programs and
my passion to partner with families is as strong as ever. I home visit
with low-income families, no income families and middle class families
who are now finding themselves in positions they have never been in
before. All who have a multitude of stresses and some that just need
another adult to talk to. Each having their own story worth listening
to, each craving the opportunity to learn and grow, each deserving to
be nurtured. The common bond with each and every one of these families
(including myself) is their child. We all want the best for them and we
want more than anything in the world, to be the ones to give it to
them.
But despite all the many proven benefits of home visiting, benefits
that I witness everyday, the lack of resources in most communities
limits the reach of home visiting services to the lucky few. A federal
investment in evidence-based home visiting, as proposed by Chairman
McDermott, Congressman Davis, and Congressman Platts, will ensure that
more families in communities across the country are given the
opportunity to participate in this valuable service. I urge every
member of this committee to support an investment in evidence-based
early childhood home visitation services and to move quickly and
thoughtfully on legislation authorizing new federal funding.
I have seen both sides of what a home visiting program can
accomplish and it's so much more than life changing. It's life
enhancing. I thank you from the bottom of my heart today for your time
and your own supportive ears.
Thank you.

Chairman MCDERMOTT. Our next witness is Sharon Sprinkle,
who is a program manager for the Nurse Family Partnership
Program. And she has been doing it for 8 years and has probably
seen a lot.
Ms. Sprinkle.

STATEMENT OF SHARON SPRINKLE, NURSE CONSULTANT, NURSE-FAMILY
PARTNERSHIP, DENVER, COLORADO

Ms. SPRINKLE. Thank you. Good morning, Mr. Chairman,
Ranking Member Linder, and Members of the Subcommittee. Thank
you for the opportunity to testify on behalf of the Nurse-
Family Partnership program in support of evidence-based early
childhood home visitation.
I am Sharon Sprinkle and I work as a nurse consultant for
the Nurse-Family Partnership National Service Office. I have
been fortunate to serve in many different capacities for Nurse-
Family Partnership, as a nurse home visitor, a nurse supervisor
and now as a nurse consultant, integrating the knowledge and
skills from my earlier roles to help guide and support our
nurses, administrators and agencies to successfully deliver
program services. I am here in support of the Obama
Administration's proposed initiative to create a new evidence-
based home visitation program for low-income families.
I would like to thank Chairman McDermott, Congressman Davis
and Members of the Subcommittee for their commitment to
improving the health and well-being of children with dedicated
funding for evidence-based home visitation. The Nurse-Family
Partnership program model has served almost 100,000 families to
date, and we currently have over 18,000 first-time families
enrolled in 28 States.
Our voluntary program provides home visitation services by
registered nurses to low-income, first-time mothers beginning
early in the pregnancy and continuing through the child's
second year of life. The children and families we serve are
overwhelmingly young, poor and minority. Our families are at
the highest risk of experiencing significant health,
educational, and employment disparities that have lasting
negative impacts on their lives and communities.
Nurse-Family Partnership has three major goals; they are to
improve pregnancy outcomes, improve child health and
development, and improve parents' economic self-sufficiency.
Nurse-Family Partnership is an evidence-based program with
multigenerational outcomes that have been demonstrated in three
randomized controlled trials conducted in both urban and rural
locations, and with Caucasians, African Americans and Hispanic
families.
A randomized controlled trial is the most rigorous research
method for measuring the effectiveness of an intervention. The
Nurse-Family Partnership model has been tested for over 30
years with the ongoing research, development and evaluation
activities conducted by Dr. David Olds. Evidence from one or
more of these trials demonstrates powerful outcomes, including
a 79-percent reduction in preterm deliveries of women who
smoked, 56-percent reduction in emergency room visits for
accidents and poisonings, 46-percent increase in fatherhood
involvement in the household, 59-percent reduction in arrests
of a child at age 15, and 72-percent reduction in arrests by
the mother of the child at age 15.
As the Nurse-Family Partnership model has moved from
science to practice, great emphasis has been placed on building
the necessary infrastructure to ensure quality and fidelity to
the research model during the replication process nationwide.
Independent evaluations have found that investments in the
Nurse-Family Partnership model lead to significant returns to
society and government. For example, the Pacific Institute for
Research Evaluation released a report in March of 2009 which
found a 154-percent return on Federal Medicaid investment over
10 years from the Nurse-Family Partnership model based on
findings from the Memphis trial that showed reduced enrollment
in Medicaid and food stamps.
I would like to take this opportunity to share an
experience I had as a nurse home visitor while working with a
client named Alice in Greensboro, North Carolina. Alice became
pregnant when she was 14 and was caring for her child while
living in an apartment with six siblings and her two parents.
She called me one morning because no one in her family could
take her to her local WIC appointment--Women, Infants and
Children. During the car ride, Alice informed me that her
household had not had power for a week, but she didn't seem too
upset by this development.
I knew immediately that Alice and her family needed
assistance identifying and connecting to community resources. I
called the Department of Social Services, but did not get much
of a response. So I decided to contact the few local community
nonprofits that would assist low-income families who are unable
to pay for food and other vital services. Two organizations
agreed to jointly cover the electric bill.
When I drove Alice home, I told her that she could tell her
father that the power would be restored the next day. Up until
this point, in my relationship with Alice and her family,
Alice's father was not very engaged during my visits. After the
electricity was restored to the house, this proud man said to
me, ``A lot of people say they will help, but you are the one
that really did it.''
This is one of the many stories about the impact that
Nurse-Family Partnership has. We can help break the cycle of
poverty by empowering young mothers to become knowledgeable
parents who can care for their children and guide them along a
healthy life course.
The Nurse-Family Partnership urges the Subcommittee to
devote resources to assist States in implementing and expanding
their home visitation programs to serve even more vulnerable
families. We encourage the Committee to target taxpayer
resources to the poorest communities that often lack the
critical maternal and child health and social resources to
ensure that the most at-risk families succeed.
I would like to thank the Subcommittee for inviting me to
testify. And I would also like to thank Chairman McDermott and
Congressman Davis and Platts for their leadership on behalf of
the Early Support for Families Act.
Chairman MCDERMOTT. Thank you very much for your testimony.
[The prepared statement of Ms. Sprinkle follows:]
Statement of Sharon Sprinkle, RN, Nurse Consultant, Nurse Family
Partnership, Denver, Colorado

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Chairman MCDERMOTT. I am going to start, I think, by
letting Mr. Linder ask the first question, because I want to
think a little bit about--you opened up so many possibilities,
I am not quite sure that the staff questions are quite what I
want to do. So I am going to wait.
Mr. LINDER. Thank you very much. I would like to ask a
question of Ms. Sprinkle.
I have seen numbers of 6,000 children are born to girls 14
and younger each year in this country. Is the prospective
mother your client or is the family your client?
Ms. SPRINKLE. The mom is the client, because when you
improve parenting capacity, the child reaps the benefits.
Mr. LINDER. The pregnant mother is the client?
Ms. SPRINKLE. Yes. We enroll clients prenatally before they
are 28 weeks pregnant. With first-time moms there is a window
of opportunity in which they are receptive to the education and
are willing to make a change and are committed and motivated to
make the change for a better life for their child.
Mr. LINDER. The program, as proposed, is going to try and
help 450,000 people a year and I am told that there is about
1.5 million in the same boat.
Who picks and chooses? Ms. Sharp?
Ms. SHARP. Well, from our point of view as a State agency,
we look at a number of factors, but the primary one is the
capacity of the local community, the implementing organization,
to be able, from their perspective using data that is available
on all sorts of measurements, to be able to target the
resources, and services to those most at need most able to be
positively impacted.
So, from our point of view, it is a local decision that we
would be guiding.
Mr. LINDER. Dr. Daro, as a scientist evaluating programs,
Ms. Sharp said in her testimony that for every dollar spent,
$3.02 is saved.
How does a scientist or an examiner make that decision?
Ms. DARO. The cost savings are determined by looking at a
group of people who receive the service and those that didn't
receive the service generally, randomly assigned to these two
conditions; and then you look at their experiences in utilizing
public resources going forward.
In the case of the Nurse-Family Partnership, they have 18,
20 years of evidence. And what you find in the individuals who
have received services, is less welfare utilization, less use
of public health care dollars because there is greater
employment. And that occurs because, as Jeanne noted, they stay
in school longer and they complete their education.
So it begins a cycle of investment in themselves such that
the social savings can be realized down the line.
Mr. LINDER. Mr. Chairman, I ask unanimous consent to put in
the record the fiscal year 2010 budget conference agreement. A
CRS memo describing on page 2 includes a provision establishing
a deficit-neutral reserve fund for establishing or expanding
home visitation programs.
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Mr. LINDER. The bill before the Committee, we are told,
will cost about 2 billion dollars over 5 years. The proposal in
the Obama budget would cost 9 billion dollars over 10 years in
just Federal funds for this new program.
Today, the President is going to speak on urging us to pay
for all new entitlements. So can anyone tell us how we are
going to pay for this?
Mr. Chairman? Mr. Davis? Do you have offsets?
Chairman MCDERMOTT. Are you asking us or are you asking the
witnesses?
Mr. LINDER. I am asking you how it is going to be paid for.
Chairman MCDERMOTT. My policy basically, Mr. Linder, is
this: One should decide what good public policy is and once you
have decided what good public policy is, then you decide how
you are going to pay for it.
I think what we are trying to do here today is determine,
what is the best public policy. And you are correct, finding
the money for it is going to be a real problem.
Mr. LINDER. Dr. Brooks-Gunn, can any of the money in this
program be used for anything else? Can it be used for drug
treatment? I assume you read the proposal. Is this a mandate
for just nurse visitations, if the State has a bigger problem
in another area, can it be used there?
Ms. BROOKS-GUNN. I think the State options--you guys are
the ones that will have to decide if there is some State----
Mr. LINDER. Flexibility.
Ms. BROOKS-GUNN. Flexibility, thank you. Flexibility in
terms of how the money is spent now.
Mr. LINDER. There isn't now?
Ms. BROOKS-GUNN. At the moment, most home-visiting
programs, because of the cost, do not offer drug treatment,
although people certainly try to link up their clients with
what might be available in their community for mental health
services and for drug treatment services.
Mr. LINDER. Thank you.
Thank you, Mr. Chairman.
Chairman MCDERMOTT. My question is this, and it really
comes off what John has said. And I read all your testimony
before you came in; and I want you for 1 minute to think about
the perfect program and what it would look like.
Because as I look at it, you can do prevention, you can
sort of say there is a high-risk bunch over there, let's focus
on them; or we can sort of, one, look for the ones like Ms.
D'Aprix, who have had some problems and put their hand up and
said, I am high risk--there are a lot of different ways to go
at this.
And are you looking at first-time mothers?
If you had limited dollars, where would you put the program
and what would it look like? I would like to hear as much as
you can give me, so you can start anywhere.
Anyone want to put their hand up and go on that?
Ms. DARO. Never shy.
I think if I were starting with some dimensions, I would
certainly begin to look during pregnancy, begin to--and do a
systematic risk assessment, not necessarily use demographic
markers for this, because I think--as we heard from Cheryl's
testimony--using the demographic markers is going to miss a
number of women that are facing significant challenges.
So it would be prenatally. Remember, these programs are all
voluntary. So you need to present them in a way that is most
welcoming and encouraging for families to come forward. So I
would start with the systematic assessment at all prenatal
clinics. I would engage OB-GYNs so they were asking a set of
questions when women came to them and then make this service
available to people.
Again--I think I have outlined the parameters of what a
successful program would look like, but the idea of targeting
simply on demographics, I think does a great disservice to the
nature of the problem and to the nature of our ability to
really reach those families that are most challenged.
Chairman MCDERMOTT. How would you--I will leave the
question alone for a second.
Go ahead, Dr. Gunn.
Ms. BROOKS-GUNN. I would probably start with the first-time
and young mothers, because I think that is a group at most
risk.
Chairman MCDERMOTT. Is your microphone on?
Ms. BROOKS-GUNN. Yes, it is on.
I would actually target first-time and young mothers. That
is the group that is most at risk, and programs such as these
ones that we are discussing today are most likely to make an
impact overall on that group of mothers. Consequently, I like
the way the bill has focused on that particular group of
mothers.
It doesn't mean other families might not be at risk. But it
is a group that on the aggregate is more at risk than probably
any other group.
Again, the education of the mother and the school readiness
of the children is for both generations. My ideal program would
focus on both generations. That is why I would love to see some
experimentation in States, in terms of combining home visiting
with child care services, and/or combining home visiting with
some of the new approaches that are being tested right now to
help moms go back to school or stay in school.
Chairman MCDERMOTT. Do you know any program that has had
any kind of positive predictive capacity to pick out child
abuse situations before they happen?
Ms. DARO. The Healthy Families America model has a
screening tool that they use for assessing risk. It examines a
variety of conditions such as asking if the mom used prenatal
care perhaps, or if she is under a great deal of stress.
When they follow these families forward, the families with
the highest number of stresses and risks during pregnancy, by
the time they give birth, are far more likely to show up in
child abuse reporting systems.
I will just say, to follow up on what she said, when we
look at families reported for child abuse, we look at the
proportion of the population of those children coming into
child welfare. It is not necessarily the first-time, teen moms
that show up in child welfare. It is the woman who is in her
20s, who is having her second or third child. Those were the
big welfare users; those are the families in the child welfare
system.
You should not limit the program only to first-time
parents. It is great if we catch them when they are first-time
parents, but if we missed them and there is no other option on
the table to provide services. We know that a second and third
child just adds to the stress of the family situation.
Chairman MCDERMOTT. Ms. Sprinkle, you are out in the field.
What would be the ideal program to deal with what you have
seen?
Ms. SPRINKLE. Chairman McDermott, I don't think there is--
--
Chairman MCDERMOTT. Your microphone is not on.
Ms. SPRINKLE. I don't think----
Chairman MCDERMOTT. Just swallow it.
Ms. SPRINKLE. My experience, I don't believe that there is
one home visitation program that fits all the needs of
families.
Programs that have been proven to be effective and have
long-term impacts are where I would place my emphasis and at
the same time recognize that there are multiple families out
there who are not first-time parents. If you really want to
make a positive impact on preventing child abuse and neglect or
reducing it, you must catch the first-time parent and teach her
what is happening with her body and the ways to cope with the
stresses in her life and to put her in touch with resources to
reduce some of those stressors.
I agree with you that education is very important.
Education is the key out of poverty in my estimation. So, if
you can provide wraparound services or support services to
those first-time moms and help her get connected or attached,
if you will, during pregnancy, then she is less likely to be
abusive to her child because she will understand or have been
taught what to look for when she is stressed and how to support
and nurture a child who is difficult to console.
Ms. SHARP. I would like to add a note.
I think it is important that we keep an R&D function
associated with these programs so that we can build the
pipeline of programs that can eventually get the research and
evaluation to establish their effectiveness. I agree otherwise
with these other commentators.
Chairman MCDERMOTT. Thank you.
Dr. Boustany.
Mr. BOUSTANY. Thank you, Mr. Chairman. Listening to all of
you and having read the testimony, I gather that programs
administered by nurses seem to be more effective than programs
administered by those who are not nurses. Is that correct,
based on current literature?
Ms. SPRINKLE. I can only share what my experience has been
with Nurse-Family Partnership. Dr. David Olds, before doing the
randomized clinical trials of which there were three across
three different decades using three different ethnic groups--
Caucasians in Elmira, New York; African Americans in Memphis;
and Hispanics in Denver, Colorado.
He did a focus group, if you will, asking potential
participants or Members in a community who would be most
trusted in terms of letting you into their homes, and
overwhelmingly it was nurses. Nurses have the trust of the
community and are seen as nurturing individuals who were there
to support them and have the medical and scientific knowledge
to support them during such a critical time in pregnancy.
Mr. BOUSTANY. Do you all agree with that?
Ms. SHARP. I will make a quick comment, and I would just
like to say that certainly nurse-delivered programs have been
proven very effective.
I will just reiterate the point in my testimony which is,
many programs have not had the opportunity to have the same
level of rigorous evaluation. So I think that there is some
evidence still out on that issue.
Mr. BOUSTANY. Thank you.
Dr. Brooks-Gunn, did you want to comment?
Ms. BROOKS-GUNN. Yes.
If we can expand to other countries besides the United
States, my read of the literature is that what is important is
a professional, not necessarily a nurse. It depends on the
goals of the program.
The Nurse-Family Partnership has very specific goals, and
so the nurse makes sense. But I think that there are
demonstrations in the literature where social workers,
educators, folks with B.A.s with terrific training can have
some of the impacts that we want to see.
My read of the literature is that the paraprofessionals--in
general, those are the programs that are least likely to
succeed.
Mr. BOUSTANY. Thank you.
Dr. Daro.
Ms. DARO. I would just add that we don't have to go
overseas. There are evaluations here in the United States. New
York State--the last time I checked, it was in this country--
has had success with paraprofessionals. A lot of the success of
the paraprofessionals, though, hinges on the quality of
training they receive and the supervision they receive.
So it is not sufficient to say what is the characteristic
of the provider, it is the way you embrace--surround that
provider with certain supports; and I think with certain
support, they certainly can be effective.
Mr. BOUSTANY. I gathered from reading your testimony that
there are a number of programs that are of questionable
effectiveness; others have been shown to be very effective. And
it seemed to me that programs administered by nurses had a more
proven track record, or at least more consistent track record.
Would you want to comment on that?
Ms. DARO. With the outcomes--as Jeanne noted, if the
program is designed toward certain outcomes, such as the Nurse-
Family Partnership, nurses may be effective, but their own
randomized trial comparing nurses and paraprofessionals found
some mixed results.
There were actually some outcomes where the
paraprofessionals did better by the time the child was 4--areas
like maternal employment, areas like enrolling a child in an
early education program. Those are important outcomes to
consider when we are thinking about long-term potential
savings.
Mr. BOUSTANY. I know our Ranking Member talked about the
cost and how all this would be paid for, given the current
deficits. There was also another cost factor in all this that I
don't think has been discussed, particularly if we are looking
at nurses. That is the acute nursing shortage we have in this
country and given current circumstances.
So if we expand with a new entitlement program that is
going to be heavily reliant upon nurses, then there is going to
be the expense of getting more nurses available and trained to
do this. I am not sure if that is included in the cost analysis
that has been provided.
I don't know if you want to comment on that.
Ms. BROOKS-GUNN. That is one reason that many of us want to
see some experimentation with different programs. So, as an
example, we have a grant pending at NIH--we will see if we get
it--to take the nurse home visiting model and have nurses come
into the home two or three times over the 3 years and then have
folks with a B.A. delivering the services. The idea was to get
what you get from a nurse home visiting program, but make it
cheaper so that a nurse--we want to leverage it. And this is
something that--again, as the field evolves, we have to keep
looking to see what makes sense.
To me and David Olds, who is going to help us with this,
this seems like a really good bet to see if this would work.
But stay tuned.
Mr. BOUSTANY. One last question if you don't mind.
There are a lot of different programs out there, a lot of
different funding sources. Given the variation in
effectiveness, has there been any systematic look at some of
these programs that are really not effective? How do we combine
resources rather than create a whole new mandatory spending
program?
Ms. DARO. The way the legislation is crafted, which is
actually very instructive and very useful, is to direct States
toward investing in stronger and stronger program models as the
legislation goes forward; and I think that is important. I
think States themselves, local communities as a field, we need
to be able to recognize those programs that are not working and
then move them off the plate so those resources can be invested
in programs that have stronger evidence.
Mr. BOUSTANY. Before increasing spending again in a new
mandatory spending program, shouldn't we look at the current
resources and try to make a more efficient use of those?
Ms. SHARP. I would like to state, as someone responsible
for administering public dollars, that we did in fact cut
funding from programs in our State based on lack of
performance; and I think a responsible administering entity
would be looking at those--this is after some attempts were
made to make sure they had the capacity--and build the capacity
to be able to deliver programs effectively. When that became--
when it became clear that was not going to be the case, then we
were able to remove funding based on these performance-based
contracts.
Mr. BOUSTANY. How many programs did you eliminate?
Ms. SHARP. A relatively small number of the total portfolio
and in some cases it was an issue at the community level in
terms of local capacity to continue to come up with the
resources to match our dollars.
But there are also just some straight-out not delivering
program with fidelity to the model, as a matter of fact,
being--straining far afield and those are the kind of things
that a funder or administrator would want to make sure they
were looking at along with the data about the outcome.
Chairman MCDERMOTT. Mr. Davis of Illinois will inquire.
Mr. DAVIS of Illinois. Thank you very much, Mr. Chairman.
You know, as you were making your earlier comments, I was
reminded myself of the fact that you did go to medical school
in Illinois; and that perhaps is one of the reasons that I was
in agreement with your comments. Let me thank you for your
leadership on this as well as a number of issues that relate to
the well-being of children and ultimately to the well-being of
our country.
I have always believed that all of us are the sum totals of
our experiences. I have spent at least 500 home visits with
visiting nurses, with community health aides, with nurse
practitioners, with individuals in training to become nurse
practitioners; and I agree with you, Ms. Sprinkle. I don't
think that there is any one set of individuals who necessarily
get the information or see certain kind of needs or can make
use of those needs in such a way that we ultimately reduce the
likelihood that children growing up or that their families are
going to cost society more than they would if we provide these
services to them.
My question is, based upon each one of your experiences,
who do you think are the people that are most likely to make
use of this program and these services once we pass the bill,
find the money, and get it established? Who are the people who
are going to make use of it?
Perhaps we will just begin with you, Ms. Sharp.
Ms. SHARP. Okay, I will start with that. My read of the
literature and understanding of the program services, one issue
becomes very clear and that is the issue of engagement. If
families, if individuals, families, moms, dads, are not brought
into the program consistent with the values within the program,
in other words, respect and honesty, all those other things
that go along with this, then you are not going to have success
in the program by any measure because engagement is a critical
part of that and retention is the other side of the engagement
process. So I think the programs, all of these programs, are
challenged by those issues of reaching out and finding the
people who would have the greatest benefit.
But I do trust the local implementers of these programs to
know their communities well enough to be able to reach deeply
into the community to find those with the greatest need who
would experience the greatest benefit.
Mr. DAVIS of Illinois. Dr. Daro.
Ms. DARO. You know, having done several surveys on the idea
of the social exchange process, people are twice as likely to
offer help as they are to ask for help. So one of the things we
have to do with voluntary prevention programs is create a
context in which parents are comfortable asking for help.
So who should ask for help? I think parents that have
questions about their own capacity to care and meet the needs
of their child, a first-time parent that may not have the
information they need or the knowledge available in how to
nurture and support that child or meet just basic care
conditions, families that are going through some particular
stress in their own lives, women that are concerned about their
own safety. There is a whole constellation of issues that need
to be brought to the table.
But I would put the responsibility on both creating a
context in which an offer of assistance will be receptive to
someone hearing this and then make it broadly available. Let
people know, again, starting at pregnancy through birth. Many
of the programs that have been most successful in reaching
high-risk families do a universal offer of assistance, a
universal visit, if you say while women are in the hospital
delivering, outlining a set of conditions, and again making
that offer available to them.
Mr. DAVIS of Illinois. Dr. Brooks-Gunn.
Ms. BROOKS-GUNN. My answer is similar to Dr. Daro's.
Mr. DAVIS of Illinois. Ms. D'Aprix.
Ms. D'APRIX. From a personal perspective, I don't think
there is a parent out there that doesn't want to learn, that
doesn't want to experience someone supporting them, whether it
is your first child, your second child.
I visit with a family who now is on their sixth child, with
two sets of twins under two, and really asking for support. And
through the temp assessment we partner with every doctor's
office, every hospital so that we can be there and available to
offer services to every family.
Mr. DAVIS of Illinois. Ms. Sprinkle.
Ms. SPRINKLE. I think the families that benefit the most
from this type of intervention will be those families from low
income, vulnerable populations who don't have the advocates in
place or the resources needed to ask for assistance or even
know to ask for assistance. So increasing an awareness of
services that are available to them in the community will make
great strides in getting families the services that they need.
Mr. DAVIS of Illinois. Thank you, Mr. Chairman.
Chairman MCDERMOTT. Thank you.
Mr. Roskam from Illinois.
Mr. ROSKAM. Thank you, Mr. Chairman; and thank each of you
for your time today.
And, Ms. D'Aprix, thank you very much for sharing your
journey. It is helpful, and it is insightful.
As we are sitting here listening, I am reminded of my older
brother who has no discernment when it comes to movies. You
call him up. ``Steve, should I go see this movie?'' ``Oh,
yeah'', he says. ``It is great. You will like it''. You go see
it, and it is not very good. And you call him up later and you
say, ``I thought you said this was good;'' and he says, ``well,
it was entertaining.'' He has no discernment whatsoever.
You call my wife and say, ``should I see this movie?'' And
she says, ``no. No magic, no plot line. They ran out of money.
They ended it too fast. Don't waste your time.''
So as I am here today, I am trying to discern, are you more
like my brother or are you more like my wife? The question is a
serious one. Because here you are, three of you. You all gave
great testimony. Three of you sort of hit a particular theme,
and I stopped writing down the number of times that you
referred to an evidentiary threshold or peer review or those
sorts of themes. And that was you, Ms. Sharp, and you, Dr.
Daro, and you, Ms. Sprinkle.
Implicit in your testimony when you use an evidence-based
argument is that there are programs that you have looked at in
this environment where you have said, ``That is a loser. We are
not going to do that.''
You mentioned a minute ago, Ms. Sharp, that there was a
program or some kind of de minimis program--I am putting words
in your mouth a little bit--but some that stuff because of a
local match you kind of waived off on. But I guess, Dr. Daro or
Ms. Sprinkle, are there programs that you have looked at in
this arena and you just said, ``This is not going to cut it?''
I will get to you, because I sense you have got something to
say.
Ms. DARO. There certainly are. I think there are programs
that are not well conceived. They are going to accomplish
everything in the world with the family. What are these
programs offering? They claim they can accomplish these broad
outcomes with three home visits. That is a no-brainer for me.
It is not going to happen.
So I think you can look at the internal consistency of a
program, their logic model, I think; and then you look at
outcomes. If time and time again they can only engage a handful
of the people they want to bring into the program, they only
retain people for a fraction of the time they want to keep
them, I think that kind of ongoing data management should begin
to tell you this program needs to go back and retool. It is not
ready for prime time.
And there are, unfortunately, a number of programs that
just crop up. We call them homegrown programs. They are not
attached to any of the national models. They just exist because
somebody thinks it is a great idea.
I think in this environment we can't fund everybody's great
idea. We need to be able to pull the plug.
Mr. ROSKAM. Thank you.
Ms. Sprinkle.
Ms. SPRINKLE. I am supportive of programs that will improve
lives of families in general, particularly low-income minority
families, because we know that they are at risk for the worst
outcomes in terms of economics and health.
Most certainly you want to put your resources where you are
going to get the greatest benefit, those programs that have a
data tracking system, that look at client characteristics, that
look at the quality of the home, that look at content and have
a curriculum or protocol with the desire and intent to make a
positive impact outcome.
Mr. ROSKAM. I don't want to cut you short. I want to
refocus you on this question. Have programs come across your
desk that are home visitation programs that have those
characteristics that you have looked at and you said, `` we are
not going to do that?'' Or have you liked every home visitation
program that you have heard about?
Ms. SPRINKLE. My experience has been exclusively with Nurse
Family Partnership.
Mr. ROSKAM. Thank you.
Ms. Sharp.
Ms. SHARP. I did want to get back to your question about
being more like your brother or your wife.
Mr. ROSKAM. Choose well.
Ms. SHARP. And I guess think of me as your sister-in-law.
Mr. ROSKAM. Fair enough.
Ms. SHARP. Yes, we have definitely come across programs
that we did not find the evidence persuasive as to their
effectiveness, and we did not include them on the list of those
that we would fund. And we are committed to reviewing the
literature and new evidence as it comes along, but clearly
there are some programs that may even do harm.
Mr. ROSKAM. One quick final word. Ms. Sprinkle, you
mentioned that, in that example of the 14-year-old that you
gave, that there were people that the family had reached out to
that weren't willing to help. And I guess part of the concern
that some of us have is how do we direct programs that are
actually getting toward that particular need? So implicit in
that is that some program is failing this family, right? A
well-intentioned, good program is failing this family. I am
going to share with you one quick quote, and it is from
President Obama's inaugural speech.
He said, ``The question we ask today is not whether
government is too big or too small but whether it works. And
where the answer is no, programs will end.''
In closing, our challenge, in light of the President who
tells us that we are broke, is how do you properly allocate
resources? How do we all properly allocate resources so that
those families that really need the help are helped and that
there is not a great deal of waste? I think that is what Dr.
Boustany was driving at, taking a step back, looking at the
totality of these programs and trying to move forward where
there is a great deal of consensus.
I think my time has expired.
Chairman MCDERMOTT. Since we have good experts here, I
thought we would go a second round, if anybody would like to.
Mr. Davis.
Mr. DAVIS of Illinois. Thank you very much, Mr. Chairman. I
had a couple of additional questions.
I guess part of my experiences have been that I am old
enough to remember when a lot of things didn't really exist.
Physician assistants, I happen to have been a Member of the new
career section of the American Public Health Association when
many of the ancillary groups who now provide certain kinds of
services did not exist.
I wanted to ask two questions. Dr. Daro, I wanted to ask
you, we have talked a great deal about stable funding. Although
I agree with Chairman McDermott, if we come up with good social
policy, then we can determine how to get the money once we
decided that it is good. But why is a stable funding stream so
important in the development of a program like this one?
Ms. DARO. I think when you are talking about investing in
newborns and their parents and you are trying to do it on a
scale large enough to impact the population-based indicators
that most distress you, like reducing child abuse, like making
sure children arrive at school ready to learn, families need to
know that this isn't a program that is going to be here today
and gone tomorrow. They need to know that it is going to be
here for them when they have their first child or their second
child, that they can refer their neighbors to it.
And too often programs that are quite good--I mean, one of
the problems is it is not just poor programs in the
marketplace, it is good programs in the marketplace that have
way too many families that they can't possibly reach or serve.
It is good programs in the marketplace that lose their
foundation funding so they have to close their doors. That does
a disservice to the communities, and that is why the stable
funding is so important.
Mr. DAVIS of Illinois. So we talk a great deal about these
things but do them much less. I mean, I was saying that after
all is said and done, more is generally said than done. So
there is a lot of conversation, not movement to the action.
My last question, Ms. Sprinkle. I notice that you placed a
great deal of emphasis on low-income people. Why did you place
so much emphasis, on low-income, disadvantaged individuals?
Ms. SPRINKLE. Low-income, disadvantaged individuals
typically don't have the advocates needed to help them get the
resources to meet their needs.
My experience, growing up here in Washington, D.C., within
walking distance from the Capitol here is an experience in
which I grew up in a low-income environment; and those are the
families that can benefit greatest from this type of service.
Mr. DAVIS of Illinois. So you are saying that if we don't
create special attention for these individuals for as long as
they live, as long as their children live, and as long as their
population group lives, they will still be low-income,
disadvantaged people?
Ms. SPRINKLE. When families are presented a program that
helps meet their needs, hopefully it breaks the cycle of
poverty and has a positive multi-generational impact.
Mr. DAVIS of Illinois. Thank you very much.
Thank you, Mr. Chairman.
Chairman MCDERMOTT. Dr. Boustany.
Mr. BOUSTANY. Ms. Sprinkle, are the nurses in your programs
RNs or LPNs or both?
Ms. SPRINKLE. The nurses in the Nurse Family Partnership
are registered nurses, predominantly baccalaureate prepared
registered nurses.
Mr. BOUSTANY. My son is a counselor. He does home visits.
He finished with a master's degree and jumped into one program,
and it was very disorganized. A lot of people were quitting.
There was no continuity of care with the families. He went to
another one, the same sort of thing. Now he is doing something
different in counseling, but he was very frustrated. He said,
``We are not going to make a dent in any of this because we are
not measuring outcomes properly.''
The continuity issue is a real problem. There was just no
structure to any of the programs. I was thinking, ``Okay, that
is two programs in my home State of Louisiana, a lot of it
being funded by Medicaid dollars.'' States are struggling with
their budgets across the country. How many more of these kinds
of programs are out there, and how do you root them out? You
talked about having a way of doing it in your home State. But
are the other States equipped to do this? Are they doing a good
job?
Ms. SHARP. I guess I would just like to add that our
ability to sort through and make these performance-based
contracts work, along with the capacity building, goes back 20
years to our focus on outcome-based evaluation. We felt that,
as a funder, our best value add for these local organizations
was to help them understand how to be outcome-based and to know
how to measure and report those results. And so that has been
the key to their sustainability.
So it is part of our learning organization way of doing
business to sort of focus on those kind of things. And those
can--while it sounds very specific to a reporting process, it
actually is what builds the organizational capacity to deliver
programs with effective service delivery models.
Mr. BOUSTANY. Thank you.
I know Senator Moynihan has talked about all this back in
the seventies, and breaking this cycle of poverty is something
I am certainly interested in. I have got a high degree of
poverty in my district. I am frustrated because it seems like
we throw a lot of money into programs, but we never weed out
the bad ones, consolidate the good ones, and focus the
resources, as my colleague, Mr. Roskam, was saying earlier.
I guess I have one final question, in the spirit of
Father's Day, which is approaching. What share of households
have the fathers in the picture in this? And can you talk to me
about some of the best practices of what is happening there?
Ms. DARO. Almost all of the models now have explicit
instructions to visitors when they go in the home to engage as
many as they can. And I think the Nurse Family Partnership does
a wonderful job with fatherhood. I know Healthy Families
America does as do many of the other programs that are out
there. I mean, people recognize that dads are a big part of the
picture, and they need to be there at the beginning, hopefully
engaged in the pregnancy, if at all possible.
Mr. BOUSTANY. Thank you.
Ms. BROOKS-GUNN. The best way to do that, actually, could
be programs that really start in the hospitals. We talk about
the magic moment, and that is when the child is born. And you
can often get fathers very engaged at that point whether or not
they are in the household or they are living elsewhere.
Ms. SPRINKLE. In my experience working in Greensboro, North
Carolina, operating a Nurse Family Partnership program, we had
a fatherhood component where the services were designed
exclusively for the dad, to get him involved in the life of the
child early on; and you can see the positive impacts it has on
the child when the dad is involved, if not physically present
in the home, emotionally present in the child's life in a
positive way.
Mr. BOUSTANY. So you do make efforts to reach out when the
dad is not in the home to make contact with him? And so that
is, in effect, a separate visit, or at least phone calls?
Ms. SPRINKLE. He can be included in the visit during the
time of the home visit in Nurse Family Partnership. There are
some programs that are specifically designed to serve fathers
outside of that relationship with the mother, because they have
their own needs and resources.
Chairman MCDERMOTT. If the gentleman will yield, Ms.
D'Aprix, you are sitting there rocking your head, but you are
not saying anything. Come on.
Ms. D'APRIX. I am. We have a fatherhood program within the
Starting Together Program for Madison County. When we go out to
visit a family for the first time, we take the information
about him; and we set up a visit for the family to meet with
him. And that is every single family.
Mr. BOUSTANY. What kind of outcomes are you getting with
trying to get the father involved? Do you have some metrics on
that? I mean, success rates? Is the trend good or bad or
neutral?
Ms. SPRINKLE. Nurse Family Partnership has been able to
demonstrate a 46-percent increase in fatherhood involvement
within the Nurse Family Partnership program.
Ms. SHARP. I will have to get back to you on that one.
Ms. BROOKS-GUNN. It is going to have to be anecdotal. There
is not much in the literature about what is happening to the
father as a function of home visiting programs.
Mr. BOUSTANY. Should that be part of the metrics, though?
Ms. SHARP. I mean, it goes back to my point about building
the pipeline. Because we are funding some very exciting
programs that are showing very strong outcomes related to
father engagement, et cetera. But they are not at this point
evidence-based programs.
Chairman MCDERMOTT. Thank you.
I would just close by saying in my training back in 1965,
the Mental Health Act had passed in the U.S. Congress and the
first mental health centers were opening across the country of
Illinois, the money went--in every State, it went to the
Governor, except in Illinois. Mayor Daley got a chunk of it.
I was at the University of Illinois, and it was there where
we started the first mental health center in the Woodlawn area
south of the University of Chicago. It was an area that was
troublesome to the Mayor; and he said, well, what they need is
a mental health center. So they sent a group of us down there
to start a mental health center in the Woodlawn area.
And when they got together with the community, they said to
them, what do you want this mental health center to do? And
they said, well, it is over for us as adults, but we care about
our kids. We want this mental health center to focus on the
kids.
And we did research for a number of years there around what
affects school performance and how kids do and so forth. And
getting the parents involved and actually going up to school
and actually seeing what the kids did really was the most
effective thing, because suddenly they knew their parents cared
about what was going on.
That research was done 1965, 1966, 1967, 1968. I don't
think there has ever been a program funded off of it. And what
a struggle I think our Subcommittee has is to figure out which
one of these evidence-based programs or how we should put the
money out there so that States will look at it in that way that
that is--we ought to take things that have already been
researched and implement them and give them a solid funding
base, which is really what Mr. Davis is talking about. We start
them, stop them. And one gets going and looks good and then we
defund it.
So I think that is what the Committee on both sides of the
aisle is really looking at, it is how can we figure out where
the best place to put the money is and actually fund things
that we know have had positive effect. So I am thankful and we
are all thankful for your coming here and spending the time
trying to educate us and we will see what works out in the
future.
Thank you. The meeting is ended.
[Whereupon, at 11:27 a.m., the Subcommittee was adjourned.]
[Submissions for the Record follow:]
Statement of Alice Kitchen
My name is Alice Kitchen. I am a social worker and the Principal
Investigator for the Team for Infants Endangered by Substance Abuse
(TIES) sponsored by Children's Mercy Hospitals and Clinics in Kansas
City, Missouri. We strongly support passage of the Early Support for
Families Act (H.R. 2667) because we too have experienced and documented
the impact of home visitation on mothers, infants, and young children.
TIES has been in existence for over 18 years, with most of those
years having been funded by the Administration of Children Youth and
Families Children's Bureau Abandoned Infants Administration. TIES is an
intensive in-home intervention program serving high risk parenting
women abusing drugs and alcohol while pregnant or after delivery in the
urban Kansas City, Missouri area. Our support for this federal
legislation is based on our years of experience that adds to the body
of experience and research stated in the legislation. Our experience
provides evidence that early childhood community based in-home
interventions are effective tools for not only reducing out of home
placement and child abuse/neglect but providing skill building in the
areas of parenting, reducing drug use, promoting physical and mental
health, securing economic stability, and maintaining housing.
The TIES evaluation was conducted by the Institute for Human
Development (IHD) affiliated with the University of Missouri-Kansas
City (an Applied Research and Interdisciplinary Training Center for
Human Services) led by Kathryn L. Fuger, Ph.D. and her team. TIES has
been a grant awardee for four cycles of four years through the U.S.
Department of Health and Human Services Children's Bureau Abandoned
Infants Assistance Program, Grant # 90-CB-0139/04.
Participants in the TIES Program were rated in five goal areas: (1)
becoming drug free, (2) improving parenting, (3) accessing appropriate
child health care, (4) gaining economic stability, and (5) maintaining
adequate housing. The goal attainment for each of the five areas ranged
from 1 (poor) to 5 (optimal) parenting outcomes.
TIES participants were rated initially (Time period 1), at 3 months
after enrollment (Time period 2), at the child's age of 13 months (Time
period 3), and at discharge (Time period 4). Participants showed gains
in all five primary goal areas, with improvements reaching statistical
significance in all areas except housing. The evaluation team findings
include:

Regarding the goal of becoming drug free, women initially
were below the expected outcome. They improved consistently between
Time 1 and Time 3 to reach the expected outcome level, with a slight
decline at Time 4.
Goal ratings on improved parenting increased from Time 1
to Time 2, and then remained at roughly the expected outcome level for
the other time periods.
Regarding the goal of providing children with health care
services, ratings improved from the expected level initially to better
than expected for all other assessment times. The majority of
participants were rated above the expected outcome from 3 months until
discharge.
Regarding the goal of economic stability, only 13% of
participants were at or above the expected outcome at intake, but
significant improvement was seen in all analyses of change over time.
Even with these gains, mean scores only rose to 2.4 on the 5-point
scale when comparing those assessed at all four time periods.
Goal ratings on the adequacy of housing for participating
families ranged from very poor to very good each time period. By Time
3, some improvements in mean ratings occurred, but did not reach
statistical significance. Of the 5 goals, it appeared that adequate
housing took longer to achieve.
The level of engagement over time was a factor in the success of
goal attainment, as seen by these statistically significant
associations:
Child health and housing ratings at intake were associated
with the level of engagement with program staff at 3 months.
The goal ratings of becoming drug-free, parenting, child
health, and housing at 3 months and at discharge were associated with
the level of engagement at 3 months.
Parenting and economic stability ratings were also
associated with the level of engagement at 13 months.

Relative caregivers tended to improve in child health care,
economic stability, and housing as they progressed through the TIES
Program and stabilized at discharge, suggesting they were providing a
more stable, healthy environment for the children in their care. (E-3
Executive Summary, TIES Report to AIA, CB, DHSS, December, 2008)
Our experience is based on an intensive community based model using
social workers in the role we call Family Support Specialist. The two
most important ingredients that are essential for success are 1.) early
intervention in the home, and 2.) a selection of high quality
experienced professional staff who are comfortable in the setting and
have strong social work skills.
As you can tell from the research findings, the social workers are
very adept at establishing relationships with the mothers and using
their interpersonal skills to draw out the strength in each mother and
her family. Given the risk factors this population presents, this is an
enormous challenge for any professional staff. Careful attention has
been paid to hiring staff that are of the same ethnic population, have
extensive experience in child welfare with our local population and
have proven they are skilled and comfortable in a high risk
environment. Social workers add value to this proven model in that
their education and practicum go beyond developing skills in work with
the individual, the families, and the community. Social workers start
where the person/family is and help to empower the family members to
develop their own strengths. Social workers also are expected to work
simultaneously to change the environment and the policies that keep
families from helping their children survive in highly toxic
environments.
Our TIES complete December 2008 evaluation is available upon
request. We will be pleased to assist in any manner we can to support
the Early Support for Families Act (H.R 2667).
Witness Information:
Alice Kitchen, LCSW, MPA
Director of Social Work and Community Services
Children's Mercy Hospitals and Clinics

Statement of Children and Family Futures
Children and Family Futures thanks you for the opportunity to
submit this written statement for the record of the June 9, 2009
Hearing on Proposals to Provide Federal Funding for Early Childhood
Home Visitation Programs held by the House Committee on Ways and Means
Subcommittee on Income Security and Family Support. Our comments
reflect the views of our own organization and do not represent those of
any of our funders or sponsors.
Children and Family Futures (CFF) is a non-for-profit organization
based in Irvine, California. Our mission is to improve the lives of
children and families, particularly those affected by substance use
disorders. CFF consults with government agencies and service providers
to ensure that effective services are provided to families. CFF advises
Federal, State, and local government and community-based agencies,
conducts research on the best ways to prevent and address the problem,
and provides comprehensive and innovative solutions to policy makers
and practitioners.
We thank the Subcommittee for its leadership in this critical area.
Home visitation is a strategy for ensuring good parenting and
preventing child maltreatment, and as research has demonstrated,
appears to show considerable promise towards improving the well-being
of low-income families and their children. The typical home visitation
program involves a trained worker--a nurse or sometimes a
paraprofessional--who visits families in their homes and provides
parent education and support services. Sometimes the program begins
during prenatal visits, in other cases it begins in the hospital after
a birth or with a referral of an at-risk family. A recent publication
on State home visitation programs summarized the approach:
Home visiting for families with young children is a longstanding
strategy offering information, guidance, risk assessment, and parenting
support interventions at home. The typical ``home visiting program'' is
designed to improve some combination of pregnancy outcomes, parenting
skills and early childhood health and development, particularly for
families at higher social risk . . . When funded by government, such
programs generally target low-income families who face excess risks for
infant mortality, family violence, developmental delays, disabilities,
social isolation, unequal access to health care, environmental
exposures, and other adverse conditions.\1\
---------------------------------------------------------------------------
\1\ K. Johnson (2009) State-based Home Visiting: Strengthening
Programs through State Leadership. National Center for Children in
Poverty. 3, 5
---------------------------------------------------------------------------
This list of risk factors underscores an important question about
home visitation programs: what problems do they screen for among target
families and how do they intervene to improve outcomes in those problem
areas?
The impact and co-occurrence of substance abuse
The impact of substance abuse on families with younger children is
well-documented to have major effects on a significant number of these
children and families, and to co-occur with other, closely linked
problems, including mental illness, developmental delays, and family
violence. One in eleven children--a total of six million--live in
families in which one or more caretakers are alcoholic or chemically
dependent on illicit drugs. Another group of children living with the
effects of parental substance abuse are the estimated 500-600,000
infants who are born each year having been prenatally exposed to
alcohol or illicit drugs. Only about 5% of them are identified at
birth, and even fewer are referred to child protective services and
removed from their families. Cumulatively, this means that nine million
children and youth under 18 were prenatally exposed and are at risk due
to that exposure and the co-occurring problems that accompany
exposure.\2\
---------------------------------------------------------------------------
\2\ The assumptions underlying these estimates include:
500-600,000: This is a conservative estimate based on recent
prenatal screenings in multiple sites, as well as prevalence studies
based on screening at birth. N. Young et al., (2008) Substance-Exposed
Infants: State Responses to the Problem. National Center on Substance
Abuse and Child Welfare, Irvine, CA. A May 2009 report based on the
National Household Survey on Drug Abuse indicated that 19% of pregnant
mothers used alcohol in their first trimester of pregnancy; projecting
this number to the 2007 total of births would raise the estimate of
prenatal exposure to 820,000 annually. Substance Use among Women During
Pregnancy and Following Childbirth, SAMHSA May 21, 2009. http://
oas.samhsa.gov/2k9/135/PregWoSubUse.htm
5% prenatally exposed identified: the 5% figure is the product of
comparisons of infants reported to CPS in several jurisdictions to
available data about overall prevalence of prenatal exposure [Orange
County study: http://www.ochealthinfo.com/docs/public/2007-Substance-
Expose-Baby.pdf; N. Young et al., op.cit.
6 million: National Household Survey on Drug Abuse, June 2003,
Children Living with Substance-Abusing or Substance-Dependent Parents,
SAMHSA. http://www.oas.samhsa.gov/2k3/children/children.htm
---------------------------------------------------------------------------
The omission of substance abuse
But despite their emphasis upon risk factors and prevention of poor
outcomes, many home visitation programs de-emphasize parental substance
abuse and prenatal exposure far below the relative importance of these
factors. Several reviews of home visitation programs have cited the
downplaying or omission of substance abuse as a risk factor. One recent
summary of home visitation programs as they affect child maltreatment
has a full chapter on substance abuse, which includes a detailed review
of how home visitation programs tend to minimize substance abuse as an
issue in working with families. The author concludes that most home
visitation programs simply list substance abuse as one of many problems
in a screening and risk protocol and refer clients out to substance
abuse programs when they self-report.\3\ This source documents the
importance of screening for substance use disorders in home visitation
programs by citing the literature that found that substance abuse is
``a strong predictor for physical abuse and neglect, tripling the risk
for later maltreatment.''
---------------------------------------------------------------------------
\3\ Neil Guterman, (2001) Stopping Child Maltreatment Before It
Starts: Emerging Horizons in Early Home Visitation Services, Sage
Publications.115-120
---------------------------------------------------------------------------
Early home visitation services have rarely reported tailored or
integrative service protocols for home visitors working with families
also contending with substance abuse.''. . . Home visitation programs
still face a need to augment their intervention strategies to
effectively address the ongoing and intertwining problems of substance
and child abuse risk. . .\4\
---------------------------------------------------------------------------
\4\ Ibid 120.
---------------------------------------------------------------------------
Another recent evaluation of a widely used program in California
concluded:
Moreover, substance abuse specific interventions have not been
developed for use within this model. Indeed, when substance abuse is
identified to occur, the individual is referred to a substance abuse
provider in the community, or is denied from enrolling . . . if the
substance abuser is not enrolled in a substance abuse program . . .
Therefore, although the intervention components. . . appear promising,
the investigators do not recommend its use for substance abuse
issues.\5\
---------------------------------------------------------------------------
\5\ Donohue, B., Romero, V., & Hill, H. H. (2006). Treatment of co-
occurring child maltreatment and substance abuse. Aggression and
Violent Behavior, 11 (6), 626-640.
---------------------------------------------------------------------------
Finally, a review of home visitation outcomes concluded:
While many program evaluations show positive effects on primary
prevention by improving daily reading, parent communication skills,
discipline strategies, and parent confidence, fewer have shown impact
on maternal depression, family violence, and substance abuse. Some
limited success was shown with highly tailored models for specific
concerns such as substance abuse, as opposed to multi-risk families.
Opportunities exist to improve the training and supervision for home
visitors, as well as to create enhanced interventions that engage and
embed more highly trained professionals from the social work, mental
health, or substance abuse fields.\6\
---------------------------------------------------------------------------
\6\ K. Johnson op.cit, 15 A.Butz, et al. 2001. Effectiveness of a
Home Intervention for Perceived Child Behavioral Problems and Parenting
Stress in Children With In Utero Drug Exposure. Archives of Pediatrics
& Adolescent Medicine 155(9): 1029-37. Eckenrode, et al. 2000.
Preventing Child Abuse and Neglect with a Program of Nurse Home
Visitation: The Limiting Effects of Domestic Violence. Journal of the
American Medical Association 284(11): 1385-91.
---------------------------------------------------------------------------
How can substance abuse be addressed?
Guterman sets forth four practice principles that would improve the
capacity of home visitation programs to address substance abuse in
greater depth.

``Home visitors should routinely and sensitively assess
the presence and role of substance and/or alcohol use and abuse early
in their work with families.''
When substance abuse has been identified, home visitors
should work to reduce the risks and harm on the developing child and
family.
``Home visitors must intensively and persistently
orchestrate formal supports to maintain essential health, economic, and
social supports'' for substance-abusing mothers
Home visitors should work with substance-abusing parents
to develop informal support networks to reduce both substance and child
abuse risk

Building on Guterman's comments and other reviews of HV as they
address substance abuse, there are at least five critical questions in
home visitation with respect to substance abuse:
1. As clients enter the program, is the possibility of substance
abuse explored in depth through screening by trained staff using proven
screening protocols?
2. If services begin with prenatal visits, are adequate screening
tools used and followed up with adequate interventions when substance
abuse is detected?
3. Is prenatal exposure a trigger for referring clients and
establishing clients' need for prevention and treatment services?
4. Is substance abuse used as a factor to screen some clients out
of the program?
5. Do clients who are less likely to enroll or be retained in
voluntary services due to their substance abuse problems receive
adequate engagement and retention efforts that address those problems?
What do current models do?
In determining what current home visitation programs do to address
substance use, we reviewed information on four models in wide use
throughout the country: Healthy Families America (HFA), the Home
Instruction for Parents of Preschool Youngsters (HIPPY) Program, Nurse-
Family Partnership, and Parents as Teachers. Early Head Start and the
Parent-Child Home Program are also included in some listings of the
most frequently adopted programs but were not part of this review.
In assessing how each of these home visitation programs seek to
address substance use disorders, it is difficult to conclude how
adequately the models accomplish this, since most of these models refer
to substance abuse as one of a series of risk factors but do not
provide descriptive details on how it is to be handled. Evaluations of
these models are also of limited value, since substance use outcomes
are not included routinely in most evaluations of the results of home
visitation. It is also worth noting that sometimes these models are
combined; for example, 136 Parents as Teachers sites are combined with
HFA programs.
Healthy Families America (HFA)
The base model for HFA does not emphasize substance abuse; a
summary of services content simply says:
A single home visit may cover between 5 and 9 different topics,
with a median of about 6 topics. Topics are grouped into broad areas
such as parent-child interaction or child development.\7\
---------------------------------------------------------------------------
\7\ http://www.healthyfamiliesamerica.org /downloads/
hfa_impl_service_content.pdf
---------------------------------------------------------------------------
A fifty-eight page chapter on HFA program design mentions substance
abuse briefly as one of many conditions that may need to be addressed.
One of the state evaluations indicated that fewer than 1% of the
clients were referred for substance abuse services.\8\
---------------------------------------------------------------------------
\8\ http://www.healthyfamiliesamerica.org /downloads/
eval_hfm_tufts_2005.pdf
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However, one of the HFA models in the District of Columbia was
awarded a three-year Starting Early, Starting Smart (SESS) grant by the
Substance Abuse and Mental Health Services Administration (SAMHSA) in
partnership with the Casey Family Programs. This national partnership
was designed to support the integration of mental health and substance
abuse services into primary health care and early childhood settings
serving children ages 0-5 years and their families/caregivers. This
site used the SESS model to supplement the HFA base model with these
special services. While outcomes of this project are not available, the
project shows that the HFA model can be adapted to include greater
attention to substance abuse issues.
Home Instruction for Parents of Preschool Youngsters (HIPPY)
The HIPPY model uses home visitors and family group sessions
targeted on younger children to improve parent involvement and school
readiness outcomes. Its research summary does not refer to substance
abuse.\9\
---------------------------------------------------------------------------
\9\ http://www.hippyusa.org/refId,28036/refDownload.pml
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Nurse-Family Partnership
Under the Nurse-Family Partnership program, nurses conduct a series
of home visits to low-income, first-time mothers, starting during
pregnancy and continuing through the child's second birthday. Some NFP
research cites reductions in smoking, but there are few references to
use of alcohol or other drugs. In one of the most recent evaluations of
NFP, conducted by the program's original designers, substance use by
mothers was assessed and summarized:
Earlier reported impacts of the Elmira program on `maternal
behavioral problems due to substance abuse' [was] . . . no longer
statistically significant in the new analysis.\10\
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\10\ http://www.nursefamilypartnership.org /content/
index.cfm?fuseaction=showContent&contentID=4&navID=4
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Parents as Teachers
Although Parents as Teachers (PAT) models emphasize equipping
parents to understand child development and include developmental
screening, there is no reference to prenatal exposure or substance
abuse-related outcomes in the research summaries published by
(PAT).\11\ However, a recently issued guide to working with children
with special needs briefly discusses fetal alcohol effects.
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\11\ http://www.parentsasteachers.org /atf/cf/%7B00812ECA-A71B-
4C2C-8FF3-8F16A5742EEA%7D/ Research--Quality--Booklet.pdf
---------------------------------------------------------------------------
Why substance abuse must be addressed
Because substance abuse affects developmental outcomes and school
readiness
Home visitation programs often cite school readiness as a major
goal. In seeking to serve children and families with high risk factors,
the overlapping group of children living with substance-abusing parents
and those who were prenatally exposed are at considerably greater risk
for developmental delays, behavior problems, and difficulties as they
enter school. A recent study of children whose school attendance is
substandard noted that parental substance abuse can be a contributing
factor in poor attendance; \12\ again, one in eleven children lives in
a family where substance abuse is serious enough to be classified as
alcoholism or chemical dependency. But with the exception of the above-
mentioned HFA program that was linked to Starting Early, Starting
Smart, there are few examples of home visitation models that directly
address these risks.
---------------------------------------------------------------------------
\12\ H. Chang, and M. Romero, (2008) Present, Engaged, and
Accounted For: The Critical Importance of Addressing Chronic Absence in
the Early Grades. National Center for Children in Poverty. N. Connors,
et al. 2004. Children of Mothers with Serious Substance Abuse Problems:
An Accumulation of Risks. American Journal of Drug and Alcohol Abuse
30(1): 85-100. http://www.nccp.org/publications/pub_837.html
---------------------------------------------------------------------------
As the exception makes clear, that gap is not for lack of models.
Home visitation programs that are formally linked with center-based
early childhood education can address the substance abuse issues by
using one of the two widely recognized programs designed for linking
substance abuse services and early care and education: Starting Early,
Starting Smart or the Free to Grow model developed by the Head Start
program. Both of these are promising approaches that should be
encouraged further as means of improving the focus of early childhood
programs on substance abuse effects impacting millions of children.
Because substance abuse is intergenerational
Because substance use disorders are inherently intergenerational,
with a genetic component, a component that is affected by multi-
generational family patterns, and effects of both organic and
environmental exposure on children, family-centered home visitation
must provide services to parents and children that specifically address
substance use disorders.
Because home visitation addresses other problems that co-occur with
substance use disorders.
To address mental illness, family stress, domestic violence, and
other conditions that co-occur with substance use disorders as though
they were each separable ignores the reality of co-occurring disorders.
It is not possible to neatly separate the mental health and family
violence portions of family risk factors from substance abuse.
Approximately one half of the people who have one of these
conditions--a mental illness or a substance abuse disorder--also have
the other condition. The proportion of co-morbidity may be even higher
in adolescent populations . . . Availability of integrated treatment
for mental health and substance abuse problems is currently the
exception rather than the rule.\13\
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\13\ California Mental Health Services Oversight and Accountability
Commission Report: Co-Occurring Disorders, March 2007.
---------------------------------------------------------------------------
Because home visitation appears to benefit higher-risk families more
than lower-risk ones
The finding that ``home visiting appears to carry more benefits for
high-risk families than for low-risk ones'' \14\ raises the issue of
which risks are being addressed. Combined with the finding that high--
quality programs are more likely to assess family needs and link them
with community resources, this suggests that identifying substance
abuse as it affects both parents and children is a necessary component
of addressing major risk factors to promote strong families and healthy
child development.
---------------------------------------------------------------------------
\14\ ``Home Visiting: Strengthening Families by Promoting Parenting
Success,'' Policy Brief No. 23, National Human Services Assembly.
November 2007.
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Identifying those parents needing treatment would also help to
reduce the sizable gap between those needing and those receiving
treatment. Based on the National Survey on Drug Use and Health (NSDUH)
data, in 2007 of the 23.2 million persons over 12 who needed treatment
for illicit drug or alcohol use, only 2.4 million received treatment.
To the extent that home visitation programs have been shown to have
the highest payoff for families with higher at-risk profiles, the
families affected by co-occurring substance abuse, mental illness, and
domestic violence-related trauma are those that would benefit most from
home visitation programs designed to respond to these challenges.
Legislative Options
The legislation emerging from Congress can build upon these lessons
drawn from the recent history of home visitation, in recognizing the
importance of substance abuse as a critical risk factor. We thank
Chairman McDermott for your leadership in this critical area through
your sponsorship of the Early Support for Families Act of 2009 (H.R.
2667) along with Representatives Danny Davis and Todd Platts. We also
commend Representatives Davis and Platts for their sponsorship of
similar legislation, the Education Begins at Home Act of 2009 (H.R.
2205). These important pieces of legislation offer a significant
opportunity to States and Tribes to create and expand early childhood
home visitation programs. However as currently drafted, the Early
Support for Families Act of 2009 (H.R. 2667) does not specifically
mention nor speak to the issue of substance abuse. Similarly, in the
Education Begins at Home Act of 2009 (H.R. 2205), substance abuse is
mentioned only once as one of the agencies that should be collaborating
with the central program organization. It is left out of lists of
several risk factors, is left out of a list of agencies to which
families should be referred for services, and is left out of a list of
technical assistance topics.
To ensure that substance abuse is given appropriate attention in
home visitation models, we offer the following recommendations on
provisions that could be included in legislation:
1. Require that state or local plans for home visitation programs
that are developed also include the prevalence of substance abuse in a
formal needs assessment and indicate how substance abuse agencies will
be actively engaged in program design and services effectively
coordinated, how the training of home visitation personnel will include
training on proper risk and safety assessment techniques that include
substance use, and include information on the program's outcomes
including how effective the program model has been in conducting risk
assessments, the number of parents (when appropriate and necessary)
referred for treatment, and the outcomes of treatment for those
referred.
2. Require that home visitation programs that begin with prenatal
visits include a proven risk assessment and safety model that
identifies substance use and links pregnant women with treatment
services in effective agencies that are full partners with the home
visitation programs.
3. Require that parents with substance use disorders receive
continuing care following treatment.
4. Require that children of substance-abusing parents receive
developmental screening and are given eligibility for intervention
services in the case of developmental delays, linked with Individuals
with Disabilities Education Act (IDEA) eligibility.
5. Require that any set-asides for training and technical
assistance also require funds to support the development and
dissemination of risk and safety assessment protocols that at a minimum
address substance abuse to expand the capacity of existing and
promising home visitation models in addressing substance abuse among
these high-risk families.
6. Require that the Secretary of the U.S. Department of Health and
Human Services in administrating this home visitation program to States
and Tribes implement a multi-agency approach including participation by
the Administration for Children and Families, the Substance Abuse and
Mental Health Services Administration, the Health Resources and
Services Administration, as well as any other agencies the Secretary
determines may be appropriate to ensure a coordinated system of family
support is implemented.
Again, we thank the Committee for holding this important hearing
and for the opportunity to submit this statement for the record. We
look forward to working with you as this legislation moves forward to
ensure that the promise of home visitation is realized for low-income
families, and in particular, that home visitation strategies seek to
improve the lives of families and children impacted with substance use
disorders.

Statement of the Children's Defense Fund
The Children's Defense Fund (CDF) appreciates the opportunity to
submit written testimony for the record for the Hearing on Proposals to
Provide Federal Funding for Early Childhood Home Visitation Programs
held on June 9, 2009, by the Subcommittee on Income Security and Family
Support.
The Children's Defense Fund has worked very hard for 36 years to
ensure every child a Healthy Start, a Head Start, a Fair Start, a Safe
Start, and a Moral Start in life and successful passage to adulthood
with the help of caring families and communities. CDF seeks to provide
a strong, effective and independent voice for all the children in
America who cannot vote, lobby, or speak for themselves, but we pay
particular attention to the needs of poor and minority children and
those with disabilities. CDF encourages preventive investments in
children before they get sick, get pregnant, drop out of school, get
into trouble, suffer family breakdown, or get sucked into the dangerous
``Cradle to Prison Pipeline.''
CDF works to ensure a level playing field for every child and
recognizes that for every minute we waste, we lose another child.
Consider that a child is born into poverty every 33 seconds, a child is
born without health insurance every 39 seconds, and a child is abused
or neglected every 40 seconds. CDF has for decades advocated for
improvements in child welfare policies that would help to enhance
outcomes for vulnerable children and families across the country.
We want to begin by thanking the Subcommittee for its bi-partisan
leadership in the 110th Congress, which led to the enactment
of the Fostering Connections to Success and Increasing Adoptions Act of
2008 (P.L. 110-351). These reforms for abused and neglected children in
foster care, the most significant in more than a decade, hold the
promise of greater stability and permanence and enhanced well-being for
tens of thousands of children and youths across the country.
We are very pleased that you now are focusing attention on the
front end of the child welfare system to expand opportunities to
prevent problems from occurring, such as developmental delays, poor
child health, and child abuse and neglect, all of which can bring
children to the door of the child welfare system. The need for
prevention has long been ignored, and the Early Support for Families
Act (H.R. 2667) represents a significant step forward in establishing
and expanding home visiting programs that can reach hundreds of
thousands of children.
We applaud the efforts of both Chairman McDermott and
Representative Danny Davis, as well as Representative Todd Platts, to
highlight home visiting as an important strategy to strengthen outcomes
for both children and parents. The Early Support for Families Act
builds on both the evidence-based home visitation initiative included
in President Obama's Fiscal Year 2010 budget and on the reserve clauses
in both the House and Senate-passed 2010 Budget Resolutions. It
recognizes how children could positively benefit from a significant
expansion of quality home visitation programs that improve multiple
outcomes for children and families, both in the short term and over
time.
In our statement for the record, we want to emphasize the multiple
ways that children and families can benefit from home visitation,
describe the lack of coordinated attention to home visiting that
currently exists at the federal level, and then highlight the most
important features of the Early Support for Families Act and several
ways it might be further strengthened.
First-time pregnant women, parents of young children with
disabilities, teen parents having a second or third child, and single
fathers raising children and others can all benefit from different
models of home visitation programs. Thousands of parents like these are
looking to the Subcommittee to push forward this year an investment in
quality evidence-based home visitation that can have real positive
impacts for them and their children.
Investments in Quality Home Visiting Programs Are Essential for
Improving Outcomes for Children quality home visiting programs
offer congress an opportunity to build on what we know works.
Under the Early Support for Families Act, programs with the
strongest level of evidence will be able to expand to reach more
children and families with different needs, and emerging programs will
also be able to prove their effectiveness with children and families
over time.
Home visiting is a program model and a family engagement strategy
that has a long track record and has evolved over the years. As
elaborated below, there are at least five national models of home
visitation programs, all of which are associated with a national
organization that has comprehensive standards that ensure high quality
service delivery and continuous program quality improvement. They all
have been operating in some form for at least a decade and in some
cases two or three decades. There are also other models and approaches
being used that hold promise. And still others that have come and gone
over the years. When Rep. Roskam asked the hearing witnesses on June 9,
if they had ever met a home visitation program they didn't like, the
answer for most was a resounding ``yes.'' The witnesses recognized the
challenges in operating quality programs and the need to target ongoing
federal support to programs that meet at least the basic requirements
spelled out in the Early Support for Families Act.
Research from the five national home visiting program models,
described only briefly below, demonstrates that quality home visiting
programs can improve outcomes for children and parents by preventing
child abuse and neglect, improving school readiness, increasing
positive parenting and parental involvement, and improving child and
maternal health. The randomized controlled trial of the Nurse Family
Partnership, one of the five models, was first conducted in 1977, more
than 30 years ago. Since then several subsequent randomized controlled
trials have been conducted, and each of the national models has had at
least one randomized controlled trial.
Healthy Families America (HFA), a program of Prevent Child Abuse
America, is a voluntary home visiting model designed to help expectant
and new parents get their children off to a healthy start. The program
works with participants starting prenatally or at birth up to the time
the child reaches three to five years of age to promote positive
parenting, enhance child health and development and prevent child abuse
and neglect.

A study published in the March 2008 issue of the journal
Child Abuse and Neglect indicated that Healthy Families New York (HFNY)
decreased the incidence of child abuse and neglect during the first two
years of life, and reduced the use of aggressive and harsh parenting
practices, particularly among first-time mothers under age 19 who were
offered HFNY early in their pregnancy.i
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\i\ DuMont, et al. (2008). Healthy Families New York (HFNY)
randomized trial: Effects on early child abuse and neglect. Child Abuse
& Neglect, 32(3), 295-315.
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Two randomized control trial studies of HFA found that
participation in the program positively impacted children's cognitive
development when measured on the Bayley Scales of Infant Development
(which measures developmental function of infants and toddlers and
assists in diagnosis and treatment planning for those with
developmental delays or disabilities).ii
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\ii\ Caldera, et al. (2007). Impact of a statewide home visiting
program on parenting and on child health and development. Child Abuse &
Neglect, 31(8), 829-852. Landsverk, Carrilio, et al. (2002). Healthy
Families San Diego Clinical Trial: Technical Report. Child and
Adolescent Services Research Center, San Diego Children's Hospital and
Health Center.

Home Instruction for Parents of Preschool Youngersters (HIPPY) is a
voluntary home-based, family focused, parent involvement program that
provides solutions that strengthen families and helps parents prepare
their three-, four-, and five-year-old children for success in school
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and beyond.

A two-site, two-cohort longitudinal study of children's
school performance through second grade found that children
participating in HIPPY scored higher on standardized achievement tests,
were perceived by their teachers as being better prepared, and had
better school attendance than those who did not receive HIPPY
services.iii
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\iii\ Baker & Piotrkowski, 1996, National Council of Jewish Women
Center for the Child (U.S. Department of Education funded study of
HIPPY).

Nurse Family Partnership (NFP) is a voluntary program that provides
home visitation services by registered nurses to low-income first-time
mothers, beginning early in pregnancy and continuing through the
---------------------------------------------------------------------------
child's second year of life.

In a 15-year follow-up to a randomized control trial,
there were 48 percent fewer officially-verified child abuse and neglect
reports for the families served by NFP as compared to the control
group; and women served by NFP had experienced 19 percent fewer
subsequent births than those in the control group.iv
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\iv\ Luckey, Dennis W., David L. Olds, Weiming Zhang, Charles
Henderson, Michael Knudtson John Eckenrode, Harriet Kitzman, Robert
Cole, and Lisa Pettitt, ``Revised Analysis of 15-Year Outcomes in the
Elmira Trial of the Nurse-Family Partnership,'' Prevention Research
Center for Family and Child Health, University of Colorado Department
of Pediatrics, 2008. Olds, David L., Charles R. Henderson Jr, Robert
Cole, John Eckenrode, Harriet Kitzman, Dennis Luckey, Lisa Pettitt,
Kimberly Sidora, Pamela Morris, and Jane Powers, ``Long-term Effects of
Nurse Home Visitation on Children's Criminal and Antisocial Behavior:
15-Year Follow-up of a Randomized Controlled Trial,'' Journal of the
American Medical Association, vol. 280, no. 14, October 14, 1998, pp.
1238-1244. Olds, David L., John Eckenrode, Charles R. Henderson Jr,
Harriet Kitzman, Jane Powers, Robert Cole, Kimberly Sidora, Pamela
Morris, Lisa M. Pettitt, and Dennis Luckey, ``Long-term Effects of Home
Visitation on Maternal Life Course and Child Abuse and Neglect: 15-Year
Follow-up of a Randomized Trial,'' Journal of the American Medical
Association, August 27, 1997, vol. 278, no. 8, pp. 637-643.
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In another randomized control trial, children who were
served by NFP at age two had spent 78 percent fewer days in the
hospital for injuries or ingestions compared to those in the control
group.v
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\v\ Olds, David L., Harriet Kitzman, Carole Hanks, Robert Cole,
Elizabeth Anson, Kimberly Sidora-Arcoleo, Dennis W. Luckey, Charles R.
Henderson Jr, John Holmberg, Robin A. Tutt, Amanda J. Stevenson and
Jessica Bondy. ``Effects of Nurse Home Visiting on Maternal and Child
Functioning: Age-9 Follow-up of a Randomized Trial,'' Pediatrics, vol.
120, October 2007, pp. e832-e845.

Parent-Child Home Program (PCHP) is a voluntary early childhood
parent education and family support model serving families throughout
pregnancy until their child enters kindergarten, usually at age five.
It is designed to enhance child development and school achievement
through education delivered by parent educators, who all have at least
a bachelor's degree. It combines home visiting and group meetings, is
accessible to all families and has been adapted to fit differing
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community and family needs.

More than 5,700 public school children from a stratified
random sample of Missouri districts and schools were examined at
kindergarten entry and at the end of third grade. Path analysis showed
that participation in PAT, together with preschool, positively impacted
children's school readiness and school achievement scores and also
narrowed the achievement gap between children in poverty and those from
non-poverty households.vi
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\vi\ Zigler, E., Pfannenstiel, J.C., & Seitz, V. (2008). The
Parents as Teachers Program and School Success: A Replication and
Extension. Journal of Primary Prevention, 29, 103-120.

In a randomized control trial, children participating in
PAT were much more likely to be fully immunized for their given age and
were less likely to be treated for an injury in the previous year than
children in the control group.vii
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\vii\ Wagner, M., Iida, E. & Spiker, D. (2001). The multisite
evaluation of the Parents as Teachers home visiting program: Three-year
findings from one community. Menlo Park, CA: SRI International.
Obtained from www.sri.com/policy/cehs/early/pat.html.

Parent-Child Home Program (PCHP) is a voluntary early literacy,
school readiness, and parenting program serving families with two- and
three-year-olds who are challenged by poverty, low levels of education,
language and literacy barriers and other obstacles to educational
success. The model uses intensive home visiting to prepare families for
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school success.

Indiana University of Pennsylvania's independent
evaluation of PCHP replications in two Pennsylvania counties indicates
that positive parent behaviors increased dramatically as a result of
program participation. Half of the children identified as ``at risk''
in their home environments at the start of the program were found to no
longer be at risk at the completion of the program.viii
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\viii\ Knickebein, B. (2005). The Parent-Child Home Program Final
Report, Center for Educational and Program Evaluation, Department of
Educational and School Psychology, Indiana University of Pennsylvania.
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A longitudinal randomized control group study of PCHP
found that low-income children who completed two years of the program
went on to graduate from high school at the rate of middle class
children nationally, a 20 percent higher rate than their socio-economic
peers and 30 percent higher than the control group in the
community.ix
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\ix\ Levenstein, P., Levenstein, S., Shiminski, J. A., & Stolzberg,
J. E. (1998). Long-term impact of a verbal interaction program for at-
risk toddlers: An exploratory study of high school outcomes in a
replication of the Mother-Child Home Program. Journal of Applied
Developmental Psychology; 19, 267-285.
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Quality home visitation programs impact children and families in
multiple ways.
Home visiting recognizes the uniqueness of individual children and
families and acknowledges that a single program strategy may have
different impacts on the same children and families over time and
different impacts on children and families with differing needs. As
demonstrated above, it is not unusual for home visiting programs to
have multiple impacts on children and families perhaps most notably
improved child health and development, enhanced school readiness, and
the prevention of abuse and neglect. The five major models described
above also have had an impact on parents and their parenting skills and
leadership. Perhaps most significant, several of these models have had
even greater impacts when coupled with other early childhood programs.
A number of states have established multiple models of home
visiting programs or combined program model elements to create blended
programs, recognizing that families' needs vary. For example, the
Illinois Department of Human Services and the New Jersey Department of
Children and Families are both beginning to use the Nurse Family
Partnership, Healthy Families America and Parents as Teachers models to
prevent child abuse and neglect. Such an approach allows them to reach
families with multiple needs and gives staff helpful discretion in
matching the needs of families with the strengths of a particular
model. New York is also implementing the Nurse Family Partnership,
Healthy Families New York, and Parents as Teachers.
There are many other examples of states using multiple programs in
different parts of a community or parts of a state. For example, 60
percent of Medicaid-financed births, a proxy here for low-income
births, are to women who already have one child, ruling out a model
that is limited to first-time births. Models that serve parents after
the birth of a child are often needed to respond to the thousands of
low-income women in our country who receive no prenatal care, yet could
benefit from quality home visiting models with their babies.
Home visiting programs also are intergenerational and can impact
more children than the one who is seen as the recipient of the service.
All five national models, for example, track both child and parent
specific outcomes. Few, however, have examined the impact of such
programs on the future or existing siblings of the child being served.
It is not a stretch to think that programs like these may well impact
the trajectory of family's lives, foster improvements in health, safety
and well-being over time, and can affect multiple children.
Home visiting programs have been proven to result in long-term benefits
when their impact on children and families can be tracked over
time
The Nurse Family Partnership Program has longitudinal data
documenting the fact that for every public benefit dollar invested in a
local Nurse Family Partnership program, communities can realize more
than $5.00 in return. In fact, in its very earliest study in Elmira,
New York, initiated in 1977, researchers found that the community could
recover the costs of the program by the time the child reached the age
of four, and additional savings accrued after that. Data from the 15-
year follow-up of this same study show positive effects for the nurse
visited families for more than 12 years after the visits had concluded.
While the other models generally do not have results from
longitudinal studies, a number do have documented outcomes for children
and families, which can be linked to long-term cost savings related to
special education, health care, and child welfare and criminal justice
system involvement. Increased school readiness, for example, can help
to prevent the need later for extra support or investments in sometimes
costly special education programs. There are also data that show the
benefits of child abuse prevention, by contrasting it with the adverse
impacts of child abuse and neglect on later problems in adulthood--
problems that result in lost opportunity costs and costly treatment.
Similarly, increases in healthy births can help to offset the costs of
low birth weight babies. The cost of hospitalization for a preterm or
low birth weight baby is 25 times that of when a healthy baby is born.
Children born at low birth weight are twice as likely to have
clinically significant behavior problems, such as hyperactivity, and
are 50 percent more likely to score below average on measures of
reading and mathematics by age 17.
Access to the funding in the Early Support for Families Act will
help grantees to continue to assess outcomes and also offer the
opportunity for additional longitudinal studies to document long-term
cost savings.
There is currently no targeted guaranteed funding stream for prevention
in young children.
Currently there is no targeted guaranteed funding stream for
prevention in young children. President Obama's evidence-based home
visitation initiative and The Early Support for Families Act are
intended to do just that to help expand the reach of home visiting to
children and families across the country, and to continue to document
their benefits to the children and families served.
This Committee's Promoting Safe and Stable Families Program was
first established in 1993 and then given its current name in 1997. It
includes some funding from family support and family preservation
programs, but it also includes dollars to help children in foster care
be safely reunified with their families or to be supported in adoptive
families. Similarly, some funds from the Temporary Assistance for Needy
Families Program and the Maternal and Child Health Program are also
used for home visiting, but since both of these are fixed amount block
grants, home visiting must compete with many other activities. There
are also programs, like Early Head Start, where home visiting is one of
a multitude of activities provided to participating children and
families.
New dedicated funding for home visitation will promote the
coordination of this current patchwork of funding and enable states to
assess how best to complement existing programs with new investments to
continue to make progress in reaching all the children and families who
can benefit from home visiting programs. Currently, the Nurse Family
Partnership is in 28 states across the country, serving about 18,000
families. The Parents as Teachers Program is in all 50 states, but in
some there are only a small number of programs, most often established
in school systems. Healthy Families America is in 35 states. And both
the Parent-Child Home Program and HIPPY are smaller with programs in 16
and 23 states respectively. Clearly more new programs and expanded
programs that build on successful models are needed to reach more young
children and families.
The Early Support for Families Act Moves Toward a System of Quality
Evidence-Based Home Visitation Programs
The grant program established by the Early Support for Families Act
seeks to establish in states a coordinated system of quality evidence-
based home visitation programs. It is more than just another funding
stream for these programs. It takes important steps toward
establishment of a system of quality, evidence-based home visitation
that will build on and coordinate with existing early childhood
programs. It focuses on models with the strongest level of
effectiveness, requires states to conduct a statewide needs assessment
to describes programs already underway, who they are serving, how they
are funded, gaps in service, and the training and technical assistance
already in place to support the goals of home visitation. It also
requires federal evaluations of the effectiveness of home visitation on
parent and child outcomes and on different populations. Congress must
also be kept informed about the service models being used, the target
communities and families served, and outcomes reported, as well as the
cost of the program per family served. Much of this information, which
now is generally not very accessible within or across programs, will be
made available within and across program models so effective planning
can be done to best serve children.
In closing, these are three areas that we want to mention briefly
that we believe are important to strengthen in the Early Family Support
Act as it moves forward.

Further definition of strongest level of effectiveness. To
help provide consistency and continuity for states and programs as the
grant program is developed and implemented over time, we believe it is
important for the statute to establish parameters to make clear what a
program must do to get any funding under the bill and then to
distinguish between models with the strongest level of effectiveness
and others. Such parameters will also send a useful message about the
standard to which home visiting models just getting underway will be
held accountable as their work progresses.

Beginning with the strongest level of effectiveness, we would like
to recommend that the Subcommittee consider language that was developed
and has been agreed to by members of the Steering Committee of the Home
Visiting Coalition of which CDF is a member. It defines the ``strongest
level of effectiveness'' in relation to the research standard for
evidence-based home visitation that will distinguish those models that
are eligible for funding from those with the strongest level of
effectiveness. Over time all funded programs will aspire to reach this
level of research. The standard developed reads:
Evidence-based home visitation programs with the strongest level of
effectiveness are those that have demonstrated positive outcomes for
children and families consistent with the outcomes being sought (for
the populations being served) when evaluated using well-designed and
well-conducted rigorous evaluations, including but not limited to
randomized controlled trials, that provide valid estimates of program
impact and demonstrate replicability and generalizability to diverse
communities and families.
The members of the Home Visiting Coalition supporting this
definition include, in addition to CDF, the five home visiting models
described above (Healthy Families America/Prevent Child Abuse America,
HIPPY, Nurse Family Partnership, Parents as Teachers and the Parent-
Child Home Programs) as well as six other national organizations (Child
Welfare League of America, CLASP, Fight Crime Invest in Kids, National
Child Abuse Coalition, and Voices for America's Children).

Increased coordination at all levels. The Early Support
for Families Act recognizes the importance of quality evidence-based
home visiting as a part of a larger coordinated service effort to meet
the needs of young children and their families. In addition to
supporting the expansion of home visiting models, the bill also offers
support to ensure programs can meet the multiple needs of at risk
families by connecting them to service delivery systems at multiple
levels. Connections can be made at the federal, state and local levels;
and processes should also be in place to link individual families to
what they need. We believe that there are a number of ways coordination
could be strengthened, and ask the Subcommittee to consider them.
At the federal level, it would be helpful to require that
the Secretary of Health and Human Services consult with the Secretary
of Education in determining what to require with regard to state
applications for funding under the program, since some home visiting
programs are funded through the federal Department of Education.
At the state level, states should be required to consult
with other state agencies that currently support home visiting programs
for young children. This would help ensure that the new federal support
for home visitation would build on any existing infrastructure to
strengthen services for young children and families across the state.
Home visiting should also be coordinated in states with child care
services, health and mental health services, income supports, early
childhood development services, education programs, and other child and
family supports.
At the individual model level, each model funded under
this new federal program must be required to establish appropriate
linkages and referrals to other community resources and supports, such
as those listed above, to ensure that children and families will have
access to all the services they need in their local communities.
Further recognition of the need for multiples types of
research and evaluation. We are pleased that the Early Support for
Families Act highlights the importance of evaluation. It makes
evaluation an eligible use of funds for grantees and sets aside funds
for a national evaluation by the Department of Health and Human
Services. Given that the goal of this program is to fund quality
evidence-based programs, it is essential to ensure that evaluation and
research to maintain fidelity to program models and adapt models to new
populations be funded appropriately. As the proposal is being
finalized, the funds set aside for evaluation--of all home visitation
models and the new federal program itself--must be significant enough
to serve the needs of the models in proving that they meet the
strongest level of evidence to continue receiving funding and assess
the federal monitoring of overall quality.

The Children's Defense Fund is supportive of the Early Support for
Families Act and steps taken to move toward a major guaranteed
investment in quality evidence-based home visiting and we look forward
to working with you as the bill progresses. Thank you again for your
leadership on behalf of vulnerable children and families.

Statement of Dan Satterberg
Chairman McDermott and members of the subcommittee, thank you for
holding this important hearing, and for the opportunity to submit this
testimony for the Record. I also wish to thank Chairman McDermott,
Representative Danny Davis and Representative Todd Platts for
introducing the ``Early Support for Families Act'' (H.R. 2667).
My name is Dan Satterberg, and I am the Prosecuting Attorney of
King County, Washington. I worked in the Prosecuting Attorney's Office
for more than 20 years before being elected Prosecuting Attorney in
2007.
I submit this testimony as a member of Fight Crime: Invest in Kids,
an organization of over 5,000 police chiefs, sheriffs, prosecutors,
other law enforcement leaders, and victims of violence--including 215
in Washington--who have come together to take a hard-nosed look at the
research about what really works to keep kids from becoming criminals.
My colleagues and I know from the front lines in the fight against
crime--and the research--that among the most powerful weapons against
crime are quality investments in kids that give them the right start in
life.
As a criminal justice leader, I am proud to support the ``Early
Support for Families Act,'' which invests $2 billion over 5 years in
guaranteed funding to establish and expand programs providing
voluntary, quality home visiting to assist families with young
children, and families expecting children, especially in high-need
communities. These are programs that my colleagues and I in Washington
State have advocated for, both with the Governor and in our
Legislature.
Child Abuse Leads to Later Crime and Violence
In 2007, there were 794,000 confirmed cases of child abuse and
neglect in the United States. In my home state of Washington, there
were more than 7,000 confirmed cases of child abuse and neglect. This
statistic is alarming enough on its own, but it cannot account for the
thousands of additional cases that either go unreported or unconfirmed
by overburdened State child welfare agencies. Research shows the true
number of victims nationwide, including those never reported to
authorities, may be well over 2 million.
Child abuse and neglect killed 1,760 children nationwide in 2007.
In Washington, there were an average of 12 deaths a year between 2002
and 2006 that stemmed from child abuse or neglect.
Even though the majority of children who survive abuse or neglect
do not become violent criminals, these children carry the emotional
scars of maltreatment for life, and many do go on to commit violent
crimes. Best available research, based on the confirmed cases of abuse
and neglect nationwide in just one year, indicates that an additional
30,000 children will become violent criminals and 200 may become
murderers as adults as a direct result of the abuse and neglect they
endured.
Evidence-Based Home Visiting Programs Help Reduce Child Abuse and Later
Crime and Violence
Fortunately, research also indicates that evidence-based home
visiting programs can prevent abuse and neglect and reduce later crime
and violence. These programs offer frequent, voluntary home visits by
trained professionals to help new parents get the information, skills,
and support they need to raise healthy and safe kids. While there are
many models of home visiting, all are dedicated to helping young
children get a good start in life and improving outcomes for family.
Research shows that these programs work.
Evidence-Based Home Visiting Programs Are Sound Investments That Result
in Substantial Cost Savings
Prevent Child Abuse America estimates that child abuse and neglect
cost Americans $104 billion a year. Research has demonstrated that
quality, evidence-based home visiting programs offer significant
returns for money invested. For example, a 2008 study by Steve Aos of
the Washington State Institute for Public Policy found NFP produced
$18,000 in net savings per family served and saved three dollars for
every dollar invested. Other home visiting models have also
demonstrated positive cost savings.
I urge this Committee to make investments in high quality,
evidence-based home visiting programs. These programs should be a
priority as you work on health care reform. Investments made in
programs with a proven ability to produce positive outcomes for
children and their families will result in safer communities and cost
savings.
Current Funding Does Not Meet the Overwhelming Need
Existing guaranteed funding streams, such as Medicaid, State CHIP,
and TANF, as well as discretionary programs such as Healthy Start,
Early Head Start, Head Start, Special Education, Child Welfare, Social
Services, Community Services, and others, have not been able to provide
meaningful investments in quality, evidence-based home visiting
programs. We can no longer afford to wait for a patchwork of partial
funding from multiple programs to meet the overwhelming need for these
services. We must have dedicated, guaranteed funding for this proven-
effective approach.
Every year in the United States, over 600,000 low-income women
become mothers for the first time. 1.5 million women who are pregnant
or have a child under the age of two are eligible for NFP at any given
time. However, due to lack of funding, the program is only able to
serve about 20,000 mothers annually. Other home visiting programs serve
an additional 400,000 families, many of whom are not in high-need
communities. The result of inadequate funding is hundreds of thousands
of at-risk families nationwide do not have access to quality home
visiting.
Early Support for Families Act (H.R. 2667)
I applaud the introduction of the ``Early Support for Families
Act,'' based on President Obama's initiative in his FY 2010 proposed
budget. By investing $2 billion in guaranteed funding over 5 years,
H.R. 2667 takes a significant step forward toward meeting the as-yet-
unmet need for quality, evidence-based home visiting programs.
Funds will be distributed using a two-tiered approach. First-tier
programs--those with the strongest research evidence of effectiveness--
will receive the majority of funding. First-tier programs must adhere
to clear evidence-based models of home visitation that have
demonstrated significant positive effects on important child and
parenting outcomes, such as reducing abuse and neglect and improving
child health and development. A second tier of promising program
models--those with some research evidence of effectiveness and
adaptations of previously evaluated programs--will have a chance to
upgrade to the first tier if they are proven to be effective through
rigorous evaluations.
The ``Early Support for Families Act'' also prioritizes investments
in high-need communities. States will be required to identify and
prioritize high-need communities, especially those with a high
proportion of low-income families or a high incidence of child
maltreatment. To receive funding, States must submit (1) the results of
a comprehensive, statewide needs assessment; (2) a grant application
describing the high quality programs supported by the grant, including
evidence supporting the effectiveness of the programs; and (3) an
annual progress report, including the outcomes of programs supported by
the grant.
To ensure federal funds support quality, evidence-based home
visiting programs, this legislation provides an annual set-aside of $10
million for federal evaluation and technical assistance to the States.
Conclusion
Investments in quality, evidence-based home visiting programs work.
Research has shown that these programs can help achieve profound
reductions in child abuse and neglect, crime, and violence while at the
same time producing significant cost savings for the public. The
``Early Support for Families Act'' makes an important--and necessary--
commitment to expanding access to these programs for at-risk families.
We urge you to make these proven investments in kids that help them
get the right start in life and in turn reduce later crime and
violence.
Thank you again for introducing the ``Early Support for Families
Act,'' and for the opportunity to submit this testimony. The law
enforcement leaders of Fight Crime: Invest in Kids look forward to
working with you to achieve enactment of such legislation, through
health reform this year.

Letter from David Mon
I wanted to address the issue of Social Security beneficiaries
returning to work and have earnings that are significant enough to
reduce the monthly SSI and or SSDI to which they are entitled who
report the work earnings in a timely manner but continue to receive
benefits to which they are not entitled because SSA lacks the necessary
representatives to input the reported changes.
As a community work incentive coordinator who works with
beneficiaries on a one-to-one basis who return to work, I advise the
beneficiaries that I work with that reporting the earnings are the
first step. It is necessary for them to carefully track, with my
assistance, work earnings that result in a reduction of benefits, and
SSDI monthly payments to which they are no longer entitled, and to make
arrangements to return this money, even before SSA makes a
determination that an overpayment has occurred.
Advising beneficiaries on proper reporting and steps to prevent
overpayments before they occur has become standard practice in the area
of Work Incentive Planning and Assistance.
Sincerely,
David Mon
Community Work Incentive Coordinator
Center for the Independence of the Disabled
San Mateo, CA

Statement of Every Child Succeeds
Chairman McDermott, Ranking Member Linder, and members of the
Subcommittee on Income
Security and Family Support of the Committee on Ways and Means, on
behalf of Every Child Succeeds in Southwest Ohio and Northern Kentucky,
I am happy to submit this testimony in support of H.R. 2667, the Early
Support for Families Act. We would like to thank the sponsors of this
legislation, Representatives Jim McDermott (D-WA), James McGovern (D-
MA), Lynn Woolsey (D-CA), Mazie Hirono (D-HI), Jim Cooper (D-TN), Danny
Davis (D-IL), and Todd Platts (R-PA).
Every Child Succeeds (ECS) is a voluntary home visiting program
whose aim is to improve the health and development of at-risk children
in the Cincinnati region. Our prevention/early intervention program is
founded upon the knowledge that what happens in the earliest days and
months of life has profound implication for the lifetime course of
parents and children. ECS has provided home visiting services to nearly
16,000 families during the past ten years, with the goal of helping
these children get off to a good start in the most critical period of
their lives--prenatal to age 3. We and the communities we serve believe
that home visiting is an effective and important way to support high
risk families and help them succeed in parenting.
The mission of ECS is to ensure an optimal start for children by
helping families achieve positive health, parenting and child
development outcomes. The goals of home visitation, as provided by ECS,
are: (1) to improve pregnancy outcomes through nutrition education and
substance use reduction, (2) to support parents in providing children
with a safe, nurturing, and stimulating home environment, (3) to
optimize child health and development, (4) to link families to health
care and other needed services, and (5) to promote economic self-
sufficiency.
Public-private partnership has been at the center of our approach
to financing and delivering services. ECS was founded by Cincinnati
Children's Hospital Medical Center, United Way of Greater Cincinnati
and Hamilton County Community Action Agency/HeadStart and began
operation in July, 1999. The program has thousands of community
stakeholders and contracts with more than 30 social service and health
agencies, and all local birth hospitals. Our board and advisors include
a variety of business leaders and experts who have helped to guide our
program and our quality improvement efforts.
Funding for ECS also is provided through a blend of public (50
percent) and private (50 percent) dollars. The level of private funds
for ECS from the United Way of Greater Cincinnati has been continually
increased based on outstanding performance and outcomes, as well as the
demonstrated need for ECS services. Funding from the Temporary
Assistance to Needy Families (TANF) program has been essential in the
development of ECS in four counties in Southwest Ohio through the State
``Help Me Grow'' program. Public funds are available for our three
Kentucky counties to fund the state HANDS program through Medicaid and
proceeds from the Kentucky state tobacco settlement.
The ECS program matches at risk, first-time pregnant women or new
mothers with infants under three months of age with a network of
trained professional home visitors who work with them and their young
children for up to 3 years. Families are recruited primarily through
prenatal clinics or birth hospitals. Program elements include care
coordination, health promotion, medical liaison, child development
assessment, and goal-setting through the Individual Family Service Plan
(IFSP).
ECS uses two national models of home visitation, namely, Nurse-
Family Partnership (NFP) and Healthy Families America (HFA). Both NFP
and HFA models, and research about them, have had value in improving
the quality of the ECS approach. In a series of studies, Olds and
colleagues have found that home visiting for first time mothers by
nurses reduced smoking during pregnancy, decreased preterm birth rates
for smokers, increased birth weights among adolescent mothers, and
decreased rates of child abuse and accidental injuries in children.
(Olds et al.) Studies of HFA inform us about how to serve a broader
array of families, including those whose risks are identified following
the birth of a baby. (Healthy Families America) In addition, our own
ECS quality studies, evaluative research, and randomized clinical
trials are guiding us to state-of-the-art, evidence-based practice.
Mothers eligible for ECS have one or more of four risk
characteristics, including; (1) unmarried, (2) inadequate income (up to
300% of poverty level, receipt of Medicaid, or reported concerns about
finances), (3) 18 years of age, or (4) suboptimal prenatal care. Women
are enrolled either during pregnancy (before 28 weeks for NFP) or
before their child reaches 3 months of age (HFA only). Regular home
visits are provided by social workers, child development specialists or
related professionals (82%), trained nurses (12%), or paraprofessionals
(6%). Home visits are made until the child reaches 2 years (NFP) or 3
years (HFA) of age, starting with weekly or more-frequent visits and
tapering to fewer visits as the child ages.
ECS is an evidence-based model with a comprehensive ongoing
evaluation component. The ECS research and evaluation system provides
ongoing data about process and outcomes. To date, we have achieved and
can reliably report the following results.
Infant Mortality
- Infant mortality rate for ECS families is 4.7 per 1,000 live
births, significantly below those for Ohio (7.8), Kentucky (6.9),
Hamilton County (9.7) or the City of Cincinnati (17.4). (See Figure 1.)
- An analysis of 1,655 mothers and babies enrolled in ECS between
2000--2002 and a comparison group of 4,995 non-participants from the
same region, showed that non-participants were 2.5 times more likely to
die in infancy, compared with those enrolled in ECS.
Child Health and Development
- 95% of children are developing normally in language, physical
coordination, and social abilities.
- 98% of babies have a medical home
- 76% of children are fully immunized by age two
Maternal Health and Well-being
- Of the 33% of mothers with clinically significant levels of
depression, 52% improve after 9 months in home visitation. Using a
grant from the Health Foundation of Greater Cincinnati, ECS developed
an in-home treatment for depressed mothers through a unique Maternal
Depression Treatment Program that is currently being studied in
randomized clinical trials through a grant from the National Institute
on Mental Health.
- After 6 months in the program, 77% of mothers are in school or
are working.
- 80% of mothers report high levels of social support, a factor
associated with effective parenting and maternal mental health
- Of those ECS mothers who smoke during pregnancy, 94% quit or
substantially reduce their tobacco use by the time of the baby's birth.
ECS home visitors help mothers decrease smoking and reduce second hand
smoke in the baby's environment through the Assuring Smoke Free Homes
(ASH) Project (funded by a grant from the Ohio Tobacco Use Prevention
and Control Foundation).

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Perhaps the most important aspect of the ECS design is continuous
quality improvement guided by evidence-based practice and data about
our providers and clients. We believe, as described by Daro, that the
quality of home visiting programs is based in having self-evaluation in
each program and in applying what we know about quality.
``Greater positive impacts among a broad range of home visitation
models reflect, in part, two trends--improved program quality and
improved conceptual clarity. With respect to quality, the six major
national home visitation models are each engaged in a series of self-
evaluation efforts designed to better articulate those factors
associated with stronger impacts and to better monitor their
replication efforts''
As Congress moves to adopt legislation that can support and guide
home visiting programs across the country, we make three
recommendations.
1. Provide funding for the core work of home visiting programs. To
date, home visiting programs--ECS included--have had to cobble together
a variety of funding sources and keep families on waiting lists until
funds become available. Current federal funding streams such as TANF
and Medicaid are not designed to fund home visiting. In trying to use
these existing funding streams, programs often must divert effort or
change the structure of service delivery to families. With a more
reliable and continuous source of federal funding, ECS and other
programs can optimize private, as well as state and local, resources.
2. Support outcomes-driven programs that make evidence-based
decisions. Expand policy and operational programs that have credible
evaluations and that are shown to work. We do not recommend relying on
a tiered funding approach that tends to reward high performers while
limiting dollars available for innovation, quality improvement and
improved implementation among other good programs.
3. Focus on quality, not one model. Taken together, the body of
research knowledge about home visiting tells us that successful
programs have well-trained staff, solid supervision, ongoing
relationships with families, a design that fits the specific program
activities to desired outcomes, and linkages to other community
programs such as child care and health care. Ongoing data collection
analysis and evaluation, as well as training activities, are essential
to achieving desired results. Congress and the Obama Administration
have an opportunity to provide a framework such as that used in Head
Start or Community Health Centers, through which performance standards
and program guidelines help local programs deliver quality services and
outcomes. This could be created out of the thousands of existing
programs, including 40 state-based home visiting programs in operation
today. (Johnson)
Recognize that home visiting programs target multiple outcomes. A
new federal home visiting program should aim not only to prevent child
abuse and neglect; but also aim to improve an array of outcomes that
affect early childhood health and development. ECS has shown that a
single program can have impact on infant mortality, parenting skills,
maternal depression, well-child visits, smoking reduction, and more.
Congress should expect quality programs that provide quality services
and data to show their results in multiple areas.
References
Ammerman, RT, Putnam FW, Kopke JE, Gannon TA, Short JA, Van Ginkel
JB, Clark MJ, Carrozza MA, Spector AR. Development and implementation
of a quality assurance infrastructure in a multisite home visitation
program in Ohio and Kentucky. Journal of Prevention and Intervention in
the Community. 2007; 34, 89-107; Ammerman RT, Putnam FW, Altaye M.
Chen, Holleb L., Stevens J., Short JA & Van Ginkel JB. Changes in
depressive symptoms in first time mothers in home visitation. Child
Abuse & Neglect, 2009; 33, 127-138.
Daro D. 2006. Home Visitation: Assessing Progress, Managing
Expectations. Chicago, IL. Ounce of Prevention Fund and Chapin Hall.
Donovan EF, Ammerman RT, Besl J, Atherton H, Khoury JC, Altaye M,
Putnam FW and Van Ginkel JB. Intensive Home Visiting Is Associated With
Decreased Risk of Infant Death. Pediatrics. 2007; 119:1145-1151.
Healthy Families America Effectiveness: A comprehensive review of
outcomes. Journal of Prevention and Intervention in the Community.
2007; The evaluation of Healthy Families Arizona: A multisite home
visitation program. Journal of Prevention and Intervention in the
Community. 2007; 34(1-2):109-127; Caldera D, Burrell L, Rodriguez K, et
al. Impact of a statewide home visiting program on parenting and on
child health and development. Child Abuse Neglect. 2007 Aug;31(8):829-
52; Duggan A, McFarlane E, Fuddy L, Burrell L, et al. Randomized trial
of a statewide home visiting program: impact in preventing child abuse
and neglect. Child Abuse Neglect. 2004; 28(6):597-622; Barnes-Boyd C,
Nacion KW, and Norr KF. Evaluation of an interagency home visiting
program to reduce postneonatal mortality in disadvantaged communities.
Public Health Nursing. 1996; 13:201-8.
Johnson K. State-based Home Visiting Programs. New York: National
Center for Children in Poverty. 2009. Available at www.nccp.org;
Johnson, K. No Place Like Home: State Home Visiting Policies and
Programs. New York: The Commonwealth Fund. 2001. Available at
www.cmwf.org
Olds D, Henderson C, Tatelbaum R, Chamberlin R. Improving the
delivery of prenatal care and outcomes of pregnancy: a randomized trial
of nurse home visitation. Pediatrics. 1986; 77: 16-28; Olds D,
Henderson C, Chamberlin R, Tatelbaum R. Preventing child abuse and
neglect: a randomized trial of nurse home visitation. Pediatrics. 1986;
78:65-78; Olds DL, Henderson CR, Tatelbaum R, and Chamberlin R.
Improving the life-course development of socially disadvantaged
mothers: A randomized trial of nurse home visitation. American Journal
of Public Health. 1988; 78(11):1436-45; Olds D and Kitzman H. Can home
visitation improve the health of women and children at environmental
risk? Pediatrics 1990; 8-16; Olds DL, Henderson CR, Phelps C et al.
Effect of Prenatal and Infancy Nurse Home Visitation on Government
Spending. Medical Care. 1993; 5-74; Olds DL, Robinson J, Pettit L, et
al. Effects of home visits by paraprofessionals and by nurses: age 4
follow-up results of a randomized trial. Pediatrics. 2004; 114:1560-
1568; Olds DL, Kitzman H, Hanks C, et al. Effects of nurse home
visiting on maternal and child functioning: age-9 follow-up of a
randomized trial. Pediatrics. 2007; 120(4):e832-45.
Sweet MA, Appelbaum MI. Is home visiting an effective strategy? A
meta-analytic review of home visiting programs for families with young
children. Child Development. 2004 Sep-Oct;75(5):1435-56; Bilukha O,
Hahn RA, Crosby A, Fullilove MT, Liberman A, Moscicki E, Snyder S, Tuma
F, Corso P, Schofield A, Briss PA; Task Force on Community Preventive
Services. The effectiveness of early childhood home visitation in
preventing violence: a systematic review. Am J Prev Med. 2005 Feb;28(2
Suppl 1):11-39; Bennett C, Macdonald GM, Dennis J, Coren E, Patterson
J, Astin M, Abbott J.
Home-based support for disadvantaged adult mothers. Cochrane
Database Syst Rev. 2007 Jul 18;(3):CD003759. Update in: Cochrane
Database Syst Rev. 2008;(1):CD003759; Geeraert, L., Van den Noorgate,
W., Grietens, H., & Onghena, P. The effects of early prevention
programs for families with young children at risk for physical child
abuse and neglect: A meta-analysis. Child Maltreatment. 2004; 9(3):277-
291.

Statement of The Family Violence Prevention Fund
Chairman McDermott, Ranking Member Linder and Members of the
Subcommittee, thank you for the opportunity to comment on the value of
home visitation programs and specifically the Early Support for Young
Families Act.
The Family Violence Prevention Fund is a national non-profit
organization based in San Francisco. We were founded almost 30 years
ago with a simple mission: to end violence against women and children.
Like many domestic violence organizations at the time, we began by
focusing on the criminalization of violent behaviors by men toward
their wives and girlfriends. However we quickly came to focus on the
strong link between the safety and well-being of mothers and the safety
and well-being of their children.
That is why we emphasize prevention and the critical need to ensure
that all family members are safe and healthy. We have identified early
supports for young and vulnerable families as an essential strategy
both for preventing initial perpetration of violence and for early
identification of children living in violent homes. Importantly, these
early interventions can also mitigate the effects of the violence on
children and provide support to the non-abusing parent, typically the
mother, to improve her and her children's safety and stability.
We commend the Committee for its commitment to the safety and well-
being of children and families and particularly for your focus on home
visitation programs. As you well know, home visitation is one of the
few documented, well-evaluated interventions that works to prevent
child abuse and maltreatment. While there are several models out
there--and we would support funding for multiple types of programs--the
Nurse-Family Partnership model is probably the most rigorously
evaluated. This intervention targets younger and lower-income pregnant
women, and has been shown to significantly reduce reported rates of
child abuse throughout childhood and into adolescence. One of the
most--if not the most--significant barrier to the success of home
visitation, however, is domestic violence. That is the focus of our
comments.
Domestic Violence Limits Effectiveness of Home Visitation
While we strongly support home visitation as an effective strategy
for improving health outcomes for children and reducing child abuse and
neglect, we are convinced that home visitation programs must address
domestic violence. The first reason is simply that domestic violence is
so prevalent. Approximately 15.5 million children witness domestic
violence each year in their homes. This means that almost one-third of
American children cared for by married or cohabitating parents are
exposed to domestic violence.
The consequences of children's exposure to domestic violence are
well-documented. Children who witness domestic violence display a host
of problematic behaviors at far greater rates than children not exposed
to violence. These include being more likely to become a perpetrator of
such abuse (for boys) as well as higher rates of violence, aggression,
suicide, school failure and mental health problems. The effects of
witnessing abuse on children may be equal to, or in some cases worse,
than the direct experience of being abused. However, it also is
important to note that many children who witness adult domestic
violence do just fine. Often the reason is the child's strong
relationship with her or his mother, even if that mother is
experiencing abuse, because it serves as a protective factor. Home
visitation programs are thus critical in identifying these children,
helping them be safe and cope with what they have witnessed, linking
abused mothers to helpful community resources, and supporting strong
relationships between mother and child.
We also recommend that home visitation programs address domestic
violence because it serves as a major--if not the major--barrier to the
effectiveness of these programs. Research reported in the Journal of
the American Medical Association in 2000 detailed the most convincing
rationale: first, about half the mothers participating in the well-
known Nurse-Family partnership study experienced domestic violence; and
where domestic violence did exist, the effectiveness of home visitation
to reduce abuse and improve child outcomes diminished. Among mothers
experiencing the higher rates of and more severe abuse, the beneficial
effects of the program disappeared entirely.
This research appears consistent with other studies that show
varying impact and effectiveness of home visitation programs, though
few have teased out as clearly the impact of domestic violence. Because
domestic violence rates are so high and because they hinder the
effectiveness of the programs, it is essential that home visitation
programs tailor their interventions and provide training to staff on
how to talk to young parents about violence and its effects on
children, and how to recognize and respond to families already
experiencing violence.
Home visitation programs have the ability to not only help families
when domestic violence is occurring, but also to provide primary
prevention of both child abuse and domestic violence. Healthy, non-
violent relationships are fundamental to healthy parenting.
Specifically, we strongly recommend that any home visiting
legislation include the following four components:

1. State plans and/or assessments should include information on
how domestic violence will be addressed and how programs will safely
and confidentially refer women to domestic violence services when
necessary;
2. Training and technical assistance for home visitation programs
should be funded and should include:
a. information on how to safely assess for domestic
violence in the families being served,
b. promotion of healthy and non-violent partnering as
helpful to a child's health and development,
c. how and when to talk to men and fathers who use
violence about how domestic violence can affect
parenting and how to get help;
3. Community-based service providers referenced should include
domestic violence, fatherhood and batterers intervention programs so
families are given the information and referrals they need; and
4. Women living in domestic violence shelters should be eligible
for services, assuming these services can be provided in a safe and
confidential manner.
Thank you for the opportunity to comment on this critical
legislation. For additional information, please go to www.endabuse.org;
or contact our Washington, D.C. office.

Statement of First 5 Alameda County Home Visitation Programs: A
Multidisciplinary Approach
Background
First 5 Alameda County Every Child Counts (F5AC), funded by
revenues from the California 1998 Proposition 10 tobacco tax, works to
ensure that every child reaches his or her developmental potential.
F5AC focuses on children and families from prenatal to age five years.
Alameda County is the seventh most populous county in California
with a population of 1,454,159 (American Community Survey Demographic
Estimates, 2005-2007) and one of the most ethnically diverse regions in
the United States. It is a county with sprawling urban areas as well as
agricultural centers, and is as large as many states with over 821
square miles.
In 2007, 125,450 children aged 0-5 years lived in Alameda County.
Young Latino and Asian children are the fastest growing populations
accounting for approximately 33% and 25% of all births, respectively
(State Department of Finance, Demographic Research Unit, 2007).

----------------------------------------------------------------------------------------------------------------
Alameda County Population
Race/Ethnicity (1) Birth Population (2)
----------------------------------------------------------------------------------------------------------------
African American/Black 13.0% 11.0%
----------------------------------------------------------------------------------------------------------------
Asian 24.6% 24.5%
----------------------------------------------------------------------------------------------------------------
Caucasian/White 24.4% 22.0%
----------------------------------------------------------------------------------------------------------------
Latino 21.4% 42.2%
----------------------------------------------------------------------------------------------------------------
Native American 0.6% 0.2%
----------------------------------------------------------------------------------------------------------------
Pacific Islander 0.8% -
----------------------------------------------------------------------------------------------------------------
Multiracial 3.6% -
----------------------------------------------------------------------------------------------------------------
Other/Unknown 11.7% 0.1%
----------------------------------------------------------------------------------------------------------------

Sources: American Community Survey 2006 (1); Alameda County Public
Health Department Vital Stats, 2007 (2)
Overall, in 2006, an estimated 3,149 (3.0%) of all children ages 0-
5 in Alameda County were foreign born, and 2,483 (2.4%) were not U.S.
citizens (American Community Survey, 2006). Linguistically, 43.5% of
the 5+ population speak a language other than English at home and 19.1%
speak English less than very well. Among these 19.1%, 45.1% speak
Spanish and 42.5% speak Asian and Pacific Islander languages (American
Community Survey, 2006).
As evidenced by the data above, Alameda County needed to address a
variety of factors in developing programs to meet the needs of a large
and diverse county. F5AC began planning for the implementation of a
voluntary home visitation strategy in 1999. F5AC explored several best
practice home visitation models in existence at that time: Hawaii's
Healthy Start, Healthy Families America, The Nurse Family Partnership-
Olds Model and Parents as Teachers. F5AC decided not to utilize one
particular model, but rather embraced the best practice standards that
were emerging by creating a set of tenets to infuse into F5AC home
visitation programs for the prenatal to five population in Alameda
County.
FSS Tenets provides a framework for continuous quality improvements
to meet evolving needs in targeted populations.

1. Family-centered: acknowledges the reciprocal nature of family
well-being and child development, and includes support to the family as
a whole rather than restricted to child-level services.
2. Relationship-based services: Emphasizes that the family-
provider relationship is the most important tool for provider and
addresses the need for staff to be supported to ``reflect'' on her/his
responses to individual cases.
3. Child development focused: Expects the service provider to
continually observe and use opportunities to help families understand
their child's behavior in the context of child development;
incorporates a ``child find'' strategy for early identification and
intervention by requiring completed developmental screenings/
assessments throughout the period of services.
4. Appropriate caseload ratios: Maintains a case ratio of 1:20-25
per case manager (and 1:13 for families at risk for child abuse) to
support the manageability and intensity of family support services by
individual staff.
5. Reflective supervision: Supports staff to understand the
importance of reflection as a tool in their intervention work with
families. Supervisor/staff relationships parallel the provider/family
relationship.
6. Multi-disciplinary approach: Emphasizes the use of a variety of
professional disciplines to meet family needs.

Implementing home visitation models in Alameda County also relied
on key operational factors: the ability to access a large number and
diverse pool of nurses to serve our diverse community; the cost of
using PHNs to provide services; capacity to address language and
cultural continuity for parents; the need to utilize existing programs;
the desire to avoid investing in unsustainable programs; the capacity
to meet diverse and multiple family risk factors.

Relying on the nursing supply in Alameda County severely
limited the number and diversity of families able to receive home
visits: Of the approximately 21,000 annual births in Alameda County,
7,000 were to very low-income mothers qualifying for California's
Medicaid and Healthy Families programs; 1,504 were born low birth
weight; 1,325 to teen mothers. The number and cost of Public Health
Nurses who had both linguistic capacity and reflected the cultural
backgrounds of our community could not possibly meet the demand for
services.
The high risk nature of clients targeted by F5AC required
multi-disciplinary approaches to engage difficult-to-reach families:
F5AC families targeted to receive home visitation included pregnant and
parenting teens, parents of infants discharged from the neonatal
intensive care unit due to severe and long-term health issues at the
time of birth, and children at-risk of neglect or abuse due to
substance use, mental illness or other unstable family environments. Up
to 36% of mothers experienced postpartum depression, 7% of children
were exposed to substance use, and 9% of families were involved with
Child Protective Services. Each significant risk factor necessitated
immediate attention by a multi-disciplinary team of providers who were
most able to offer timely support services--which were pre-requisites
for maintaining a quality, trusting and continuous relationship between
a home visitor and the family.
Meeting culturally and linguistically diverse needs of
families necessitated an agile and culturally responsive workforce:
Community organizations offered comparative advantages by staffing the
programs with home visitors who reflected the face of the county's
community. A children's hospital and family services department of
Alameda County Public Health provided a mix of nurses and
paraprofessional community health workers who effectively addressed
long-term health and child development issues of children discharged
from the Neonatal Intensive Care Unit. Multi-lingual and bi-cultural
specialists helped families navigate community resources and medical
specialists critical to the stability and health of the families.
Community-based organizations that focused on reaching teen parents
worked with schools and Social Services Agency to help young parents
remain on track with high school requirements and to assist in
obtaining services to which they are entitled to give their children a
healthy start. Three community-based organizations demonstrated success
in offering alternative response intensive case management to families
already known to the Child Abuse Hotline but who did not qualify for
immediate investigation by Child Protective Services.

Over the past 9 years, F5AC collected individual client level case
management and outcomes data to support a robust accountability
framework of continuous program quality assurance and impact
measurement. F5AC's home visitation models produced impressive
outcomes.

Sec. Children stayed healthy and up-to-date on preventive care:
Over the last 8 years, F5AC home visiting programs consistently
reported 86-99% of children had health insurance; 94-98% were up-to-
date with immunizations; 92-97% had an identified primary pediatric
provider (medical home); 95-98% had all the appropriate well-child
visits for age.
Sec. Early identification and treatment of maternal depression:
Early identification of mental health issues and referral to
appropriate supports and treatment options provided the necessary
foundation for a socially and emotionally secure parent-child
relationship. F5AC implemented a county-wide standard to screen every
at-risk parent for depression. 20-36% of mothers who received home
visits screened positive for maternal depression. Those who screened
positive for depression were also more likely to have children who
screened ``of concern'' in at least one developmental domain.
Sec. Anticipatory guidance and early screening and support for
children's development: Home visitors used their encounters with
families to help parents learn what to expect as their baby grows. A
county-wide strategy to promote developmental screening of every child
helped identify 20-63% of children with developmental concerns.
Sec. Positive breastfeeding trends: In addition to promoting
bonding between parent and child, 56% of teen parents and 63% of
parents of children discharged from the NICU breastfed or used breast
milk as the primary source of nutrition for their babies. Of those who
breastfed, over 30% did so for more than six months.
Sec. Low incidence of ER visits and hospitalizations for
preventable illnesses and intentional injuries: Less than 1% of
children without chronic medical conditions visited the emergency room
while fewer than 4 per 100,000 suffered intentional injuries.
Sec. Teen parents stayed in school or graduated: Almost 60% of
teens who received home visits remained in school or graduated from
high school.
Summary
In implementing home-based early intervention services, First 5
Alameda County had to take into account the particular demographic
needs and workforce issues within our community. A key to successful
program implementation was staying true to F5AC family support tenets
while structural and demographic changes continuously shifted in the
county. We were guided by evidence-based practice, but above all else,
needed to have the flexibility to use the evidence base tailored to the
circumstances of the populations to be served (pregnant and parenting
teens, infants discharged from the neonatal intensive care unit,
children referred to child protective services, parents in need of
family support during the transition to parenthood). Each one of these
populations had different needs in reference to dosage, single
discipline versus multidisciplinary, and type of professional providing
the intervention. What unified our providers in the provision of home-
based services was the common language we developed over the years, the
ongoing training and support to staff, and continuous monitoring and
quality improvement measures put in place to assure we were having an
impact on families.

Statement of Gaylord Gieseke
I, Gaylord Gieseke, as the Interim President of Voices for Illinois
Children, would like to submit the following in support of the Early
Support for Families Act (H.R. 2667). Voices for Illinois Children
builds better lives by working across all issue areas to improve the
lives of children of all ages. We envision Illinois as a place where
all children have the opportunity to grow up healthy, happy, safe,
loved and well educated.
The importance of starting early
``One of the most valuable things I can say I learned through the
home visits is that I am the example my children will follow;
therefore, I have to take the lead.'' i Spoken by Monica, a
teen mother participating in an Illinois home visitation program, this
statement communicates the motivation and hope many mothers are able to
find with the support of a home visitor.
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\i\ Monica of Lifelink in Bensenville, Illinois. (2008, November
21). Home Visitors Celebration Lunch: Recognizing Success and
Achievement.
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Home visiting participants come from all walks of life, but often
they resemble the story of a 17-year-old high school student who
unexpectedly became pregnant. Enrolling in a home visitation program,
she learned about healthy nutrition and then chose more healthy foods
for herself and her growing baby. Although the mother had a difficult
birth, she and the baby bonded well--the home visitor provided
encouragement and education about how to interact with a fussy baby
during sleepless nights, and helped the mother identify signals the
baby may give to indicate what he likes and doesn't like. Initially
unsure about how to talk to doctors or social workers, the mother has
become an advocate for both herself and her baby, having observed and
practiced communicating her needs effectively with the home visitor.
Since graduation, the mother has started work as a Certified Nursing
Assistant, obtained a driver's license, and started saving for a car,
which would enable her to begin taking courses at a nearby community
college. In preparation for college, the home visitor is helping the
mother find and fill out scholarship applications.
With the support of a home visitor, teen parents are accessing the
resources they need to build better lives for their children.
Recognizing the importance of the parenting role and that learning
begins at birth, home visitation programs around the country offer in-
home services designed to strengthen parenting skills, assist in the
development of a safe and nurturing home environment, and promote early
learning for children, from the months before birth to age five.
The importance of interventions in early childhood--including the
months before birth--has been supported many times over by an
impressive quantity of research on children's brain development. Brain
scans indicate that the brains of well-cared for babies are
fundamentally different from those of neglected infants, with lasting
implications for each child. Beginning in the 1980s and continuing to
the present day, researchers consistently find that brain development
happens in the context of the child's environment and is not a stand-
alone biological phenomenon.ii,iii
---------------------------------------------------------------------------
\ii\ Shonkoff, J.P., & Phillips, D. (Eds.) (2000). From neurons to
neighborhoods: The science of early childhood development. Committee on
Integrating the Science of Early Childhood Development. Washington, DC:
National Academy Press.
\iii\ Bradley, R.H., Caldwell, B.M. Rock, S.L., Ramey, C.T., et al.
(1989). Home environment and cognitive development in the first three
years of life: A collaborative study involving six sites and three
ethnic groups in North America. Developmental Psychology, 25, 217-235.
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As a child bonds with a caregiver, builds vocabulary, plays with
toys, and otherwise engages the broader world around him through his
five senses, he increases brain activity, which in turn preserves
neurons to be used in future learning. Without these experiences, or
when a young child is exposed to stress without supportive
relationships to mitigate its impact, the brain pares down neurons,
creating future learning challenges for the neglected
child.iv,v Acting in this critical window for
development, early childhood interventions support the creation of an
environment in which infants may develop a secure attachment to a
responsive caregiver--science tells us this enhances brain development.
All later interventions work with the brain function already
established in infancy and early childhood.
---------------------------------------------------------------------------
\iv\ Nelson, C.A., Levitt, P., & Gunnar, M.R. (2008, June 27). The
impact of early adversity on brain development. National Symposium on
Early Childhood Science and Policy for the National Scientific Council
on the Developing Child.
\v\ Harvard Center on the Developing hild. (n.d.) InBrief: The
science of early childhood development. Retrieved on February 16, 2009,
from http://www.developingchild.harvard.edu/content/downloads/inbrief-
ecd.pdf.
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The Education Continuum: Beginning Earlier with Home Visiting Programs
Although the continuum of education has traditionally been P-12
(kindergarten through high school), brain research makes it clear that
age five is much too late to first offer educational supports to the
child and family. A child's experiences before entering kindergarten
may hinder or promote her chances of successfully finishing high school
and reaching college. Recognizing the need to expand the education
continuum to include much, much younger ages, professionals around the
country began developing programs, known as ``Home Visiting Programs,''
to fill the early childhood gap and to support parents of young
children.
For all programs, participation is entirely voluntary; program
models are generally designed to include weekly or biweekly home
visits, which last two to five years. By having nurses or
paraprofessionals visit families in their homes, home visiting programs
reduce the obstacles that may otherwise prevent a family from accessing
services. Seven nationally recognized home visiting programs are Early
Head Start, Healthy Families America, Nurse-Family Partnership, Parents
as Teachers, the Parent-Child Home Program, Parents Too Soon, and Home
Instruction for Parents of Preschool Youngsters (HIPPY). HIPPY and
Parents as Teachers are universal access programs, while the others
target teen mothers, single mothers, low-income parents, or families
with some other significant risk factor.
Several home visiting programs are designed to engage families when
children are at their earliest ages--during pregnancy and infancy. Home
visitors provide or link women to prenatal care and assist the family
with establishing a medical home and making and attending the baby's
well-being appointments. Doulas may work with a mother to prepare for
delivery and begin breastfeeding. Furthermore, home visitors talk with
parents about caring for the baby, discuss the child's developmental
stages, and help moms and dads develop practical and appropriate
parenting skills and strategies. Overall, these programs emphasize the
importance of family health, economic self-sufficiency, and parenting
skills--factors that significantly affect the home environment and the
child's developmental foundation.
As children reach the toddler and preschool years, home visiting
programs build on healthy development and empower parents to be their
child's first and most important teacher. Arriving with an educational
toy or book, visitors teach or model parent-child interactions that
stimulate brain development, and they encourage parents to take
advantage of preschool. Reading, talking with the child, and promoting
age-appropriate exploration and choices contribute to the development
of the child's burgeoning vocabulary, self-confidence, and ability to
reason. Parent involvement in nurturing verbal, reasoning, and social
skills in the informal home environment is critical to preparing
children to learn in the more formal school environment. These programs
also provide parents with information about their child's development
and related capabilities and limitations.
Illinois' commitment to Home Visiting
As a state, Illinois has long recognized the benefits associated
with home visitation and has been investing in programs since 1982. On
average, these programs serve 15,880 children each year in Illinois
through the Healthy Families, Parents as Teachers, Parents too Soon,
and Nurse Family Partnership models.vi However, especially
in these difficult economic times, the current level of programming is
not meeting the need for home visiting. As financial pressures increase
for a family, so does the risk of child abuse and the need for
preventive services. Including children receiving Medicaid assistance,
Illinois currently serves only 48 percent of the 35,000 infants born
each year who are most likely to benefit developmentally and
academically from home visitation.vii There are still many
children and families yet to be served.
---------------------------------------------------------------------------
\vi\ Ibid
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However, this is also an exciting time, as Illinois has a critical
opportunity to broaden the reach and strengthen the quality of home
visiting in Illinois through the Strong Foundations Project. The
Illinois Department of Human Services, along with the Department of
Child and Family Services and the State Board of Education, has
received a $500,000 five-year federal grant for this project. Having
previously and independently funded home visiting programs, these
agencies are working together and with service providers and advocacy
groups to support and expand home visiting across the state.
Specifically, Strong Foundations will operate under the Illinois
Early Learning Council as a new committee--the Home Visiting Task
Force. The Early Learning Council is charged with the coordination of
services for young children, and the Home Visiting Task Force will
coordinate resource allocation, community capacity-building, training,
data collection, monitoring, and technical assistance across the three
state agencies and more than 150 home visiting programs involved in the
project. This project will support high-quality service delivery, and
to this end will develop special trainings to help home visitors serve
particularly vulnerable populations, such as those experiencing mental
illness, substance abuse, domestic violence, or developmental
disability.
Research has clearly identified the importance of a nurturing
family environment during early childhood brain development. Moreover,
evaluations have affirmed the effectiveness of home visiting as a means
to improve child and family outcomes on a number of health, safety,
economic, academic, and social indicators. Though the needs are great
in these economic times, the passage H.R. 2667 would demonstrate the
national commitment to enhancing children's well-being through a wide
array of approaches, of which home visiting is clearly an integral
part. It is critical that the recognition and support of home
visitation is established in sound federal policy as our nation seeks
to improve the educational and developmental outcomes for our nation's
children.
If you would like additional information regarding home visiting in
Illinois, please contact Gaylord Gieseke.

Letter from Gladys Carrion, Esq.
Thank you for your recent legislative effort to subsidize and
support evidence-based home visitation programs. The legislation, the
Early Support for Families Act, adds Subpart 3 to Title IV-B of the
Social Security Act to provide grants to states to establish or expand
quality home visitation programs for families with young children and
those expecting children.
The National Association of Public Child Welfare Administrator's
(NAPCWA) discusses briefly in its submission for the record, that New
York State currently administers an evidence-based home visitation
program with positive outcomes. That program, the Healthy Families New
York (HFNY) home visitation program has successfully provided child
abuse prevention services to low-income families for many years. As
Commissioner of the New York State Office of Children and Family
Services (OCFS), I wholeheartedly agree with Congress' decision to make
home visitation an important part of its investment strategy for
preventive services.
The economic downturn has forced many states to reduce
substantially their investment in home visitation and other prevention
programs in order to preserve dwindling resources for mandated child
welfare services. In New York State, despite strong evidence from a
randomized controlled trial demonstrating the effectiveness of HFNY,
the program sustained an 8% cut in SFY 2008-2009 and maintained that
cut in SFY 2009-2010. The availability of significant federal funding
for home visiting purposes will likely allow states to continue to
invest in this strategy and permit more families to participate. In
2003, Healthy Families America (HFA) programs alone assessed 71,000
families and provided home visiting services to 47,500 families across
the country.
Based on the Healthy Families America home visitation model, HFNY
targets expectant parents and parents with an infant less than three
months of age who have characteristics that place them at high risk for
child abuse or neglect and live in vulnerable communities marked by
high rates of poverty, infant mortality, and teen pregnancy. Specially
trained paraprofessionals, who typically live in the same communities
as participating families and share their language and cultural
background, deliver home visitation services until the child reaches
five or is enrolled in Head Start or kindergarten. HFNY's home visitors
provide families with support, education, and linkages to community
services designed to address the following goals: 1) to prevent child
abuse and neglect, 2) to enhance parenting skills and parent-child
interactions, 3) to provide optimal prenatal care and promote child
health and development, and 4) to increase parents' self-sufficiency.
Since its inception in 1995, HFNY has provided more than 600,000 home
visits to over 20,000 families.
HFNY has been rigorously evaluated using a randomized controlled
trial. The evaluation has reported positive program effects in terms of
childbirth outcomes, child abuse and neglect, parenting practices, and
access to health care. A study published in the January 2009 issue of
the American Journal of Preventive Medicine showed that mothers who are
enrolled in HFNY before their 31st week of pregnancy were only half as
likely to have low birth weight babies as mothers in a control group.
HFNY was particularly effective in reducing low birth weight among
African-American and Hispanic mothers, groups that persistently
experience high levels of poor birth outcomes. For example, 3.1 percent
of the African-American mothers in the HFNY group delivered low birth
weight babies, compared to 10.2 percent of the African-American mothers
assigned to the control group. In addition to the impacts on low birth
weight, HFNY has been shown to increase access to health care,
particularly among African-American and Hispanic women. A study
published in the March 2008 issue of the journal Child Abuse and
Neglect indicated that HFNY decreased the incidence of child abuse and
neglect during the first two years of life, and reduced the use of
aggressive and harsh parenting practices, particularly among first-time
mothers under age 19 who were offered HFNY early in pregnancy. Finally,
HFNY has been found to promote the use of positive parenting skills
that support and encourage children's cognitive and social development
(Published Report/Working Paper, 2008, available at
www.ocfs.state.ny.us).
Based on the evaluation's rigorous random assignment design and the
program's significant and positive effects on a range of outcomes, HFNY
was designated as a ``proven program'' by RAND's Promising Practice
Network and an effective program by both Child Trends and the Office of
Juvenile Justice and Delinquency Prevention. In addition, the
evaluation received grants from both the National Institute of Justice
and the Doris Duke Charitable Trust Foundation to support the extension
of the randomized trial into its seventh year.
HFNY and other evidence-based home visiting programs that rely on
paraprofessionals and those professionals other than nurses to deliver
home visitation services can help address the serious shortage of
nurses in low-income communities and the under representation of
minorities in the nursing field.
I applaud Congress on their sensitivity to this issue. I urge you
to consider funding this program in a manner that does not impose
unfunded mandates or administrative burdens. In addition, please
consider restructuring the matching and Maintenance of Effort
strategies so that states may be better prepared to participate in this
federal funding program in these times of economic distress. I look
forward to the success of this legislation's intent and am willing to
offer my assistance to you in achieving this goal.
Sincerely,
Gladys Carrion, Esq.

Statement of Healthy Families Florida
On behalf of our network of 38 community-based service providers
and the more than 13,000 Florida families they serve annually, Healthy
Families Florida is grateful for this opportunity to provide testimony
in support of federal investment in early childhood home visitation.
This testimony will briefly explain the value of home visiting
services to Florida families and how Healthy Families home visiting
services are being effectively implemented in Florida to prevent child
abuse and neglect in our state's highest risk families before abuse
ever happens.
Federal Investment in Home Visiting to Promote Positive Parent-Child
Relationships and Healthy Child Development Makes Sense
Early childhood experiences, especially interaction with parents
and caregivers, influence a child's developing brain and provide the
foundation for all future development. While stable, nurturing
experiences can help children develop the resilience to overcome
typical adversities in life, experiencing child abuse and neglect can
be devastating to child development, often setting in motion a chain of
events that has lifelong consequences as children grow to adulthood. In
addition to increasing the likelihood of delinquency, criminal
involvement, substance abuse and low educational achievement, child
abuse and neglect has a long-term impact on physical and mental health.
Research shows that the added stress low-income families face
during economically depressed times causes child abuse and neglect to
increase. The human and monetary costs of child abuse and neglect are
unconscionable, especially compared to the low cost of effective
prevention.
Prevention services, like those offered through Healthy Families
Florida and other evidence-based home visiting programs in Florida,
support healthy child development and family stability at a fraction of
the cost of providing services that intervene after abuse and neglect
have occurred.
About Healthy Families Florida
Healthy Families Florida is a statewide, nationally accredited,
voluntary home visiting program that is proven to prevent child abuse
and neglect before it ever starts. The program is modeled after Healthy
Families America, an evidence-based initiative of Prevent Child Abuse
America. Healthy Families America is recognized by the U.S. Office of
Juvenile Justice and Delinquency Prevention as an ``effective
prevention program, demonstrating empirical findings using a sound
conceptual framework and an evaluation design of high-quality.``
Healthy Families New York, which implements the same model, is also
acknowledged as a successful and proven program by the Rand
Corporation, a non-profit institution that addresses the challenges
facing the public and private sectors around the world.
Healthy Families Florida equips parents and other caregivers with
the knowledge and skills they need to create stable home environments
free from child abuse and neglect so their children can grow up
healthy, safe, nurtured and ready to succeed in school and in life.
Highly trained home visitors provide parents and other caregivers
information, guidance and emotional and practical support by:

Modeling positive parent-child interaction to enhance
their child's development.
Providing education on child health and development and
the importance of immunizations and well-baby check-ups.
Teaching about safe and unsafe sleeping environments for
infants, coping with crying and other prevention topics.
Conducting child screenings for developmental delays.
Connecting families to medical providers and making
referrals to other community services.
Teaching how to recognize and address child safety
hazards in and around the home, in the car, in and around water and in
other environments.
Helping to develop appropriate problem-solving skills
and identify positive ways to manage stress.
Promoting personal responsibility for their future and
the future of their families by helping them to set and achieve goals,
such as furthering their education and acquiring stable employment.

Who do we serve?
Research shows that the key to preventing child abuse and neglect
is intervening early, during pregnancy or shortly after the birth of a
baby. Healthy Families services begin during pregnancy or within three
months of a baby's birth and can last for up to five years depending on
the unique needs of each family. Healthy Families uses a validated
assessment tool to determine which families are experiencing a variety
of difficult circumstances that place their children at high risk for
abuse and neglect and other adverse outcomes that are preventable
through intensive home visiting services.
Most Healthy Families participants are low-income single parents
with less than a high school education and little awareness of
appropriate discipline options for their children. Participants often
experienced abuse or neglect during childhood. Other common participant
risk factors include:

Late or inadequate prenatal care
Multiple children under five years of age
Prior involvement with Child Protection Services
Inappropriate coping mechanisms
Current maternal depression or history of mental illness
Unrealistic expectations about child development
Limited contact with close friends and/or family
History of, or current, domestic violence or other abuse
Raised in an unstable home
History of, or current, substance abuse

Healthy Families services are available in all of Florida's 67
counties; in some throughout the entire county and in others only in
targeted high-risk zip code areas.
How do we know it works?
Healthy Families Florida has undergone a rigorous five-year quasi-
experimental study conducted by independent evaluators to determine
whether the program makes a measurable difference in participants'
lives. The evaluators concluded that HFF has a significant impact in
preventing child abuse and neglect and achieves positive outcomes for
both parent and child:

Before their second birthday, children in families who
received intensive HFF services experienced 58 percent less child abuse
and neglect than children of the same age in families who received
little or no HFF services.
Children whose families did not receive HFF services were
nearly four times more likely to suffer maltreatment before their
second birthday than children of the same age in families who completed
the program.
Participants who completed the program were more likely to
be employed within 36 months than those in the comparison group who
received little or no service.
Mothers who participated in HFF for three or more years
were significantly more likely to read to their children.
93 percent of children participating in HFF services were
fully immunized by age two.
92 percent of mothers participating in HFF services did
not have a subsequent pregnancy within two years.
81 percent of participants who completed the program
improved their education level, received job training or became
gainfully employed while enrolled in the program (measures of increased
self-sufficiency).

HFF has sustained high performance in promoting positive outcomes
for parents and their children since its inception in 1998.
Why is Healthy Families So Successful?
Key elements that contribute to Healthy Families success include:

Services are voluntary, which empowers families to make
positive changes in their behaviors and the way they lead their lives.
Home visits are frequent and long-term. Families start
out with weekly visits for at least six months. As families progress in
establishing stable, safe and nurturing environments for their
children, the frequency of the visits decreases to bi-weekly, then
monthly, then quarterly.
Services are available during non-traditional hours,
including evenings and Saturdays, to accommodate families' work and
school schedules.
Intensive training prepares staff for their roles and
responsibilities and helps them succeed in their work with families.
Quality supervision allows supervisors to review the
progress of families with staff on a weekly basis in order to provide
guidance and clinical support and develop the skills of the home
visitors.
Low caseloads allow home visitors to spend the time they
need to meet the individual needs of each high-risk family.
A strong statewide system that includes a central office
that provides annual quality assurance visits to ensure accountability
and fidelity to the Healthy Families program model; ongoing technical
assistance and training; fiscal oversight and data management; and
ongoing evaluation that identifies progress toward measurable outcomes
and areas in need of improvement or change.
Strong community partnerships provide families with
additional services such as child care, mental health counseling,
substance abuse treatment and domestic violence intervention.
Conclusion
In closing, the value of public investments in young children and
their families is obvious when looking at the long-term societal
benefits. According to the Center on the Developing Child at Harvard
University, ``the empirical data from cost-benefit studies presents a
compelling case for early public investments targeted towards children
who are at greatest risk for failure in school, in the workplace, and
in society at large.'' Home visitation is an effective, evidence-based,
and cost-efficient way to bring families and resources together, and
help families to make choices that will give their children the chance
to grow up healthy and ready to learn. Florida recognizes that an array
of home visiting services is needed to meet the diverse needs of
families throughout our state. We believe that HR 2667 is an important
step towards ensuring that families have access to these valuable
services so that all children have the opportunity to grow up in a
safe, healthy, and nurturing environment.
Contact Information:
Carol McNally, Executive Director
Healthy Families Florida

Statement of Howard S. Garval
What could be more important than preventing child abuse and
strengthening families? Nothing. That is why I am writing in strong
support of HR 2667 The Early Support for Families Act and I urge
passage of this important bill.
Hawaii invented Healthy Start, an evidence-based model of home
visiting for parents of newborns who are at various levels of risk of
child abuse. Healthy Start led to the replication in over 35 states of
similar programs under the Healthy Families America umbrella. In Hawaii
we have had a longstanding partnership with Johns Hopkins University as
the evaluator for this statewide effort. Child & Family Service is one
of six providers in the state and also the largest provider of Healthy
Start services. In Hawaii we added Child Development Specialists and
Clinical Specialists to the team with paraprofessional family support
workers because we found that the severity of many of the families
dealing with substance abuse, mental health problems and domestic
violence were beyond the competency of the home visitors. By adding
these positions and providing increased training by a seventh
organization here, we have strengthened the program and more recent
evaluations have been very encouraging. For several years now we know
that for families that stay one year or more in this voluntary program
there has been a success rate of over 99% as defined by no report of
child abuse/neglect. 50% of families stay a year or more and Hawaii's
results compare favorably to many programs in other states. For a
voluntary program, 50% retention after one year is a good result. We
are also beginning to define more clearly where the current model is
especially successful; i.e. with anxious moms. We continue to look at
ways we can make the program even more effective and Hawaii was
recently one of only 17 states to be awarded a $2.5 million grant by
ACF to work on further improvements to the program and to share the
results of these efforts nationally. ACF recognized all that Hawaii has
done in this area and wants us to share what we are learning and will
learn with the rest of the country.
There is a growing body of evidence from research that shows the
effectiveness of home visiting programs to prevent child abuse. There
is also abundant research to show the importance of early childhood
experiences in future outcomes for children. The ACE (Adverse Childhood
Experiences) study is one good example that actually shows that many
costly and serious medical problems are more prominent in adults who as
children suffered adverse childhood experiences like the trauma of
child abuse. We also know the huge cost in human, social, and economic
terms of not preventing child abuse. In this economic downturn where
states are cutting back services, more children and families are at
risk of serious negative outcomes. This legislation could not come at a
better time for this reason, but at any time this is a smart and good
investment in resources that will pay huge dividends in the years to
come. It will offer hope to the youngest and most vulnerable in our
communities and strengthen the family as the foundation for healthy
child development.
I urge you to strongly support HR 2667 The Early Support for
Families Act.
Thank you for the opportunity to submit testimony.
With much Aloha,
Howard S. Garval, MSW

Statement of Kansas Children's Service League
Kansas Children's Service League (KCSL) thanks the Chairman and the
other distinguished members of the U.S. House Committee on Ways and
Means Subcommittee on Income Security and Family Support for this
opportunity to provide the organization's perspective on the need for a
federal investment in early childhood home visitation. In particular,
we would like to thank Chairman McDermott, Representative Danny Davis
and Representative Todd Platts for their leadership on this issue, as
most recently demonstrated with their introduction of the Early Support
for Families Act of 2009 (HR 2667).
Kansas Children's Service League (KCSL) is a not-for-profit agency
standing on 116 years of tradition serving children and families
throughout the state of Kansas, strengthened by a mission to protect
and promote the well being of children. KCSL serves as the Kansas
Chapter of Prevent Child Abuse America; is a charter member of the
Child Welfare League of America; and has achieved national
accreditation from the Council on Accreditation and Healthy Families
America. Our collective efforts are aimed at keeping children safe,
families strong and communities involved. Through this testimony our
organization will identify the value of the Healthy Families home
visitation programs in Kansas along with our full support for federal
investment to enhance and expand our nation's ability to promote
healthy early childhood experiences.
KCSL fully supports and reiterates testimony submitted by Prevent
Child Abuse America on June 9, 2009 to the U.S. House of
Representatives Committee on Ways and Means. In the 13 years of our
Healthy Families intensive home visitation programs in Kansas, our
experience tells us that this program keeps children healthy and free
from abuse and neglect. Our results mirror those found among our sister
programs across the nation including:

96% of the children served are current on immunizations;
84% of the families served have a primary medical
provider;
87% have smoke free homes;
99% receive nutrition and physical activity information
and training; and
99% are free of abuse and neglect.

This is incredible given that these families enter the program
facing numerous (often 4 or more) risk factors heightening the
potential chance of child maltreatment.
We would like to take this opportunity to share with you the story
of one of our families. Maria's baby, Jennifer, was born with only one
functioning kidney. Maria, a 22-year-old first time single parent
entered our program unemployed, without stable housing and less than a
high school education. Her own childhood had been somewhat disruptive.
Maria stated that her grandmother did most of the caretaking because
her father came and went and her mother ``worked hard to put food on
the table''. Maria admits to being a very strong willed child and to
being hit with a switch ``or anything she could get her hands on'' when
she wouldn't listen to her mother. The KCSL Healthy Families worker
completed weekly home visits and developmental screens to make sure
Jennifer was doing well with her physical, social and emotional
development. The developmental screen performed by the KCSL Healthy
Families worker confirmed a possible delay and the family was connected
with an area Infant/Toddler program so that she could receive home-
based speech therapy.
Over the 3.5 years that the family has been in the program they
have met nearly 90% (8/9) of their goals. These goals have been focused
on a variety of needs including: Jennifer's medical condition;
employment; healthy relationships; stable housing; and parenting.
Jennifer has received a clean bill of health from her medical provider
and kidney specialist and is on target or ahead of the developmental
milestones for her age. Maria is proud as she reviews all of her
family's progress thus far. She will graduate from the Healthy Families
program this summer as Jennifer prepares to enter preschool in the
fall. The smile on Maria's face shows this pride as well as the
knowledge that she is doing everything she can to help her child remain
healthy and thrive.
As you can see, the home visitation and services of Healthy
Families is vital to the well-being of children and their families.
Thank you for this opportunity to submit testimony and please accept
our full support for the Early Support for Families Act of 2009 (HR
2667).

Statement of Kathee Richter
I am the Child Development Director of Neighborhood House, a non-
profit organization serving the Seattle/King County area in Washington
State.
Our organization is strongly in support of the Committee's efforts
to advance legislation supporting investments in evidence-based home
visiting programs that enhance early learning and reduce child abuse
and neglect.
For the last four years, Neighborhood House has delivered the
Parent-Child Home Program (PCHP) to 80 immigrant and refugee families a
year with strong outcomes for both the parents and the children ages 2
and 3 who are the program participants. PCHP is one of the major
national home visiting programs. Substantial research exists supporting
its ability to improve school performance, lower high school dropout
rates and improve high school graduation rates.
We employ paraprofessional home visitors who are bilingual or
multilingual and from the cultures of the families served. I do not
believe we would have been able to engage or effectively serve these
families if our staff did not speak their language or was not from the
same culture.
Overview of Neighborhood House
The mission of Neighborhood House is to help diverse communities of
people with limited resources attain their goals for self-
sufficiency, financial independence, health and community
building.
From our earliest beginnings serving Jewish immigrants in the 1900s
to our work today with people from numerous countries and cultures,
Neighborhood House has helped generations of families fulfill the
promise of America--an education for their children, self-sufficiency
for their families and a meaningful place in a caring community.
Our case workers, teachers, volunteers and tutors (many of whom are
bilingual or multilingual) work in neighborhoods across King County. We
provide tutoring, citizenship classes, early learning programs, job
training, case management, community health programs and transportation
to more than 11,000 low-income people each year.
Selection of Neighborhood House for Funding from Business Partnership
for Early Learning
Neighborhood House was selected in a competitive request for
proposal in 2005 to receive a grant from the Business Partnership for
Early Learning (BPEL). BPEL is a group of business and philanthropic
leaders in King County investing in closing the school achievement gap
for those children most likely to arrive at kindergarten with a
``preparedness gap'' they may never be able to overcome and for those
parents are the most isolated.
Neighborhood House was selected because BPEL knew from public
school data that a sizable proportion of the students with low school
success and graduation rates are those who are English Language
Learners and whose families live in poverty. Neighborhood House has a
success track record of serving immigrant and refugee families from all
over the world in its family support and early learning programs.
Overview of the Parent-Child Home Program
The Parent-Child Home Program is a research-based school readiness
home visiting program for 2- to 3-year-olds and their parents.
Paraprofessionals provide home visits twice weekly over a two-year
period and bring gifts of books and educational toys. The home visitors
provide parent coaching by modeling behaviors that stimulate early
learning and help the parents experience the intrinsic rewards of
seeing their child enjoy learning.
Description of Families Served with PCHP

None of the 160 families a year that we serve have English
as their home language.
As many as 75 percent of parents have limited literacy
levels and cannot easily read English or their home language.
Among the more than a dozen languages spoken by the
families are Vietnamese, Chinese, Cambodian, Cham, Spanish, Somali,
Amharic, Oromo, and Tigrinya.
Almost 90 percent of our families have an annual income of
$25,000 or less; 40 percent have an income of $10,000 or less.
Many parents are unfamiliar with the notion of children as
young as age 2 being able to learn or engage with books.
Description of our Staff for the Parent-Child Home Program
We have two Program Coordinators who hire, train and supervise the
home visitors. One coordinator has a Bachelor of Arts degree and speaks
Tigrinya, Tigre, Amharic, Arabic and English. The other coordinator was
a medical doctor in Cambodia and has a Masters Degree in social work
and population leadership on reproductive and child health programs.
She speaks Cambodian/Khmer, Thai, Lao, French and some Vietnamese. We
employ 9 home visitors. Their ethnicity and the languages they speak
are as follows: Mexican (Spanish), Somali (Somali), Cambodian (Khmer),
Vietnamese (Vietnamese, Cham), Ethiopian (Amharic, Tigrinya, Oromo,
Afari, Arabic)
The Success of Parents and Children in Our Parent-Child Home Program
In each of the four years we have delivered the Parent-Child Home
Program, both the children ages 2 and 3 and their parents have
achieved, based on a third-party outcome evaluation, statistically
significant increases from baseline to end of Year 1 and from end of
Year 1 to end of Year 2 on all items observed by coordinators.
Parents reported an increased understanding of their role in
helping prepare their child for school, increased parenting skills and
a greater commitment to participate in the education of their child.
Children increased their use of behaviors that are beneficial for
school readiness, including social skills, learning skills, and pre-
literacy skills.
We have achieved a 90 percent or higher retention rate over the
two-year program. Families only leave the program if they move out of
our service area or for another reason that precludes them from
continuing.
Our programs were certified by The Parent-Child Home Program's
national office in 2008 as meeting all requirements of its replication
agreement and implementing those components with fidelity and quality.
We also believe PCHP helps prevent child abuse and neglect, as it
builds the protective factors in both parents and children that are
known to prevent child abuse and neglect. We know that positive parent-
child interaction, one of the key outcomes of PCHP, is a critical
factor in the prevention of child abuse. However, we do not have the
capacity or resources to track reduction in child abuse and neglect for
our families who receive PCHP services.
Factors Influencing Our Successful Implementation of PCHP
We consider it absolutely essential to employ home visitors who
share the language and cultural backgrounds of the families they visit.
This is required because:

Facilitates communication with families for recruitment,
enrollment and service coordination.
Home visitors are able to quickly establish trust and
relationships with families.
Home visitors are accepted and considered to be trusted,
credible sources of information about parenting and child development.
Home visitors understand and are able to effectively
talk with parents regarding beliefs about parenting and child
development shaped by cultural background and experience.
Supports parents who may not be strong readers in
feeling competent and confident to share books with their children by
modeling techniques such as ``picture reading'' (telling a story
through description of pictures instead of reading verbatim from a
book). Parents are then more likely to share books with their children
on their own.
Supports parents' belief in their children's ability to
learn, so parents are more likely to become invested in their role as
``first teacher'' and help their child prepare for school.
Facilitates communication and understanding regarding
how fathers might be involved in sharing books and toys with children,
even if this is not a traditional parenting role.

Each home visitor receives 16 hours of initial training and a
minimum of two hours of supervision each week. In addition, home
visitors attend local classes and workshops in early learning and
receive extensive coaching and problem-solving support from the Program
Coordinators.
Community Need to Continue and Expand Parent-Child Home Program
We are contacted regularly and asked to serve additional families
both within our service area and outside it. We currently do not have
the resources to serve any more families.
We believe there are hundreds of families just in the Seattle/King
County area who would greatly benefit from participation in PCHP.
We know that about 45 percent of Washington State children ages 0
to 5 are at home with their parents and another 21 percent are cared
for by relatives, friends and neighbors. This means that about two-
thirds of young children statewide are largely overlooked and
underserved by investments in child care centers and preschools. Many
of those children will not be ready for school if we do not go where
the children are and engage their parents in ways that are effective
and culturally appropriate.
Conclusion
Thank you for the opportunity to provide you with information on
the success of our replication of the Parent-Child Home Program, using
paraprofessionals who speak the languages and are from the cultures of
the diverse immigrant and refugee families we serve.
We believe these home visiting programs, and other evidence-based
programs, are essential to giving all young children a fair chance to
succeed in school and life. In turn, they make our communities stronger
and reduce the cost of bad outcomes for our children.
Kathee Richter
Child Development Director, Neighborhood House
Seattle, Washington

Statement of Lenette Azzi-Lessing, Ph.D.
Dear Congressman McDermott and Subcommittee Members:
I am writing to provide testimony on proposals to provide federal
funding for early childhood home visitation programs. Last week, the
subcommittee heard testimony on the Administration's plan to target
$8.6 billion--over the next 10 years--for home-visiting programs for
disadvantaged families with young children. Early childhood advocates
strongly support this policy direction, given the damaging impact that
poverty has on children's long-term ability to learn and succeed in
school and in life.
In recent years, home visiting programs for poor families have won
the backing of political leaders on both sides of the aisle as well as
that of business leaders and economists. Much of this support stems
from expectations that these programs will reduce the likelihood that
poor children will fail in school, become delinquent or need welfare.
Economic analyses indicating that home visiting programs can deliver an
excellent return on investment by shrinking public expenditures for
juvenile justice and welfare programs have caught the attention of
members of Congress as well as of President Obama, who, as a candidate,
pledged to extend these services to 570,000 families a year.
The President deserves high praise for allocating substantial
resources to improve the life chances of young children in poverty.
However, not all home-visiting programs are alike and it is critical
that these new funds are targeted towards strategies that hold the
greatest promise. Much of the return on investment argument is based on
the results of a study conducted 30 years ago, in which nurses provided
home-visits to a relatively small group of first-time mothers living in
rural parts of Elmira, New York. This program, known as Nurse Family
Partnership (NFP), utilizes nurses to support and educate new mothers
during their pregnancy and throughout their child's first two years of
life. Babies born to NFP-participating mothers in Elmira were healthier
at birth, and their families were on welfare for substantially shorter
periods of time than families not enrolled in the program.
What set NFP apart from other home visiting programs was its
rigorous evaluation, in which families were randomly assigned to
participate in NFP or to be in a control group. Similar to procedures
used by the FDA for testing new medications, this type of evaluation is
considered the gold standard for measuring program effectiveness. The
compelling results from the Elmira program, along its the stringent
evaluation methods won support for NFP as a ``proven'' program that is
now a frontrunner for expansion with the new federal funding.
Receiving far less attention are the results of two subsequent
tests of NFP that were conducted in the 1990's with larger groups of
poor women and their babies in the inner cities of Memphis and Denver.
Many of the benefits experienced by the Elmira participants faded or
disappeared altogether for the families in these two studies. The
diminished outcomes in later evaluations of NFP point to the pitfalls
inherent in attempting to apply a one-size-fits all model of
intervention to an increasingly diverse array of families. It is likely
that the families in the Memphis and Denver studies were more
vulnerable than those in Elmira, due to high crime rates and other
stresses of inner-city life and the shrinking safety-net that
culminated in the mid 1990's with the passage of welfare reform. NFP's
capacity to help was probably outstripped by the multiple challenges
facing these more contemporary families.
More-recent evaluations of home-visiting programs provide critical
information about was does and doesn't work in intervening with today's
vulnerable families. Programs that combine group learning opportunities
for infants and toddlers--like those offered in the best childcare
centers--with home visits to educate and support parents, appear to
hold the most promise for improving poor children's learning abilities.
Moreover, home visiting programs that offer a flexible range of
services that can be customized to meet the unique needs of each family
served are often most effective. In order to significantly improve the
prospects of disadvantaged children, however, interventions must get at
the root cause of their plight, which is poverty. This means providing
poor parents with education and job training as well as subsidizing
their childcare and health care costs as they work their way up from
low-paying, entry-level jobs.
Developed 15 years ago by the nation's top experts in child
development, the federal Early Head Start program incorporates many of
these recent findings. This program aims to help poor infants and
toddlers reach their full learning potential while assisting their
parents with employment, housing, mental health and a range of other
needs. Like NFP, Early Head Start utilizes nurses, but the program also
draws upon the expertise of early childhood educators, social workers
and mental health specialists to offer a more comprehensive array of
services.
Early Head Start has the capacity to provide a customized mix of
home visits and services delivered to children in daycare centers--
making the program accessible to working families. Moreover, the
program works with families that have more than one child and can be
adapted to serve infants and toddlers with disabilities as well as
those placed in foster care--children at particularly high risk for
poor outcomes. Evaluation of Early Head Start--utilizing methods as
rigorous as those used by NFP--is currently underway in 17 sites across
the country and results are encouraging. Participating children are
showing improvements in mental and emotional development; these gains
are especially strong for children receiving a combination of home and
center-based services.
Dollars allocated to home-visiting in the proposed federal spending
plan should go towards expanding Early Head Start and for rigorously
evaluating other comprehensive but smaller-scale approaches operating
in a number of communities. Currently funded at $1 billion year, Early
Head Start serves only about 3% of the low-income infants and toddlers
who are eligible for the program. The stimulus package allocates an
additional $1.1 billion that will double the number of children
participating in Early Head Start; but reaching only 6% of the
youngest, poorest and most vulnerable children in America is an anemic
example of change we can believe in.
Members of the Committee must recognize the complex and
recalcitrant nature of the factors that threaten the future prospects
of disadvantaged, young children--factors made worse by the current
recession. These children need and deserve the most promising
interventions we have: those that are proven to work under the
extraordinarily challenging conditions confronting poor families today.
Lenette Azzi-Lessing, Ph.D., is on the faculty of the School of
Social Work and Family Studies at Wheelock College, Boston. She has 25
years experience in developing, operating and evaluating programs for
disadvantaged, young children and their families and is currently
writing a book on strategies for eliminating childhood poverty in the
United States. She can be reached at lalessing@wheelock.edu.

Statement of Marcia Slagle
In 1998 the Anderson County Health Council received a three-year
demonstration grant from Covenant Health to implement Healthy Start of
Anderson County. In 1995 and 1998 Anderson County did not qualify for
funding from the Division of Maternal and Child Health (Tennessee Dept
of Health) because money was directed to areas with the lowest income
and highest minority population. Although Anderson County's average
income looks high (due to Oak Ridge), many areas of the county reflect
the surrounding area's isolation, poverty of income and opportunity.
Healthy Start of Anderson County is credentialed by Healthy
Families America, the parent organization. The goals are set by the
national organization and are as follows:

promote positive parenting
encourage and improve child health and development
prevent and/or reduce child abuse and neglect.

These goals are met by providing in-home education for the parents.
The weekly visits involve teaching age-appropriate curriculum for the
baby, mentoring of good parenting skills, monitoring the baby's growth
and development, and providing referrals for community resources.
Parents at greater risk to use inappropriate child-rearing techniques
are those who lack basic resources, support and information about
effective child-rearing and have limited educational and work
experiences. When children from these families grow up, they are at
increased risk to develop serious problems with truancy, drug abuse,
delinquency or mental illness. The positive outcomes of prevention
programs, with even relatively small reductions in the rate of child
maltreatment, demonstrate that prevention can be cost-effective. Most
of the investments in prevention, particularly as they apply to
investments in families with young children, are likely to have
``payback curves'' that extend over a long period of time, with much of
the savings occurring when the child reaches a healthy, productive and
nonviolent adulthood.
Research shows that about 25,000 children are abused or neglected
every year in Tennessee. The Department of Children's Services recently
stated that ``every foster child in state's custody costs the state
$50,000 a year.'' A recent news article stated that Tennessee taxpayers
pay approximately $850,000,000 yearly in costs related to child abuse.
There is legislation before Congress now called ``Education Begins at
Home Act'' (s.503). The bill would provide $500 million in federal
funds over three years to establish and/or expand home visitation
programs in all 50 states. Anderson County has had a program like this
for 10 years and that program is Healthy Start!
The Healthy Start advocacy committee was formed in 2007. This
committee has helped introduce the residents of Anderson County to the
important work of Healthy Starts. A ``Blue Ribbon Campaign'' in April
was held in conjunction with Prevent Child Abuse Awareness Month.
Proclamations from the County Commission as well as local city
governments designated April as prevent child abuse awareness month.
There were two social events held (one in Clinton and one in Oak Ridge)
to spread awareness of Healthy Start. The committee has completed a
letter campaign to raise funds. The committee also saw a need to hire a
part-time grant writer to help secure more funding. The grant writer
searches for foundations and other funding sources to apply for monies.
The League of Women Voters continues to be our advocate to the local
and state leaders to find new funds. In October 2006, we began a
collaboration with the Oak Ridge Unitarian Church congregation to
provide volunteers to assist with our families. The members of this
congregation have supported us this past year with transportation
needs, hauling furniture, and meeting emergency financial needs of our
families as they arise.
On December 5, 2007, the Centers for Disease Control reported that
``for the first time in 14 years, the number of teenagers having babies
in the United States rose.'' It was also stated that one reason for the
teen birth rate rise might be partly a result of not reaching hard-to-
reach teens. Many programs addressing teen pregnancy had been
eliminated because teen pregnancy and teen births had lessened
consistently since 1991. Healthy Start had to eliminate the job of the
Family Support worker serving the rural parts of Anderson County
because of cuts in funding in 2005. All of the participants served in
the rural areas prior to 2005 were teenagers (ages 14-19). One of the
goals for Healthy Start in 2009 is to hire a Family Support worker to
serve the first-time parents in the rural parts of the county again.
Description of Agency:
The Anderson County Health Council was chartered as a private non-
profit agency in 1968 for the purpose of promoting and assuring the
highest level of health obtainable for every resident of Anderson
County. 501(c)(3) status was received November 29, 1972. The volunteer
Board of Directors consists of twenty-seven residents (nine residing in
Oak Ridge), who serve on different committees which give focus and
determine the direction of the Health Council's efforts. The Anderson
County Health Council receives funding from United Way of Anderson
County; private, state and federal grants; local governments; and
private donations.
Services Offered:
To qualify for the Healthy Start program a family must be a first
time parent, meet the risk assessment that documents need for the
program, and be a resident of Anderson County. Services include, but
are not limited to: educational and supportive home visits;
developmental testing of babies; group support meetings; parent and
baby transportation to health and social services; used maternity and
children's clothing; emergency formula, diapers and food; lending
library of baby equipment and car seats; monthly age-appropriate
children's books; referrals to community services; and staff attendance
at birth of baby when appropriate.

June 9, 2009
Mr. Chairman and Members of the Subcommittee:
I am pleased to submit the following written testimony to the
Subcommittee on Income Security and Family Support on behalf of ZERO TO
THREE. My name is Matthew Melmed and for the last 14 years, I have been
the Executive Director of ZERO TO THREE, a national non-profit
organization that has worked to advance the healthy development of
America's infants and toddlers for over 30 years. I would like to start
by thanking the Subcommittee for its interest in examining the issue of
early childhood home visiting programs and for providing me the
opportunity to address the interaction between these programs and other
policies and programs that focus on infants and toddlers.
Any new parent will likely tell you that parenting is the most
rewarding and the most difficult job they have ever had. Especially
during the first years of their child's life, parents play the most
active and influential role in their baby's healthy development, and it
can be challenging to do so without support from others.\1\
Unfortunately, many parents face obstacles--such as those caused by
stress, geographic and social isolation, and poverty--that impact their
ability to fully support their baby's development during these critical
years.
---------------------------------------------------------------------------
\1\ National Research Council and Institute of Medicine, From
Neurons to Neighborhoods: The Science of Early Childhood Development.
Jack Shonkoff and Deborah A. Phillips, eds. Washington, DC: National
Academy Press, 2000.
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Almost half (43 percent) of all infants and toddlers live in low-
income families (below 200% of the federal poverty level), and 21
percent live in poor families (below 100% of the federal poverty
level).\2\ One of the most consistent associations in developmental
science is that between economic hardship and compromised child
development.\3\ Infants and toddlers in low-income families are at
greater risk than infants and toddlers in middle-to high-income
families for a variety of poor outcomes and vulnerabilities that can
jeopardize their development and readiness for school, including
learning disabilities, behavior problems, mental retardation,
developmental delays, and health impairments.\4\
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\2\ Ayana Douglas-Hall and Michelle Chau. Basic Facts about Low-
Income Children: Birth to Age 3. National Center for Children in
Poverty, 2008, http://www.nccp.org.
\3\ National Research Council and Institute of Medicine, From
Neurons to Neighborhoods.
\4\ Ibid.
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Fortunately, intervening early in the life of a child at risk for
poor development can help minimize the impacts of these risks. While
you are focusing today on a specific method of delivering services, I
urge you to think in terms of developing a comprehensive system of
services that provide a prenatal through pre-kindergarten continuum and
place home visitation squarely in that context rather than establishing
it as an isolated program. Such a system would ensure that the critical
needs of vulnerable infants and toddlers--regardless of the setting in
which they might be reached--are included in early childhood planning.
That system would help parents and early childhood professionals
promote healthy development across all domains. Services in this system
should support parents in forging bonds with their children since
developing strong attachments provides the needed foundation for a
child to explore and learn as well as to regulate their emotions as
they interact with others (social and emotional development). Such
services should also help parents and babies engage in play, reading,
and other activities that foster early language skills (cognitive
development) and they should promote good nutrition and attention to
well-child care (physical development).
Supporting Parents and Child Development through Home Visiting
Voluntary home visiting programs tailor services to meet the needs
of individual families, and they offer information, guidance, and
support directly in the home environment. While home visiting programs,
such as Healthy Families America, the Nurse-Family Partnership, the
Parent-Child Home Program, and Parents as Teachers, share similar
overall goals of enhancing child well-being and family health, they
vary in their program structure, specific intended outcomes, content of
services, and target populations. Program models also vary in the
intensity of services delivered, with the duration and frequency of
services varying based on the child's and family's needs and risks.
A growing body of research demonstrates that home visiting programs
that serve infants and toddlers can be an effective method of
delivering family support and child development services, particularly
when services are part of a comprehensive and coordinated system of
high quality, affordable early care and education, health and mental
health, and family support services for families prenatally through
pre-kindergarten. Research has shown that high quality home visiting
programs serving infants and toddlers can increase children's school
readiness, improve child health and development, reduce child abuse and
neglect, and enhance parents' abilities to support their children's
overall development.\5\ The benefits of home visiting, however, vary
across families and programs. What works for some families and in some
program models will not necessarily achieve the same success for other
families and other program models.
---------------------------------------------------------------------------
\5\ Elizabeth DiLauro, Reaching Families Where They Live:
Supporting Parents and Child Development through Home Visiting.
Washington, DC: ZERO TO THREE, 2009.
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Home Visiting within a Comprehensive Early Childhood Program: The Early
Head Start Example
Comprehensive programs serving families with young children may
incorporate a strong home-based component even though they are not
described as home visiting programs; one such model is Early Head Start
(EHS). EHS programs can use a home-based approach, a center-based
approach, or a combination of the two. The Early Head Start evaluation
results for home-based programs showed that, when compared to a control
group, parents in the programs demonstrated more positive impacts with
regard to providing more stimulating environments, gaining a greater
knowledge of child development, and reporting less parental stress.
Children in the program showed stronger vocabulary development at age
24 months compared with control group children, were more engaged with
their parents during play at this age, and, in programs that fully
implemented the Head Start Program Performance Standards, showed
positive impacts on child cognitive and language development at age 36
months.\6\
---------------------------------------------------------------------------
\6\ U.S. Department of Health and Human Services, Administration
for Children and Families, Research to Practice: Early Head Start Home-
Based Services. U.S. Department of Health and Human Services, 2003,
http://www.acf.hhs.gov.
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It is important to note, however, that other approaches to
supporting parenting and early childhood development can have a
positive impact as well. Center-based programs, by themselves, have
proven to have impacts on child cognitive development at both 24 and 36
months of age, as well as on other child and parenting outcomes, but
without a consistent pattern.\7\ On the other hand, Early Head Start
programs using a mixed approach, a combination of center- and home-
based approaches, showed strong impacts at both 24 and 36 months for
parenting and child outcomes. In fact, the national evaluation found
the strongest pattern of impacts on children and families in mixed-
approach programs.\8\
---------------------------------------------------------------------------
\7\ Ibid., fn. 3.
\8\ U.S. Department of Health and Human Services, Administration
for Children and Families, Early Head Start Benefits Children and
Families. U.S. Department of Health and Human Services, 2002, http://
www.acf.hhs.gov.
---------------------------------------------------------------------------
One issue that surfaced in the examination of Early Head Start when
services are delivered through the home is that families with more risk
factors (e.g. teen parents, parents with depressive symptoms, parents
with high school diplomas) tended to have visits that spent more time
on parent-development needs with less time aimed at child-focused
activities. More time spent on child-focused activities was associated
with better outcomes in the areas of cognitive and language development
and increased parental ability to support development. This finding
underscores the idea that program models must be prepared to tailor
services such that the needs of children and parents are carefully
balanced. Programs that are serving families with high needs require
staff who are capable of addressing such needs while also being able to
maintain a strong focus on the child and the parent-child relationship.
It is also quite possible that these children might benefit from
center-based services to further enhance development and support
families.
Translating Research into Practice: Recommendations for a New Home
Visiting Initiative
ZERO TO THREE is pleased to see that the Administration and Members
of Congress have continued to shine a spotlight on high quality home
visiting initiatives. As stated earlier, home visiting is an important
way to deliver services within a prenatal-to five-system of early
childhood development. In considering legislation to promote a two-
tiered mandatory funding approach to creating and expanding home
visiting programs in the states, we recommend that the Subcommittee
take into account the following recommendations based on the science of
early childhood development:
1. Integrate home visiting programs into a broader state early
childhood system and infrastructure, and emphasize coordination among
home visiting programs. As policymakers work to expand access and
improve home visiting services for young children and their families,
they should ensure that services are not established in isolation, but
are integrated into a broader state early childhood system that
incorporates a strategy to reach all vulnerable young children in a
coordinated way. Such a system should reach children in a variety of
settings and include professional development, training, and technical
assistance for providers; data collection; program standards; and
quality assurance and improvement efforts. Thirty-two states are
currently operating a statewide home visiting program, yet only 18
states link these home visiting programs to other supports for early
childhood development at the state level.\9\ Representatives of home
visiting programs should work with other such programs within the state
and participate in community and statewide collaborative groups to
improve the coordination of services for young children and their
families across agencies and programs, particularly since some programs
have been known to work better for families with certain risk factors.
---------------------------------------------------------------------------
\9\ National Center for Children in Poverty, United States Early
Childhood Profile. National Center for Children in Poverty, 2007,
www.nccp.org.
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Federal legislation establishing state home visiting programs
should ensure that such linkages occur by requiring that they be part
of the planning and implementation efforts of the State Advisory
Councils on Early Childhood Education and Care, created by the
Improving Head Start for School Readiness Act of 2007, as well as other
state-specific early childhood oversight boards. Governors should
appoint home visiting representatives to the Councils. The Councils are
tasked with, among other things, conducting a periodic statewide needs
assessment concerning the quality and availability of early childhood
education and development programs; identifying opportunities for, and
barriers to, collaboration and coordination among federally-funded and
state-funded child development, child care, and early childhood
education programs and services; and developing recommendations for
increasing the overall participation of children in existing early
childhood education programs. Given their role in coordinating and
planning state-level activities for very young children, home visiting
representatives are a logical fit with the Councils' activities.
2. Develop a continuum of care for young children and their
families by coordinating home visiting efforts with other child
development services in the community. No one single home visiting
program, by itself, is a silver bullet for all children, all families,
and all communities. Connecting home visiting efforts, particularly
those focused on children's well-being and healthy development, with
other child and family services at the community level will help to
ensure that young children and parents have the comprehensive support
they need. In instances when parents and children have needs that are
not addressed by the home visiting program in which they are enrolled,
they should be linked to other resources available in their community,
such as high quality child care programs and comprehensive early
childhood programs such as Early Head Start, early intervention
programs, health assistance programs, and mental health services.
3. Ensure that all home visiting initiatives incorporate known
elements of effectiveness and use a model appropriate to the needs of
the targeted population. There is growing consensus on a list of key
elements of effective home visiting models that are most likely to
achieve outcomes for young children and their families. This list
includes:

solid internal consistency that links specific program
elements to specific outcomes;
well-trained and competent staff;
high quality supervision that includes observation of
the provider and participant;
solid organizational capacity; linkages to other
community resources and supports; and
consistent implementation of program components.\10\
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\10\ Deborah Daro, Home Visitation: Assessing Progress, Managing
Expectations. Ounce of Prevention Fund and Chapin Hall Center for
Children, 2006, www.chapinhall.org.

Policymakers should ensure that a new home visiting initiative
incorporates these key elements focused on effective design and
implementation to ensure high quality and effective service delivery.
Additionally, as services are expanded within states, policymakers
should ensure that program models are implemented with families that
exhibit characteristics similar to those for whom the program has been
tested. Not all families will need the same level or intensity of
services. In a review of state-based home visiting initiatives, 31
states operating 55 programs reported using different approaches for
different families, providing more intensive services to families with
greater risks and needs.\11\ We must ensure that the most at-risk
families receive the most intense supports available, while ensuring
appropriate services for those with fewer risks for poor developmental
outcomes.
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\11\ Kay Johnson, State-based Home Visiting: Strengthening Programs
through State Leadership. New York, NY: National Center for Children in
Poverty, 2009.
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4. Support rigorous, ongoing evaluation and continuous improvement
efforts for home visiting programs. Program evaluation allows home
visitors, supervisors, funders, families, and policymakers to know
whether a program is being implemented as designed and how closely it
is meeting objectives. This information can be used to continually
refine and improve service delivery for young children and their
families, as well as provide an evidence-based rationale for the
expansion of home visiting programs. We know, based on research, that
many programs and models have made a difference in the lives of those
most at-risk. We need to continue to build on this research and provide
adequate funding to allow promising models and strategies the chance to
conduct more rigorous research. We must keep in mind, however, that not
all programs can be delivered under the ideal situations in which
rigorous evaluations are conducted. Not all populations will look
identical to those for whom evaluation data was collected and expansion
efforts should allow for innovation in serving harder to reach
populations, including families living in rural areas or those who are
homeless. When financing home visiting programs, policymakers should
ensure that adequate time and funding are included for thorough
evaluation of existing programs as well as sufficient funding to
incentivize the development, expansion, and evaluation of demonstration
projects for harder to reach families.
Conclusion
All young children should be given the opportunity to succeed in
school and in life just as all parents should receive the support they
need to nurture their children's development. While vulnerable children
may have greater challenges to overcome, we should not assume that
those challenges can only be addressed with services later in life.
Instead, we should invest in a continuum of programs, starting from the
prenatal period forward, when our investment can have the biggest
payoff and help prevent problems or delays that become more costly to
address as they grow older.
Home visiting is an important strategy in providing services to at-
risk infants, toddlers, and their families. By investing in programs
proven to be effective, and integrating those successful programs into
a broad range of services that touch the lives of infants, toddlers and
their families, we can make great strides in early childhood
development and education and lay the foundation for later school
success.
Thank you for your time and for your commitment to our nation's
infants, toddlers and their families.
WITNESS INFORMATION
Name: Matthew Melmed
Title: Executive Director
Organization: ZERO TO THREE: National Center for Infants, Toddlers
and Families
Washington, DC
References

Statement of Nancy Ashley
I am the Project Director of the Business Partnership for Early
Learning (BPEL). BPEL is a group of business and philanthropic leaders
in King County, Washington State that is investing in a home visiting
program to close the school achievement gap for those children in
isolated families that are most likely to arrive at kindergarten with a
``preparedness gap'' they may never be able to overcome.
Overview of the Business Partnership for Early Learning
The Business Partnership for Early Learning is a group of 20
Seattle area businesses that together have invested $4 million into a
five year early learning program that is reaching 400 two and three
year old disadvantaged Seattle children. Among our major investors are
the Bill & Melinda Gates Foundation, The Boeing Company, Safeco
Corporation, Group Health Cooperative, The Seattle Foundation, and
United Way of King County.
Why the Business Partnership for Early Learning is Investing in Early
Learning
BPEL believe s that investments in early learning have a very high
rate of return, and can simultaneously help kids and raise workplace
productivity. Before investing, the founders of BPEL carefully
researched the return on investments in early learning and concluded
that for them and for the state, it offers the highest return of any
social investment.
Why the Business Partnership for Early Learning is Investing in the
Parent-Child Program Home Visiting Model
BPEL investors wanted to demonstrate that an effective intervention
could be found that would reduce the achievement gap for vulnerable
children by identifying young children from the most hard-to-reach
families and providing the parents with the tools, motivation and
confidence to get their children ready for school.
They selected the Parent-Child Home Program because it was designed
for high-risk families and it targets the intervention to the parent-
child dyad. All home visits must take place with the parent and the
child together.
PCHP serves families challenged by poverty, low levels of
education, language and literacy barriers and other obstacles to
educational success. Many of them are isolated both physically and
mentally by poverty, lack of transportation, and parental stress.
In addition, the Parent-Child Home Program had 40 years of research
and evaluation behind it that confirmed the program's long-term impact
on children who complete the program. The PCHP curriculum is designed
to engage parents in non-threatening, playful activities on a
predictable schedule with a trusted, friendly Home Visitor. The
Program's approach is both research-based and research-validated: it is
an early intervention model, it focuses on early literacy both within a
social-emotional and cognitive/language development context, and it
emphasizes both the parental bond and parental responsibility.
BPEL Project Demonstrates that Home Visiting is a Powerful Strategy for
School and Life Success
BPEL provides grants to two nonprofit organizations in King County
to deliver the Parent-Child Home Program to 160 families a year. The
program reaches low-income families speaking over 15 languages, and
brings gifts of books and toys to the homes to model how parents can
guide their children's development. A large proportion of the families
are immigrants and refugees who are unfamiliar with the concept that
children can learn before they go to school and who do not understand
the role of the parent in preparing a child for school. Many families
have no books or educational toys in their homes.
Both nonprofit agencies employ paraprofessional home visitors who
speak the languages and reflect the cultures of the families they
serve.
Evaluation of BPEL's project has concluded that diverse families
and children (1) can be effectively reached in their homes, (2) the
parents can be coached to become the child's first and ongoing teacher,
and (3) the children can make substantial cognitive and pre-literacy
gains.
Specific results are shown on the following page, for parents and
children who completed the two-year program in 2008.
Expanded Home Visiting Efforts Needed in King County
Participants in BPEL know that growth in the skill level of our
work force has declined and that a greater percentage of the future
workforce will come from minority populations where levels of
educational attainment are lower. These trends can be reversed by
investing early in the lives of children from those populations, via
agencies that are trusted and respected by their diverse communities.
Research indicates that improving the quality of the parenting
environment of young disadvantaged children will bring the most
powerful results.
Many families who would benefit greatly from effective home
visiting programs are not being reached. We have very little state
funding to support home visiting, as almost all early learning funds
now are devoted to the one-third of children who are in preschools or
licensed child care centers.
Conclusion
The Business Partnership for Early Learning is strongly in support
of the Committee's efforts to advance legislation supporting
investments in evidence-based home visiting programs that enhance early
learning and reduce child abuse and neglect.
BPEL believes that evidence-based home visiting programs are
essential to giving all young children a fair chance to succeed in
school and life, so they can provide us with the skilled workforce we
need in this global economy.
Nancy Ashley
Program Director, Business Partnership for Early Learning
Seattle, Washington

Statement of The National Child Abuse Coalition
The National Child Abuse Coalition, representing a collaboration of
national organizations committed to strengthening the federal response
to the protection of children and the prevention of child abuse and
neglect, supports the introduction of H.R. 2667, the Early Support for
Families Act, legislation to provide home visitation services with
mandatory funding available to promote an array of research- and
evidence-based home visitation models that enable communities to
provide the most appropriate services suited to the families needing
them. We applaud the leadership taken by Chairman Jim McDermott with
Representatives Danny Davis and Todd Platts to carry forward the
initiative proposed by President Obama to create the first dedicated
federal funding stream for the establishment and expansion of voluntary
home visitation programs for low-income parents with young children.
The most effective strategy for preventing child maltreatment
before it occurs is to provide new parents with education and support.
Home visitation has long been identified as an approach that works to
prevent the abuse and neglect of children. In 1991, the U.S. Advisory
Board on Child Abuse and Neglect recommended as the highlight of its
report, Creating Caring Communities, the establishment of universal
voluntary home visitor services.\1\ More than a decade later, the same
conclusion was drawn by the Centers for Disease Control (CDC) Task
Force on Community Preventive Services. Its 2003 report evaluating the
effectiveness of strategies for preventing child maltreatment
``recommends early childhood home visitation for prevention of child
abuse and neglect in families at risk for maltreatment, including
disadvantaged populations and families with low-birth weight infants.''
\2\
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\1\ Panel on Research on Child Abuse and Neglect, Commission on
Behavioral and Social Sciences and Education, National Research Council
(1993). Understanding child abuse and neglect. Washington, D.C.:
National Academy Press.
\2\ Hahn, Robert A., Ph.D., First Reports Evaluating the
Effectiveness of Strategies for Preventing Violence: Early Childhood
Home Visitation, Morbidity and Mortality Weekly Report, Centers for
Disease Control and Prevention (Atlanta, GA, October 3, 2003 /
52(RR14);1-9.
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Voluntary home visitation is an effective and cost-efficient way to
ensure that all children have the opportunity to grow up healthy, safe,
ready to learn and able to become productive members of society.
Investing in this research-proven approach now will mean savings down
the road in costs associated with health, education, child maltreatment
and criminal justice. The McDermott-Davis-Platts bill would support
rigorously evaluated programs that utilize nurses, social workers,
other professionals and paraprofessionals to visit families, especially
lower-income families, on a voluntary basis. We look forward to adding
our collective voice to support this initiative as it moves toward
enactment in Congress.
An Imperative for Prevention
According to the most recent data released in April this year by
the U.S. Department of Health and Human Services (HHS),\3\ over 3
million referrals of possible child abuse and neglect cases were made
to state child protective services (CPS) agencies in the United States
in 2007. Close to 2 million of those referrals were accepted by CPS for
an investigation or assessment, resulting in some 800,000 children
found to be victims of child abuse and neglect.
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\3\ U.S. Department of Health and Human Services, Administration on
Children, Youth and Families. Child Maltreatment 2007 (Washington, DC:
U.S. Government Printing Office, 2009). U.S. Department of Health and
Human Services, Administration on Children, Youth and Families. Child
Maltreatment 2007 (Washington, DC: U.S. Government Printing Office,
2009).
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Almost one-quarter of those child victims had a history of prior
victimization. The HHS report says: ``For many victims, the efforts of
the CPS system have not been successful in preventing subsequent
victimization.'' Indeed, over one-third (37.9 percent) of child victims
reported to CPS in 2007 received no services following a substantiated
report of maltreatment. The lack of available services, a gap
desperately in need of attention, leaves children at risk of harm.
The youngest children continue to suffer the highest rate of
victimization. Infants from birth to 1 year of age are the most
vulnerable victims of abuse and neglect at the rate of 21.9 per 1,000
children of the same age group, representing 12 percent of all abuse
and neglect victims. Nearly 32 percent (31.9%) of all victims of
maltreatment were younger than 4 years old.
Fatalities due to child maltreatment remain high. An estimated
1,760 children died in 2007 as a result of abuse or neglect, up from
1,530 in 2006 and 1,460 in 2005. The rate of child fatalities was 2.35
deaths per 100,000 children, compared to a rate of 2.05 deaths per
100,000 children in 2006 and 1.96 in 2005. Again, the most endangered
are the youngest: more than 40 percent (42.2 percent) of all fatalities
were children younger than 1 year and three-quarters of children who
were killed (75.7 percent) were younger than 4 years of age.
The incidence of child abuse and neglect is beyond the capacity of
our current system of protective and treatment services to be of much
help. Our system of treating abused and neglected children and offering
some help to troubled families after the harm has been done is clearly
overworked and inadequate to the task. Prevention is an imperative and
an investment in home visiting services can focus our resources on
preventing child abuse from happening in the first place.
Home visiting programs are often targeted to serve specific groups
in a community: families with low-income; young parents; first-time
mothers; children at risk for abuse or neglect; or low birth weight,
premature, disabled, or developmentally compromised infants--those
children who are most at risk of serious harm, as shown by the annual
HHS data on child maltreatment reports.
Home visiting educates families and brings them up-to-date
information about health, child development, parenting, literacy and
school readiness, educational and work opportunities, and connects them
to critical community services.
A Cost-Effective Strategy
Voluntary early childhood home visitation programs offer training
to parents designed to enhance the well-being and development of young
children by providing information on prenatal and infant care, child
health and development, parental support and training, and referral to
other community services, such as day care, respite care, and parent
support groups. Home visits are conducted by nurses, social workers,
other professionals or paraprofessionals.
A growing body of research has found strong evidence that early
childhood home visitation programs are effective in reducing the
incidence of child abuse and neglect, and in improving child health and
development, parenting skills, and school readiness. While a majority
of states currently provide early childhood home visitation services to
a relatively small number of families, the challenge has been to take
this proven effective prevention approach to scale. The enactment of
the legislation proposed here can help to move toward that goal.
Investing in evidence-based early childhood home visitation is a
cost-effective way to address a range of issues impacting healthy child
development and later success in life at annual costs generally
averaging $1,500 to $4,000 per family served, depending upon the type
of home visiting service offered. The variation in program costs
depends on such factors as differences in the cost of living in the
communities being served, the frequency of home visits required for a
family, the inclusion of evaluation costs in the calculation, and the
staffing requirements of the program.
This modest investment leads to improved outcomes for children and
families and long-term cost savings related to special education, child
welfare, health care, criminal justice, and additional social services.
The consequences of child abuse and neglect often continue well into
adulthood with life-long effects. Research shows a strong correlation
between child abuse and neglect and debilitating and chronic health
consequences, mental health illness, and drug dependency.\4\ Studies
have demonstrated the link between childhood victimization and
delinquency, criminal behavior.\5\ Research has shown that abused and
neglected children are more likely to suffer poor prospects for success
in school.\6\
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\4\ Felitti, VJ, Anda, RF, Nordenberg, D, Williamson, DF, Spitz,
AM, Edwards, V, Koss, MP, & Marks, JS. (1998). The relationship of
adult health status to childhood abuse and household dysfunction.
American Journal of Preventive Medicine, 14, 245-258.
\5\ C.S. Widom & M.A. Ames (1994). Criminal Consequences of
Childhood Sexual Victimization. Child Abuse and Neglect. Washington,
DC: National Institute of Justice.
\6\ S.R. Morgan (1976). The Battered Child in the Classroom.
Journal of Pediatric Psychology.
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Home visiting programs link families to health care resources and
focus on healthy outcomes. Through a strong emphasis on prenatal care
significant costs associated with pre-term births, and developmental
disabilities are reduced. Linking families to consistent primary care
and immunizations means reduced emergency room costs and reduction in
chronic illness.
Current child welfare expenditures are heavily skewed toward
spending on foster care and adoption subsidies. For every federal
dollar spent on out-of-home care, the federal government spends just
fifteen cents on prevention and child protection. Implementing proven,
effective strategies to prevent child abuse and neglect can save on the
high cost of doing nothing until intervention later is inevitable.
According to a study conducted by Prevent Child Abuse America,\7\ the
direct costs of child maltreatment for foster care services,
hospitalization, mental health treatment, and law enforcement amount to
more than $33 billion annually. Indirect costs of over $70 billion
include expenditures related to chronic health problems, special
education, and the criminal justice system as well as loss of
productivity--for an expenditure of close to $104 billion per year.
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\7\ Wang, CT, & Holton, J (2007). Total estimated cost of child
abuse and neglect in the United States. Chicago, IL: Prevent Child
Abuse America.
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Home visitation programs provide the supports necessary for
families to meet the needs of their children, to address risk factors
for abuse and neglect and educate parents to improve their skills while
seeking support and guidance. Addressing some of the characteristics of
parents who are at risk of abusing their children, we see that home
visitors are there to confront a symptom before it becomes a crisis.
While no single factor accounts for abusive behavior by parents, in
combination, these features of troubled families are more likely to
create greater risk for harm to children.

Social isolation: the lack of social supports, the
isolation from a community and effective support systems, the lack of a
social network to set good examples of parenting. The home visitor
reduces a family's sense of isolation through regular visits that draw
new parents into a sense of community and belonging.
Unprepared parents: new mothers and fathers with
unrealistic expectations about their children and little knowledge
about normal child development. The home visitor builds parenting
skills and works to create better bonds between parents and their
children.
Characteristics of the child: a premature low birth-
weight child, a mentally or physically disabled child, or an ill child
difficult to nurture, all present difficulties to parents coping with a
new baby. The home visitor arranges primary medical care, so that
infants get to the pediatrician for checkups and immunizations.
Personal stress and economic difficulties: parents with
low self-esteem who are vulnerable to stress, parents addicted to
alcohol or drugs, families hit by unemployment or inadequate housing.
The home visitor assures that all families have full access to
community agencies that can support families coping with problems and
stresses.
Research Supports Positive Outcomes
Numerous researchers have documented the positive impact of home
visitation programs on child development, parenting practices, and
parent-child relationships. The results from a variety of randomized
control trials, quasi-experimental evaluations, and implementation
studies have shown positive effects in the reduction in child
maltreatment, improved parenting practices, birth outcomes, and health
care. Here is a sample.

In a randomized control trial, adolescent mothers who
received case management services and home visitors were significantly
less likely to be subjected to child abuse investigations than control
group mothers who received neither.\8\
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\8\ Wagner, M.M. & Clayton, S.L. (1999). The Parents as Teachers
Program: Results from Two Demonstrations. The Future of Children: Home
Visiting: Recent Program Evaluations, 9(1), 91-115.
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A large, randomized control trial found less physical and
psychological abuse for parents receiving home visitation services than
control parents at one year.\9\
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\9\ Mitchell-Herzfeld et al. (2005). Evaluation of Healthy Families
New York: First year program impacts. Office of Children and Family
Services.
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Families who received home visiting services were found
to be more likely to have health insurance and a medical home, to seek
prenatal and well-child care, and to get their children immunized.\10\
Another study showed that 93% of participating families, children were
fully immunized by age two compared to the statewide average of
77%.\11\
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\10\ Berkenes, J.P. (2001), HOPES Healthy Families Iowa FY 2001
Services Report; Klagholz & Associates (2000), Healthy Families
Montgomery Evaluation Report Year IV; Greene et al. (2001), Evaluation
Findings of the Healthy Families New York Home Visiting Program;
Katzev, A., Pratt, C. & McGuigan, W. (2001), Oregon Healthy Start 1999-
2000, Status Report.
\11\ Williams, Stern & Associates (2005). Healthy Families Florida
Evaluation Report, January 1, 1999-December 31, 2003.
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Babies of parents enrolled prenatally in home visitation
services have shown fewer birth complications in one randomized control
trial and higher birth weights in another randomized control trial.\12\
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\12\ Galano & Huntington (1999). Evaluation of the Hampton,
Virginia Healthy Families Partnership 1992-1998. Center for Public
Policy Research, The Thomas Jefferson Program in Public Policy, The
College of William and Mary, Williamsburg, VA. Galano et al. (2000).
Developing and Sustaining a Successful Community Prevention Initiative:
The Hampton Healthy Families Partnership. Journal of Primary
Prevention, 21(4), 495-509.; Mitchell-Herzfeld et al. (2005).

By providing critically important prevention services to families
with young children, home visiting programs make a real difference in
families' lives. We commend the sponsors of H.R. 2667 for their
leadership in moving forward with ensuring significant support to home
visiting programs in service to children and families across the
country.
Member Organizations: Alliance for Children and Families, American
Academy of Pediatrics, American Bar Association, American Humane
Association, American Professional Society on the Abuse of Children,
American Psychological Association, American Public Human Services
Association, Association of University Centers on Disabilities, CHILD
Inc., Child Welfare League of America, Children and Family Futures,
Children's Defense Fund, Every Child Matters Education Fund, Family
Violence Prevention Fund, First Focus, First Star, National Alliance of
Children's Trust and Prevention Funds, National Association of
Children's Hospitals, National Association of Counsel for Children,
National Association of Social Workers, National Center for Child
Traumatic Stress, National Center for State Courts, National CASA
Association, National Education Association, National Exchange Club
Foundation, National Network to End Domestic Violence, National
Organization of Sisters of Color Ending Sexual Assault, National PTA,
National Respite Coalition, Parents Anonymous, Prevent Child Abuse
America, Stop It Now!, Voices for America's Children

Statement of the National Indian Child Welfare Association
Portland, Oregon
Association on American Indian Affairs
Rockville, Maryland
National Congress of American Indians
Washington, DC
Submitted to the House Ways and Means Subcommittee on
Income Security and Family Support
Regarding H.R. 2667, the Early Support for Families Act
June 23, 2009
The National Indian Child Welfare Association, the Association on
American Indian Affairs and the National Congress of American Indians
jointly submit this statement in support of H.R. 2667, the Early
Support for Families Act. The voluntary early childhood home visitation
programs envisioned by the bill would be an important component in
building community-based programs whose goal is to help keep families
intact and strong. We are delighted to see that the provisions of H.R.
2667 have been included in the House Democratic draft health care
reform proposal.
We appreciate that the bill would provide a guaranteed stream of
funding for early childhood home visitation programs and would allocate
three percent of funds for distribution to tribes. The funds would be
distributed via formula to tribes who submit eligible applications,
similar to the distribution of the Social Security Act's Title IV-B
(Child Welfare) funds. Some tribes--primarily very small tribes--do not
apply for IV-B funds because the amount would be so miniscule as to not
make the application feasible. In those instances the funds are re-
allocated among tribes that have submitted eligible applications. H.R.
2667 provides for reallocation of unused state funds among states;
similarly, unused tribal funds should be reallocated among eligible
tribes. The bill is not clear on this point, and we ask for an
amendment that would make it clear that unused tribal funds would be
reallocated among eligible tribes.
We also strongly support the provision that authorizes the
Secretary, except for the application process and eligible use of
funds, to modify requirements for tribes. This provision represents a
good faith effort to try to make the program really work for tribal
governments who by and large do not have the sources of revenue or
economy of scale that states possess. We point out that tribes do not
have access to the Title XX Social Services Block Grant which states
use largely for child welfare purposes. Tribes also receive very little
funding under the Child Abuse Prevention and Treatment Act, sharing a
one percent allocation with migrant programs under one discretionary
grant program. And not all tribes receive Title IV-B funds, either
because the funding is not available to them or the amounts are so
small that it makes administration of the program unfeasible.
The voluntary home visitation assistance that would be provided in
H.R. 2667 is to be geared toward low income families with young
children and toward areas which are especially at risk for child
maltreatment. Indian Country has a young population and suffers from
the problems attendant with high rates of unemployment and poverty.
Services geared toward children are particularly important in
Native American communities, which are younger, on average, than the
general population. Statistics from the 2000 census confirm that nearly
33 percent of the American Indian and Alaskan Native population is
below the age of eighteen, compared to a national average of 26
percent.\1\ Furthermore, the median age of American Indians who live on
reservations is 25, while the median age of the same population who
live elsewhere is 35.\2\ Similar figures hold true of the Alaska Native
demographic.\3\
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\1\ Stella U. Ogunwole, We the People: American Indians and Alaska
Natives in the United States, p. 5 (U.S. Census Bureau, February 2006).
Available at: http://www.census.gov/population/www/socdemo/race/censr-
28.pdf
\2\ Id. at 15.
\3\ Id.
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Funds directed to programs in Indian Country not only target a
population that is younger than average, but also target a population
that is relatively poorer. American Indians and Alaskan Natives are
twice as likely to live in poverty as members of the general
population.\4\ Children within that population are also more likely to
face other problems. According to the Administration on Children, Youth
and Families, roughly 14.2 out of every 1000 American Indian or Alaska
Native children are victimized or maltreated.\5\
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\4\ Id. at 12 (finding that more than 25% of American Indian and
Native Alaskan people lived in poverty, compared to 12.7% of the U.S.
population as a whole).
\5\ Administration on Children, Youth and Families, Child
Maltreatment Study 2007, p. 25.
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The funds this bill would make available could be used to establish
new programs, to strengthen current home visitation programs, or to
utilize existing programs. There is a major health home visitation
program in Indian Country--the Community Health Representative (CHR)
program. The program does not provide the services envisioned under
H.R. 2667, but is an example of a successful home visitation program
operating throughout Indian Country. The CHR programs are funded and
overseen by the Indian Health Service, pursuant to the Indian Health
Care Improvement Act (as amended, Public Law 100-713, dated November
23, 1988). This program trains community members as health
paraprofessionals and provides funding to deliver health services
through integrated home visitation programs. These services are
culturally competent and community-based and offer a model that can be
helpful in the context of providing in-home services to young children
and their families as envisioned in this legislation.
The CHR program illustrates how service providers that value human
interaction and supportive relationships may yield better results than
traditional delivery methods. These home visitation programs include a
broad range of services, from patient care and case management to
health education and transportation. Paraprofessionals trained under
the CHR program also engage in injury prevention activities and educate
patients about best health practices. Though not targeted specifically
for children, these programs are proven models that advance self-
determination and deliver healthcare services to underserved households
who often live in very rural, geographically isolated areas where
health services in general are not always easily accessible. They also
raise community awareness of ongoing health issues in tribal
communities and the steps that are being taken to address them. Whether
used as a model on which to create a home visitation program or an
initial foundation from which to build, the success of the CHR program
is clear evidence that home visitation programs targeting children will
be effective in tribal communities.
While the CHR program holds promise for home visitation programs
envisioned in H.R. 2667, the legislation specifically identifies the
need to use evidence-based models, especially those with the strongest
evidence of effectiveness. Because research dollars and projects often
do not reach Indian Country it would be helpful to add a provision that
directs the Secretary of DHHS to collaborate and consult with tribes
and tribal organizations that have experience in this area. They could
evaluate the inclusion of tribal populations in current home visitation
models, assess the ability to adapt existing mainstream models for
implementation in tribal communities, identify tribal home visitation
programs that are working well in Indian Country, and develop
recommendations on how to strengthen the development and dissemination
of tribal home visitation models. Such a provision would help advance
the purposes of the bill and ensure that tribal home visitation
programs benefit from evidence-based approaches too.
The home visitation programs envisioned in this bill would benefit
American Indian and Alaska Native children and the young family
households in which they are being raised. As a source of services and
education, these programs are tools that Native families can use to
improve well-being, help prevent child abuse and neglect and advance
their children's development.
We thank Chairman McDermott and the Members of this Subcommittee
for their active interest in the welfare of children, and look forward
to working with you on this and related legislation. And we thank you
once again for the enactment last year of the Fostering Connections to
Success Act (PL 110-351) which brought long overdue eligibility for
tribal governments to administer the Title IV-E Foster Care and
Adoption Assistance programs.
If you have questions or comments regarding this testimony, please
contact NICWA Government Affairs Director, David Simmons at
desimmons@nicwa.org or AAIA Executive Director, Jack Trope at
jt.aaia@verizon.net.

Statement of Oneta Templeton McMann
My name is Oneta Templeton McMann and I am a social work manager in
a regional pediatric center. In that capacity, I oversee the operation
of two home based intervention programs for families with a pregnant
women and/or young child. I support H.R. 2667 Early Support for
Families Act because I see first hand the value of early involvement
with families of young children in supporting that parenting
relationship and thereby expanding the range of opportunities for the
children.
We work with low income, urban families who are struggling to meet
their everyday needs; and who, without support, cannot focus on the
early parenting and development of newborns and infants. While they
possess amazing strengths, those resources must often be directed to
keeping the rent paid, the utilities on and food enough for all to eat.
Without assistance, it is difficult to concentrate on the maternal-
infant dyad, building attachment and stimulating cognitive and
emotional development. Well child check ups and developmental
assessment often give way to survival issues in the families'
priorities. The social work and other staff who partner with families
in their homes can enhance these parenting relationships and teach and
model how to incorporate child development strategies into their usual
routines.
While the families with whom we work are financially and
environmentally stressed, they desire the same positive outcomes for
their children and themselves as parents that all families desire. With
information, modeling, and support families can learn to engage in
behaviors that promote safety, stability, and stimulation in the
caregiving relationship. Even when, by necessity, there are
disruptions--housing instability, community violence, multiple
caregivers, parental stress--parents can build skills that increase
their own parenting capacity, enhance their young child's development,
and begin to make the positive parenting role integral to the family's
functioning.
It's not quick and easy work and cannot be successful in a vacuum.
Quality community child care is needed for infants and young children,
for many single mothers--and married ones--must work to support their
families even when their children are very young. Quality early
childhood and pre-kindergarten services are imperative, ones that will
link families to their school systems and provide a smooth transition
to school. As necessary as those services are, the relationships that
are built in the home at birth and before will be paramount.
Many times, in our experience, the role models parents have are not
adequate. They may have been parented largely by older siblings, in
multiple extended family households, with their own parents compromised
by poverty or challenged by mental health, substance abuse or other
disabling conditions. Some have spent years of childhood in foster
care, residential placements or other alternative care. To interrupt
multi-generational poverty, child abuse, neglectful or absent parenting
long-term, intensive work in the home is needed by professionals
trained to partner with parents to help meet their own emotional and
other needs in order to teach them how to meet their children's.
For parents whose custody of their children has been disrupted by
incarceration, family violence, foster care, substance abuse or mental
illness, these services are particularly important and necessary. The
parent must feel absence of judgment, recognition of their own
strengths, willingness to hear them and an intentional desire to
partner from the home visiting professional. This is not simply a
matter of providing information and education. The relationship
established enables the parent to assimilate new information, try out
new skills, provide honest feedback about their attempts and to be
offered encouragement to try again when attempts do not go well. In a
home-based partnership, parents are supported in their own eco-system,
recognizing their interpersonal networks, their community values, the
barriers they must address and the strengths and resources they
possess. They are not viewed simply as parents, but as individuals
within a family system who have many roles and responsibilities. And
services are provided to address multiple areas in their lives so that
they can improve the outcomes for their children.
When I was a first (and second!) time mom, I benefited greatly from
the information, support, and demonstration of behaviors to promote my
child's development that I received from the parent educator from my
local school district. It reduced my anxiety, increased my confidence
and enhanced my competence as my child's first teacher. In addition to
that monthly visit, however, I had access to financial resources, paid
time off from my employment, support of a spouse and other extended
family members and the benefit of living in a safe, affordable home.
Many of the families our programs see do not have any of those, and the
intensity of the intervention they need is much greater.
The two programs I manage are a HRSA Healthy Start subcontract for
both English speaking and Spanish speaking families and a program
formerly supported by the Children's Bureau Abandoned Infants
Assistance program for families affected by alcohol and other drug
abuse and/or HIV. The families served face multiple challenges and
often live in very high risk situations. Home-based contact with the
family must be frequent, and a comprehensive array of services is
needed. Caseloads must be small to build that intense, positive
partnership and individualize services to each family's situation.
Physical and mental health care, basic needs, histories of family or
community violence, housing, and economic stability must all be
addressed in order for parents to reach their potential in promoting
their infants' development.
So, while this early intervention with high risk families in not
without significant cost, it is an excellent investment in getting
children ready for success in school, building stronger families to
support ongoing accomplishments, and helping replace unhealthy family
patterns with positive parenting whose benefits will extend well into
the future.
We have research findings available for each of the programs noted
here that we would be happy to provide for review. We are anxious to
help support this legislation in any way possible. Thank you.
Witness Information:
Oneta Templeton McMann, LCSW
Social Work and Community Services Department
Children's Mercy Hospitals and Clinics

Testimony of the Ounce of Prevention Fund
The Ounce of Prevention Fund applauds the Committee's progress in
achieving the vision laid out for young children and families by
President Obama. The Ounce of Prevention Fund is highly encouraged by
this progress, specifically by H.R. 2667, the Early Support for
Families Act, which would commit a substantial investment to home
visiting programs in the states. The Ounce of Prevention Fund is
committed to advocating for, designing and providing high quality early
childhood programs. We believe that high quality programs, including
home visiting programs, can and do make a real and sustained difference
in the lives of vulnerable children and families. In order to ensure
that this legislation creates a high quality system of home visiting
programs that meet the needs of the full range of at-risk infants,
toddlers, and their families, we offer the following comments and
suggestions.
The legislation should include a definition for what constitutes
the ``strongest evidence of effectiveness.'' We recommend the following
language, developed by the National Home Visiting Coalition, be adopted
in statute to define the ``strongest evidence of effectiveness:
Have demonstrated significant positive outcomes for children and
families consistent with the outcomes being sought (for the populations
being served) when evaluated using well-designed and well-conducted
rigorous evaluations, including but not limited to randomized
controlled trials, that provide valid estimates of program impact and
demonstrate replicability and generalizability to diverse communities
and families.''
Again, we are highly encouraged by and supportive of this important
legislation that would help our most vulnerable children get a chance
for a better start in life. Please feel free to contact me should you
have any questions or need additional information.

Statement of Parents as Teachers
Chairman McDermott, Ranking Member Linder, and members of the
Subcommittee:
The National Center for Parents as Teachers appreciates the
opportunity to submit written testimony on H.R. 2667, the Early Support
for Families Act. We strongly support the framework put forth in the
bill: to establish a mandatory federal funding stream to support
evidence based home visitation programs. We are grateful to Chairman
McDermott, Representatives Davis and Platts for sponsoring this
important legislation.
Parents as Teachers Background
Parents as Teachers is an evidence-based, voluntary parent
education and family support program designed to increase child
development and school readiness during the crucial early years of
life. Established as a Missouri pilot program in 1981 to serve 380
families, Parents as Teachers has grown exponentially since that time.
Through programs operating in every state, Parents as Teachers
currently serves more than 330,000 children nationally. Since its
inception, Parents as Teachers has helped millions of American families
by providing specialized home visitation services using our research-
based curriculum.
The Parents as Teachers curriculum is based on brain development
and neuroscience research. The program model consists of four service
delivery components: personal home visits by a certified parent
educator; parent group meetings about early childhood development and
parenting; developmental, health, vision and hearing screenings for
young children; and connections to community networks and resources.
Parents as Teachers programs serve families with children from
before birth up to kindergarten-entry age. Our programs deliver
services to families of all configurations, including single parents,
teen parents, two-parent families, grandparents raising grandchildren,
and foster parents. The families we serve deal with a range of
challenging life circumstances such as poverty, military service, low
literacy levels, substance abuse, mental health issues, incarceration,
English language challenges, and unemployment. We work with families
regardless of whether they are in their first trimester with their
first child or are raising multiple children, for example, such as a
mother in Southeast Missouri with nine children from four different
fathers. Three of her children under 5 participate in Parents as
Teachers. Because the needs of the families we serve vary greatly, the
intensity of our services also varies--from a minimum of monthly visits
to as frequently as weekly visits.
Reflecting the rich diversity of the families we serve, the Parents
as Teachers home visitors (parent educators) also come from varied
backgrounds. Our programs employ people with backgrounds ranging from
early childhood education and social work to nursing. In addition, some
programs hire experienced paraprofessionals who bring invaluable
linkages to a local cultural community or language skills that are
essential to successfully connect with non-English speaking families.
Prior to serving families, every parent educator must complete a week-
long in-depth training on the Parents as Teachers Born to Learn
curriculum, demonstrating an understanding of the material with a daily
assessment. Within three to six months of this initial training, each
parent educator goes through an additional day-long follow up training
to monitor implementation progress and answer any questions.
Additionally we are expanding our training through distance
learning applications to further increase our ongoing connection with
parent educators in the field.
Program Implementation
Parents as Teachers programs thrive in a variety of local settings
including school districts, Head Start programs, human service
agencies, health departments, mental health agencies, family resource
centers, child care centers and local United Way agencies. In some
communities the Parents as Teachers program operates as a stand-alone
entity, but the more common approach is for Parents as Teachers
services to be woven into an organization as a core family service
delivery component. We take pride in the adaptability of our model
while maintaining a commitment to model fidelity as evidenced by our
quality standards.
Beyond our partnerships with host organizations, we also
collaborate with other home visiting programs such as Healthy Families
America, HIPPY, Parent Child Home, Nurse Family Partnership and other
programs operating in individual states. These local partnerships
enhance the services provided to families and further strengthen the
continuum of care available to families in a particular community.
Parents as Teachers Research Outcomes
Parents as Teachers has a long history of independent evaluations
demonstrating positive outcomes for young children and their families.
More than two dozen research reports have been completed that show the
Parents as Teachers model produces positive outcomes in terms of school
readiness, prevention of child abuse and neglect, parental involvement,
school success and child health. Included among these studies are four
randomized control trials and five studies that have been published in
peer reviewed journals. A sampling of these research results show that:

Parents as Teachers children showed better school
readiness at the start of kindergarten, higher reading and math
readiness at the end of kindergarten, higher kindergarten grades, and
fewer remedial education placements in first grade.\i\
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\i\ Drazen, S., & Haust, M. (1995). The effects of the Parents and
Children Together (PACT) program on school achievement. Binghamton,
NY.; Drazen, S. & Haust, M. (1996). Lasting academic gains from an
early home visitation program. Paper presented at the annual meeting of
the American Psychological Association, August 1996.
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Participation in Parents as Teachers helps to close the
achievement gap between children living in poverty and those from non-
poverty households.\ii\
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\ii\ Zigler, E., Pfannenstiel, J.C., & Seitz, V. (2008). The
Parents as Teachers Program and School Success: A Replication and
Extension. Journal of Primary Prevention, 29, 103-120.
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In a randomized trial, adolescent mothers who received
case management and Parents as Teachers were significantly less likely
to be subjected to child abuse investigations than control group
mothers who received neither case management nor Parents as
Teachers.\iii\
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\iii\ Wagner, M.M. & Clayton, S.L. (1999). The Parents as Teachers
Program: Results from Two Demonstrations. The Future of Children: Home
Visiting: Recent Program Evaluations, 9(1), 91-115.
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In another randomized trial, adolescent mothers in an
urban community who participated in Parents as Teachers scored lower on
a child maltreatment precursor scale than mothers in the control group.
These adolescent mothers showed greater improvement in knowledge of
discipline, showed more positive involvement with children, and
organized their home environment in a way more conducive to child
development.\iv\
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\iv\ Pfannenstiel, J., Lambson, T., & Yarnell, V. (1991). Second
wave study of the Parents as Teachers program. Overland Park, KS:
Research & Training Associates.
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Children participating in Parents as Teachers were much
more likely to be fully immunized for their given age, and were less
likely to be treated for an injury in the previous year.\v\
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\v\ Wagner, M., Iida, E. & Spiker, D. (2001). The multisite
evaluation of the Parents as Teachers home visiting program: Three-year
findings from one community. Menlo Park, CA: SRI International.
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PAT parents were more involved in children's school
activities and engaged their children more in home learning activities,
especially literacy-related activities.\vi\
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\vi\ Albritton, S., Klotz, J., & Roberson, T. (2004) The effects of
participating in a Parents as Teachers program on parental involvement
in the learning process at school and in the home. E-Journal of
Teaching and Learning in Diverse Settings, 1(2), 108-208. http://
www.subr.edu/coeducation/ejournal/Albritton%20et%20al.Article.htm.

Parents as Teachers embraces research and evaluation of our model
not only to document effectiveness, but also as the basis for quality
improvement. We are particularly supportive of the commitment to
research and evaluation included in H.R. 2667. This set-aside
evaluation funding will allow Parents as Teachers, and other home
visiting programs, to use these evaluation results as an integral part
of our continuous quality improvement process to enhance our curriculum
and training to ensure that our materials remain up-to-date and meet
the changing needs of the families we serve.
Defining Evidence Based Home Visitation Programs
Parents as Teachers recognizes the importance of investing public
funds in proven, ``evidence-based'' home visiting programs. However, at
present there is no widely agreed upon definition of evidence-based
home visitation programs in scholarly writings, statutes, and
regulations.
Some strong advocates argue that the optimal definition of
evidence-based programs should require multiple randomized control
trials. While the Parents as Teachers research portfolio includes
studies that use randomized control designs (as described in the
previous section of this statement), we believe a definition that
relies exclusively on this single approach is potentially
counterproductive and can dissuade program innovation. A number of
notable scholars, including Dr. Deborah Daro who testified before the
Subcommittee on June 9th to discuss H.R. 2667, argue that while
randomized control trials provide insight into a program's impact on
participants under ideal circumstances, this approach does not provide
critical information about real world applications in diverse
environments.
We believe the overall quality of home visiting services would
improve and associated outcomes for children and families would
increase if programs were encouraged to select research methodologies
designed to measure the outcomes their programs were intended to
achieve. In addition to randomized control trials, programs could also
utilize research studies that use quasi experimental designs, including
regression discontinuity design which compares two groups separated by
a cut-off point (such as child's birthday to enroll in Kindergarten),
and the interrupted time series method which compares trends in pre-
implementation achievement data to post-implementation achievement
data.
Standard of Evidence in H.R. 2667
Although H.R. 2667 includes language that establishes priority
funding for home visitation programs with the ``strongest evidence''
[section (f)(2)], the bill does not provide a definition or criteria
for what constitutes this strongest level of evidence. As a result, we
conclude that the administering federal agency will be responsible for
developing this critically important definition or criteria that will
have overarching implications for implementation of this new federal
home visitation program. We therefore encourage Congress to adopt the
following definition of programs with the ``strongest evidence'':
Have demonstrated significant positive outcomes for children and
families consistent with the outcomes being sought (for the populations
being served) when evaluated using well-designed and well-conducted
rigorous evaluations, including but not limited to randomized
controlled trials, that provide valid estimates of program impact and
demonstrate replicability and generalizability to diverse communities
and families.
We believe that this definition provides a rigorous standard that
would ensure that only proven home visitation programs would be
eligible to receive the funds outlined in this section. At the same
time, this definition would allow states to develop home visitation
implementation plans that incorporate one or a combination of evidence-
based programs that can best meet the needs of families in their state
and build on existing service infrastructures at the state and local
level.
Conclusion
We congratulate the Committee for scheduling the hearing on this
important proposal and for advancing the Administration's home visiting
initiative in Congress. The National Center for Parents as Teachers,
along with our programs across the country, are enthusiastic about the
prospect of a dedicated federal mandatory funding stream of mandatory
funds that will allow us to provide quality home visitation services to
more families and stand ready to work with Congress and the
Administration to make this new program a become a reality.

Statement of Prevent Child Abuse America

Prevent Child Abuse America and its network of 47 state chapters
and over 400 Healthy Families America program sites thanks the Chairman
and the other distinguished members of the U.S. House Committee on Ways
and Means Subcommittee on Income Security and Family Support for this
opportunity to provide the organization's perspective on the need for a
federal investment in early childhood home visitation. In particular,
we would like to thank Chairman McDermott, and Representatives Danny
Davis and Todd Platts for their leadership on this issue, as most
recently demonstrated with their introduction of the Early Support for
Families Act of 2009 (HR 2667).
Through this testimony our organization will identify the value of
home visiting and the positive outcomes that a federal investment will
achieve to enhance our nation's ability to promote healthy early
childhood experiences.
About Prevent Child Abuse America
Prevent Child Abuse America was founded in 1972 and is the first
organization in the United States whose sole mission is ``to prevent
the abuse and neglect of our nation's children.'' We undertake our
mission by advocating for the full range of services needed to promote
healthy child development and provide parents with the information they
need to be the caring and effective parents they want to be. Based in
Chicago, the National Office and our networks manage over 375 different
locally based strategies to meet the mission of the organization,
including 2,900 home visitation workers, supervisors and program
managers who oversee and implement Healthy Families America, a
voluntary home visitation service.
The Importance of Fostering Healthy Child Development
When we invest in healthy child development, we are investing in
community and economic development, as flourishing children become the
foundation of a thriving society. Healthy child development starts a
chain of events that follow a child into adulthood. Unfortunately,
children are sometimes exposed to extreme and sustained stress like
child abuse and neglect, which can be devastating to a child's
development. This toxic stress damages the developing brain and
adversely affects an individual's learning and behavior, as well as
increases susceptibility to physical and mental illness.
Research shows a strong correlation between child abuse and neglect
and debilitating and chronic health consequences. The Adverse Childhood
Experiences Study (ACE), conducted by the CDC in collaboration with
Kaiser Permanente's Health Appraisal Clinic in San Diego, found that
individuals who experienced child maltreatment were more likely to
engage in risky behavior, such as smoking, substance abuse and sexual
promiscuity, and to suffer from adverse health effects such as obesity
and certain chronic diseases. Over 17,000 adults participated in the
ACE study, making it the largest investigation examining the links
between child maltreatment and later-life health and well-being ever
conducted.\1\ The ACE findings are supported by numerous studies,
including a recent population-based survey that collected data from
over 2,000 middle-aged men and women in Wisconsin. This study found
that adults who experienced abuse or neglect during childhood are more
likely to suffer from negative health consequences as adults including
asthma, bronchitis, and high blood pressure.\2\
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\1\ Felitti V, Anda R, Nordenberg D, Williamson D, Spitz A, Edwards
V, et al. Relationship of Childhood Abuse and Household Dysfunction to
Many of the Leading Causes of Death in Adults. American Journal of
Preventive Medicine 1998;14(4):245-58.
\2\ Springer, K.W., Sheridan, J., Kuo, D., & Carnes, M. (2007).
Long-term Physical and Mental Health Consequences of Childhood Physical
Abuse: Results from a Large Population-based Sample of Men and Women.
Child Abuse & Neglect, 31, 517-530.
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As ACE and similar studies demonstrate, getting prevention right
early is less costly to the nation, and to individuals, than trying to
fix things later. Prevent Child Abuse America estimates that
implementing effective policies and strategies to prevent child abuse
and neglect can save taxpayers $104 billion per year. The cost of not
doing so includes more than $33 billion in direct costs for foster care
services, hospitalization, mental health treatment, and law
enforcement. Indirect costs of over $70 billion include loss of
productivity, as well as expenditures related to chronic health
problems, special education, and the criminal justice system.\3\ An
international study by the United Nations Children's Fund (UNICEF,
February 2007) placed the United States next to last on child well-
being, among the 21 wealthiest nations in the world. Although only one
indicator of child well-being, rates of child abuse and neglect are
ultimately tied to a nation's investment in its children.
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\3\ (1) Wang, CT, & Holton, J (2007). Total estimated cost of child
abuse and neglect in the United States. Chicago, IL: Prevent Child
Abuse America. http://www.preventchildabuse.org/about_us/
media_releases/pcaa_pew_economic_impact_study_final.pdf.
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This is where an investment in home visitation, as contemplated by
HR 2667, provides the country with a great opportunity to enhance child
development, support communities, reduce child abuse and neglect, and
ultimately have a profound impact on the health and productivity of
future generations.
Role of Early Childhood Home Visitation
All expectant parents and parents of newborns have common questions
about their child's development. Early childhood home visitation
provides a voluntary and direct service in which highly trained home
visitors can help parents understand, recognize and promote age
appropriate developmental activities for children; meet the emotional
and practical needs of their families; and improve parents' capacity to
raise successful children.
Research has shown that voluntary home visitation is an effective
and cost-efficient strategy for supporting new parents and connecting
them to helpful community resources. Quality early childhood home
visitation programs lead to proven, positive outcomes for children and
families, including improved child health and development, improved
parenting practices, improved school readiness, and reductions in child
abuse and neglect.
Healthy Families America
Healthy Families America is Prevent Child Abuse America's
nationally recognized, signature home visitation program. Through
Healthy Families America, well-respected, extensively trained
assessment workers and home visitors provide valuable guidance,
information and support to help parents be the best parents they can
be. Healthy Families America focuses on three equally important goals
to: 1) promote positive parenting; 2) encourage child health and
development; and 3) prevent child abuse and neglect.
A review of 34 studies in 25 states, involving over 230 Healthy
Families America programs allows us to say with confidence and
conviction that the benefits of Healthy Families America are proven,
significant, and impact a wide range of child and family outcomes.\4\
In particular, Healthy Families America:
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\4\ Study designs include 8 randomized control trials and 8
comparison group studies. More information on the studies can be found
in the Healthy Families America Table of Evaluations at **
www.healthyfamiliesamerica.org/research/index.shtml.
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Improves Parenting Attitudes. Healthy Families America families
show positive changes in their perspectives on parenting roles and
responsibilities.
Increases Knowledge of Child Development. Healthy Families America
parents learn about infant care and development; including child care,
nutrition, and effective positive discipline.
Supports a Quality Home Environment. Healthy Families America
parents read to their children at early ages, provide appropriate
learning materials, and are more involved in their child's activities,
all factors associated with positive child development.
Promotes Positive Parent-Child Interaction. Healthy Families
America parents demonstrate better communication with, and
responsiveness to, their children. This interaction is an important
factor in social and emotional readiness to enter school.
Improves Family Health. Healthy Families America improves parents'
access to medical services, leading to high rates of well-baby visits
and high immunization rates, and helps increase breast feeding, which
is linked to many benefits for both babies and moms. Healthy Families
America has also been found to significantly reduce low birthweight
deliveries.\5\ By one estimate, each normal birth that occurs instead
of a very low birthweight birth saves $59,700 in the first year of
care.\6\
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\5\ Eunju Lee, PhD, Susan D. Mitchell-Herzfeld, MA, Ann A.
Lowenfels, MPH, Rose Greene, MA, Vajeera Dorabawila, PhD, Kimberly A.
DuMont, PhD (2009). Reducing Low Birth Weight Through Home Visitation:
A Randomized Controlled Trial. American Journal of Preventive Medicine,
36, 2,154-160.
\6\ Rogowski, J. (1998). Cost-effectiveness of Care for Very Low
Birth Weight Infants. PEDIATRICS Vol. 102 No. 1 July 1998, pp. 35-43.
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Prevents Child Abuse and Neglect. Healthy Families America has a
significant impact on preventing child maltreatment, particularly
demonstrated in recent randomized control trials.
In addition to our stewardship of Healthy Families America, Prevent
Child Abuse America partners with other effective home visiting models
working in communities across the country to create nurturing
environments for children. Our national home visiting partners include
Home Instruction for Parents of Preschool Youngsters (HIPPY USA), the
Nurse-Family Partnership, The Parent-Child Home Program, and Parents as
Teachers.
Together, we have accepted the responsibility to improve the home
visitation field. Together, we share research findings and best
practices, and together, we work toward common goals, and create areas
for cross-program cooperation and learning that strengthens the home
visit field as a whole, as well as enhances individual programs. At the
local level, Healthy Families programs partner with other home visiting
models to reach a broader population of families, to ensure that
families are receiving the home visiting service model best suited to
their needs, and to maximize limited resources.
The Need for Reliable Funding and a Coordinated Approach
Despite the many proven benefits of home visitation, home
visitation services across the country struggle with unreliable and
unsustainable funding. The current patchwork of funding results in a
home visitation system that serves only a small percentage of families.
By one estimate, approximately 400,000 children and families
participate in home visitation services each year.\7\ A report by the
National Center for Children in Poverty estimates 42% of young children
(more than 10 million children in 2005) experience one or more risk
factors associated with poor health and educational outcomes, and 10%
(nearly 2.4 million children) experience three or more risk factors.\8\
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\7\ Gomby, D. (2005). Home Visitation in 2005: Outcomes for
Children and Parents. Invest in Kids Working Paper No. 7. Committee for
Economic Development: Invest in Kids Working Group. Available at
www.ced.org/projects/kids.shtml.
\8\ Stebbins, Helene, & Knitzer, Jane (2007). State Early Childhood
Policies: Improving the Odds. NY: National Center for Children in
Poverty.
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The Early Support for Families Act (HR 2667) will address the home
visiting funding crisis by establishing a new federal mandatory grant
program dedicated solely to home visitation. HR 2667 authorizes $2
billion over 5 years in grants to states to provide evidence-based home
visitation services to support families with young children and
families expecting children. The legislation empowers states to fund
home visitation services that best suit the needs of their communities,
while putting important parameters in place to assure quality of
services. Programs funded through the new grant must:

Adhere to clear evidence-based models of home visitation
that have demonstrated significant positive effects on program-
determined outcomes;
Employ well-trained and competent staff with high quality
supervision;
Show strong organizational capacity to implement a
program; and
Establish appropriate linkages to other community
resources.

The flexibility the legislation provides to states is supported by
a compelling body of research demonstrating the effectiveness of a
range of evidence-based models employing a diverse and highly skilled
workforce. For example, Healthy Families America has documented
success, as outlined above, utilizing home visitors who are selected
based on their personal characteristics, such as the ability to
establish a trusting relationship, and their educational and
experiential background in child health and development, child
maltreatment, and parenting. HFA home visitors typically live in the
same communities as participating families and share their language and
cultural background.
The legislation also requires that a state conduct a needs
assessment prior to receiving funding to assess the reach and scope of
existing early childhood home visitation efforts and identify gaps in
services. States would have to provide an annual report on their
progress in implementing the program. The report would include
important indicators to help assess the state's effectiveness in
implementing the program, including the annual cost per family, the
outcomes experienced by recipients, the training and technical
assistance being provided to programs, and the methods to determine
whether a program is being implemented as designed.
Recommendations
HR 2667 sets a strong foundation for a new home visiting program,
however opportunities do exist to further strengthen the grant program
authorized by the bill.
Ensuring Quality
The legislation stipulates that states should prioritize funding
home visiting programs that adhere to models with the strongest
evidence. States may also direct some funding to home visiting programs
utilizing models that have not yet achieved the strongest level of
evidence. We recommend adding more specificity to:

1. The standards that all programs must meet to qualify for
funding; and
2. The standards that programs must meet to be given priority for
funding.

We are concerned that the overall quality of the services being
provided cannot be assured without setting standards that all programs
must meet. We believe that all programs funded under this grant should
be home visiting programs that adopt and demonstrate fidelity to a
clear model that:

1. Is research-based;
2. Is grounded in empirically based knowledge related to home
visiting and child health or child development;
3. Is linked to program-determined outcomes;
4. Has comprehensive home visitation program standards, including
standardized training, ongoing professional development; and high
quality supervision; and
5. Has been in existence for at least three consecutive years
prior to the program being funded under the Act.

In addition to meeting the criteria above, we recommend that home
visiting models achieve the following research standard in order to be
considered a program with ``the strongest evidence of effectiveness:''
[the model must] Have demonstrated significant positive outcomes
for children and families consistent with the outcomes being sought
(for the populations being served) when evaluated using well-designed
and well-conducted rigorous evaluations, including but not limited to
randomized controlled trials, that provide valid estimates of program
impact and demonstrate replicability and generalizability to diverse
communities and families.
Improving Coordination
Home visitation services are most effective when they are linked to
other services for children and families operating in the state, and
when there is coordination amongst the various home visiting services
provided in the state. We recommend strengthening language to ensure
greater coordination among the various models of early childhood home
visitation and between the home visiting programs and the broader
child-serving community. This can be done by:

1. Adding an assurance that the state has consulted with all of
the state agencies that currently support home visiting programs with
young children.
2. Adding criteria that the state develop a plan for coordinating
and collaborating in the delivery of home visitation services with
child care services, health and mental health services, income
supports, early childhood development services, education agencies, and
other related services. This might include, where applicable,
collaborations with an early childhood coordinating body instituted for
the purpose of coordinating services and supports for young children
and parents.

Taking this approach to implementation will lead to a more
efficient use of resources and a greater assurance that families are
receiving the most appropriate and effective home visiting services to
meet their needs. This model allows for a clear outcome driven national
public policy that promotes consistent results and allows states to
manage the services in accordance with their specific existing service
delivery systems, on-going best practices and existing public-private
partnerships.
Conclusion
Home visitation is an effective, evidence-based, and cost-efficient
way to bring families and resources together, and help families to make
choices that will give their children the chance to grow up healthy and
ready to learn. While no one piece of legislation can prevent child
abuse and neglect, we believe that HR 2667 is an important step towards
ensuring that all children have the opportunity to grow up in a safe,
healthy, and nurturing environment. The new funding proposed in HR 2667
does not represent an expenditure, but rather an investment in our
children and families, and in our future. We look forward to working
with members of this Subcommittee in moving HR 2667 towards enactment.
Contact Information:
James M. Hmurovich, President & CEO, Prevent Child Abuse America
Bridget Gavaghan, Senior Director of Public Policy, Prevent Child
Abuse America

Statement of Robin Roberts
To the Honorable Members of the House Ways and Means Committee,
I am submitting a statement for record concerning the Early Support
for Families Act. I am so very pleased that the important role parents
play in their child's learning and development is being recognized and
supported through this legislation. I am the state leader for North
Carolina Parents as Teachers Network. Last year we served approximately
10,000 children, birth to age five, through supporting parents as their
child's first and most influential teacher. This legislation will allow
us to serve even more families in need of support, thus ensuring North
Carolina's children have the best possible start in life.
While I support this legislation, there is a concern that I would
like to express. In the current legislation the language limits the
types of family support services that will be available to families. I
would ask you to consider the following:

Incorporate the definition of ``evidence-based''
proposed by the National Home Visiting Coalition.

Have demonstrated significant positive outcomes for children and
families consistent with the outcomes being sought (for the populations
being served) when evaluated using well-designed and well-conducted
rigorous evaluations, including but not limited to randomized
controlled trials, that provide valid estimates of program impact and
demonstrate replicability and generalizability to diverse communities
and families.
Members of the national home visiting coalition steering committee
include: Children's Defense Fund, Child Welfare League of America,
Center for Law and Social Policy, Fight Crime Invest in Kids, National
Child Abuse Coalition, HIPPY USA, Parent-Child Home Program, Prevent
Child Abuse America/Healthy Families America, Voices for America's
Children and the National Center for Parents as Teachers.

Understand that effective home visitors come from a
range of backgrounds, including nurses, social workers, and early
childhood educators.
Build on existing state and local home visiting
infrastructures as the federal government develops implementation plans
for this new initiative.
Recognize the range of evidence-based home visiting
programs, including Parents as Teachers, that have a long history of
providing effective services to diverse families across the country.

Research has shown that Parents as Teachers programs produce
measurable outcomes in a range of areas including school readiness,
prevention of abuse and neglect, parental involvement, later school
success and child health. The Early Support for Families Act will allow
programs such as Parents as Teachers to ensure the well-being of our
children and will lay the critical foundation for success in school and
life learning. Thank you for supporting this important piece of
legislation and your priorities on families and the earliest years for
all of our children.
Sincerely,

Robin Roberts

Statement of Stephanie Gendell

My name is Stephanie Gendell and I am the Associate Executive
Director of Policy and Public Affairs at Citizens' Committee for
Children of New York, Inc. (CCC). CCC was founded by Eleanor Roosevelt
65 years ago to be a non-profit, independent, multi-issue child
advocacy organization that blends civic activism and fact-based
advocacy. CCC's mission remains ensuring New York's children are
healthy, housed, educated and safe. We are grateful to Congressmen
McDermott and Rangel and the members of the Subcommittee on Income
Security and Family Support of the House Ways and Means Committee for
holding a hearing on federal funding for early childhood home visiting
programs and we appreciate having the opportunity to submit testimony.
We strongly support the Committee's efforts to secure federal
funding for home visiting programs, support the McDermott-Davis Early
Support for Families Act, and agree that it is logical to discuss home
visiting programs in the context of health care reform.
Throughout the country, and specifically in New York, it is widely
recognized, as well as proven, that home visiting programs are cost-
effective interventions that help to produce good outcomes for
children. Specifically, these programs have been shown to reduce child
abuse and neglect, language delays, emergency room visits for accidents
and poisonings, arrests of children, and behavioral and intellectual
problems for children.\1\ The Rand Corporation has found that there is
a $34,148 net benefit per family served by Nurse-Family Partnership,
equaling a $5.70 return on every dollar invested.\2\ While New York's
typical home visiting programs, such as Healthy Families New York and
Nurse-Family Partnership, cost approximately $4000-$7000 per family, in
New York juvenile detention costs $200,000 per child per year; foster
care costs an average of $36,000 per child per year; and special
education costs an average of $22,000 per child per year. Not only are
home visiting programs cost-effective, but they help produce the
outcomes that America's children deserve--to be healthy, housed,
educated and safe.
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\1\ Outcomes from Nurse-Family Partnership include a 48% reduction
in child abuse and neglect, 56% reduction in emergency room visits for
accidents and poisonings, and a 67% reduction in behavioral and
intellectual problems for the child at age six. Nurse-Family
Partnership. Overview. June 2008. http://
www.nursefamilypartnership.org/resources/files/PDF/Fact_Sheets/
NFP_Overview.pdf; Nurse-Family Partnership. Benefits and Costs: A
Program with Proven and Measurable Results. June 2008. http://
www.nursefamilypartnership.org/resources/files/PDF/Fact_Sheets/
NFP_Benefits&Cost.pdf.
\2\ L. Karoly, R. Kilburn & J. Cannon. Early Childhood
Interventions: Proven Results, Future Promise. (Rand Corporation 2005).
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Both New York State and New York City have been innovative in their
approaches to developing home visiting programs and funding streams for
these programs, but continued progress has been stymied by budget
shortfalls and budget uncertainties.
The types of programs currently available in New York are varied
and differ in their intensity, scope and duration. These programs range
from 1-2 visits by health workers, to three years of visits by nurses
or social workers that often begin during pregnancy, to Early Head
Start programs. While the scope, duration, intensity and eligibility
differ, all of theses programs have produced improved outcomes for the
children.
As part of New York City's Center on Economic Opportunity (CEO)
initiative to reduce poverty, the City developed a ``universal''
newborn home visiting model. In 7 high risk communities \3\ in the
City, all new mothers are offered 1-2 visits by a health worker.
Approximately 15,000 such home visits are conducted each year. While
the program is voluntary, over half of mothers agree to participate
after they are either contacted in the hospital upon giving birth or
soon afterwards by phone or mail. During the home visit the health
worker provides information on breastfeeding, SIDS/safe sleeping,
attachment, smoking cessation and health insurance; screens for
potential health or social problems (e.g. post-partum depression,
housing instability or domestic violence); and assesses the home
environment for hazards such as lead paint, missing window guards, or
missing smoke/carbon monoxide detectors. In addition, if the family
needs a crib, the home visitor will arrange for a free crib.
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\3\ These communities are Bedford-Stuyvesant, Brownsville,
Bushwick, and East New York in Brooklyn; East Harlem and Central Harlem
in Manhattan; and the South Bronx.
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While this newborn home visiting program is meeting the needs of
many families, the City is currently unable to provide these services
in Queens or Staten Island. CCC has long advocated for this program to
be truly universal and serve any new mother in any of the City's 52
community districts, but without federal funds it is unlikely that the
City could support this in the near future.
New York City, like other counties, has also been paying for more
long-term and intensive home visiting programs such as Healthy Families
and Nurse-Family Partnership. Many of these programs throughout the
state are paid for through a state matching program whereby the
counties pay 35% and the state pays 65%. Due to state budget deficits
this match has been reduced to 33.7% for the past two state fiscal
years. In this past budget cycle, the Governor proposed eliminating the
state's matching funds for these programs, but luckily the Adopted
Budget restored these funds. Furthermore, State and City legislatures
have identified home visiting programs as cost-effective and proven
interventions that improve outcomes for children and families so
annually they support these community-based programs through
legislative additions that are therefore in jeopardy during each year's
budget cycle. For example, in just the past year, Healthy Families New
York has received a 2% cut followed by a 6% cut and then threatened
with a 25% cut that was ultimately not implemented.
While New York State and New York City elected and appointed
officials understand the value of home visiting programs, the budget
deficits and negotiations create uncertainty and instability for the
community based organizations and agencies that provide these
invaluable services. Federal support for these programs, such as the
federal match proposed in the Early Support for Families Act, would
bring stability to programs that already exist and enable states and
localities to expand the services to additional high-needs communities
and families.
In addition to the financial assistance created by a federal
investment in home visiting programs, the federal commitment will have
an invaluable impact on the credibility of this cost-effective, proven
intervention and thus lead to an extensive expansion of home visiting
programs--this would undoubtedly improve outcomes for the next
generation of New Yorkers and Americans.
Thank you for this opportunity to submit testimony on federal
funding for early childhood home visiting programs. We look forward to
working with Congress and the Obama Administration on ensuring all of
America's children are healthy, housed, educated and safe.

Statement of The National Conference of State Legislatures
The National Conference of State Legislatures (NCSL) applauds your
commitment to federal funding for early childhood home visitation
programs designed to enhance the well-being and development of young
children. Such programs are particularly important during the economic
downturn, when they can help mitigate some of the consequences of
parental stress and lack of resources by supporting parents and
monitoring the health, safety and development in children's critical
early years.
NCSL has long supported home visiting programs as a means of
improving child well-being during their crucial early years. Many years
of research demonstrate that such programs positively impact childhood
development, promote child well-being, strengthen the family unit and
significantly reduce the incidence of child abuse and neglect.
States have adopted a variety of innovative ways to reach these
outcomes. Recognizing this, NCSL believes that federal action in this
area should recognize this diversity of approaches and support all
types of programs that have proven effectiveness.
Working together on this critical issue, and maintaining state
flexibility in tailoring their home visitation programs to meet local
needs, we can move forward to improve the lives of America's children.
Sincerely,

Representative Ruth Kagi
Washington
Chair, NCSL Human Services and Welfare Committee.

Statement of The Parent-Child Home Program, Inc.
The Parent-Child Home Program and its network of 150 community-
based sites across the country thanks the Chairman and the other
distinguished members of the U.S. House Committee on Ways and Means
Subcommittee on Income Security and Family Support for this opportunity
to provide testimony on the importance of a federal investment in early
childhood home visitation. We would like to thank Chairman McDermott,
and Representatives Danny Davis and Todd Platts for their leadership on
this issue and for introducing the Early Support for Families Act of
2009 (HR 2667).
Through this testimony, The Parent-Child Home Program will
highlight the value of home visiting for low-income, at-risk families
and how a federal investment in home visitation services will promote
healthy early childhood experiences and enhanced school readiness
opportunities for families in need across the country.
As a nation, we will never achieve our goal of ``No Child Left
Behind'' until we have successfully ensured that ``No Child Starts
Behind''. Today, too many families in the United States do not receive
the early support they need to ensure that their children have
appropriate and healthy early childhood experiences that will enable
them to enter school ready to be successful students, Today, too many
children enter school unprepared both ``academically'' and social-
emotionally. Much of this lack of preparation can be ameliorated simply
by providing parents the support they need to supply their children
with a language and literacy-rich environment that includes high
quality and quantity parent-child interaction. Too many students enter
school never having seen or held a book, without the basic literacy,
language, or social emotional skills they need to participate
successfully in the classroom. As a result their teachers in pre-
kindergarten and/or kindergarten have to slow or stop the curriculum
they had planned, to help these children catch up. Unfortunately, the
data shows us that most children who start behind will never catch up.
Children who do not know their letters when they enter kindergarten are
behind in reading at the end of kindergarten, at the end of first
grade, and are still having trouble reading at the end of fourth
grade.\1\
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\1\ ``A Policy Primer: Quality Pre-Kindergarten,'' Trust for Early
Education, Fall 2004.
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We also know that preschool is not the sole solution to this lack
of readiness. Children arrive in pre-kindergarten not ready just as in
the past they arrived in kindergarten not ready. Children are more
likely to be ready at any age when they have a family that knows what
it needs to do to help them get ready. All families want their children
to be successful, to do well in school and life, but many families do
not know how to prepare their children for success. If you are not
educated yourself, did not grow up in the American education system, do
not have access to early childhood and parenting support services and/
or do not have the means to purchase books and educational toys, you
may benefit from guidance to help you prepare your child for a
successful future. You may need support to provide a healthy
developmentally appropriate environment to raise your children in and
to develop the skills to support your child's growth and development.
The Early Support for Families Act (H.R. 2667) is designed to do just
that by ensuring that families receive the supports they need to
encourage their children's healthily development, and prepare their
children to enter school ready to be successful students and to go on
to graduate from high school.
Each of the evidence-based home visiting programs that would be
supported by this legislation provide services to families that enable
them to achieve the outcomes outlined in the bill, including prevention
of child maltreatment, healthy child development, school readiness and
connection to community services. Among the different evidence-based
home visiting models, different programs may be more focused on
particular outcomes or a particular target population, and for this
reason the ability to implement a number of evidence-based programs to
meet the needs of their diverse populations is vital to the success of
a national home visiting policy.
The Parent-Child Home Program is a research-based, research-
validated early literacy, school readiness, and parenting education
home visiting program developed in 1965. For over 40 years, the Program
has been serving families challenged by poverty, limited education,
language and literacy barriers, and other obstacles to school readiness
and educational success. The Parent-Child Home Program currently serves
over 6,500 families through more than 150 local sites in 14 states.
Many more families could be served in each of these communities, as all
of our sites have waiting lists at least equal to the number of
families they are currently serving. And many more families remain in
need of these services in communities across the country that have not
been able to develop funding streams for this critical early childhood
support service.
The Parent-Child Home Program works with a broad range of families
whose children are at risk of not receiving the early childhood
supports they need to enter school prepared to be successful: teen
parent families, single parent families, homeless families, immigrant,
refugee, and non-native English-speaking families, and grandparents
raising grandchildren. Working with parents and children in their own
homes helps families create language-rich home environments and lays
the foundation for school readiness and parental involvement as parents
prepare their children to enter school. Parents are able to continue to
build their children's language, literacy, and social-emotional skills
after the Program finishes and their children enter school ready to
succeed. The Program erases the ``preparation gap'' and prevents the
``achievement gap.''
The funding that would be provided by the Early Support for
Families Act is critical to ensuring that quality evidence-based home
visiting programs are able to reach families in need of services and
enable children to enter school ready to be successful students. The
families reached by home visiting are families that are isolated by
poverty and other obstacles. They are not accessing center-based early
childhood or school readiness services, including the library, play
groups, parenting workshops, and/or other community-based supports.
They do not have transportation or access to transportation to get to
these services; the services are not open or available when the parents
are available to attend; they have language or literacy barriers; and/
or they have no money to pay for programs.
We appreciate this opportunity to provide you with some specific
background information on The Parent-Child Home Program to highlight
the extent of its evaluation and validation and the depth of the
Program's experience working with high needs families across the
country. For over 40 years, we have been utilizing home visiting to
improve outcomes for children and their parents, in particular
preparing young children and their families to enter school ready to be
successful. As a result, four decades of research and evaluation
demonstrates that Parent-Child Home Program participants in communities
throughout the country enter school ready to learn and go on to succeed
in school. In fact, peer-reviewed research demonstrates that program
participants go on to graduate from high school at the rates of middle-
class children nationally, a 20% higher graduation rate than their
socio-economic peers nationally and a 30% higher rate than the control
group in the study. From the first day of school, Program participants
perform as well or better than their classmates regardless of income
level. This research, published in peer-reviewed journals, demonstrates
not only the immediate, but also the very long-term impacts of home
visiting.
Not only do child participants perform better in school, but their
parents also become actively involved in their education, as noted by
principals and teachers at the schools they attend. In addition, the
parents go on to make changes in their own lives as well, obtaining
their GEDs, returning to school, and improving their employment
situations. At least 30% of our Home Visitors across the country are
parents who were in the Program as parents; for many of them, this is
an entry into the workforce. All of these changes have significant
ramifications for their children's futures. The Parent-Child Home
Program proves that when programs are available to support parents and
children from an early age, delivering services in a way that is
accessible and meaningful to them, we can ensure that economically and
educationally disadvantaged families are able to support their
children's healthy development and prepare their children to enter
school ready to be successful. These families will never experience the
achievement gap and will attain high levels of academic success.
The Program's primary goal is to ensure that all parents have the
opportunity to be their children's first and most important teacher and
to prepare their children to enter school ready to succeed. The
Program's hallmark is its combination of intensiveness and light touch.
Each family receives two home visits a week from a trained home visitor
from their community who models verbal interaction and learning through
reading and play. The families receive a carefully-chosen book or
educational toy each week so that they may continue quality play and
interaction between home visits and long after they have completed the
Program. Often the books are the first books in the home, not just the
first children's books, and the toys are the first puzzles, games or
blocks that the child has ever experienced. The materials are the tools
the parents use to work with their children. The materials ensure that
when these children enter pre-kindergarten or kindergarten they have
experience with the materials that teachers expect all children to
know.
Most importantly, the Program is fun for families, demonstrating
for parents both the joy and the educational value of reading, playing,
and talking with their children. Children's language and early literacy
skills progress rapidly, and parents find an enormous sense of
satisfaction in the progress that comes from their work with their
children. This combination of fun and the dramatic changes families see
in their children are the reason that on average 85% of the families
who start in the Program complete the 2 years. The majority of families
who do not complete the Program fail to do so because they move to a
community where it is not available.
We know The Parent-Child Home Program is successful because of the
changes we see in the families and the success the children have when
they enter school. We also know it is successful because of the
positive responses from the local community sponsors, including school
districts, family resource centers, community health clinics, and many
community-based organizations, and from the way the Program is
continuing to expand across the country. We see that home visiting is a
service delivery method that is able to reach families whose children
would otherwise show up in pre-K or kindergarten never having held a
book, been read a story, engaged in a conversation, been encouraged to
use their imagination, played a game that involves taking turns, or put
together a puzzle.
We also know from over 40 years of practice in the field
accompanied by extensive research and evaluation that home visiting is
a critical and effective way to reach immigrant and non-native English-
speaking families and ensuring that they have access to all the tools
they need to ensure their children's healthy development and future
success. We have also seen the value of utilizing home visitors who are
a language and cultural match for families, and, in making these
matches, how well-trained and well-supervised paraprofessional home
visitors can be very effective and vital to reaching certain difficult
to access communities.
Immigrant and refugee families with young children often do not
access early childhood or family supports available in the communities
where they live.\2\ In addition, because of language and cultural
barriers, they often do not utilize community institutions like public
libraries, public schools, or community centers. They are not familiar
with the options for early childhood education for their children and
often miss accessing center-based programming because they are unaware
that it is available or that their children are eligible. Even if they
are aware of programs, families may not trust the institutions, might
not approach them because of language barriers, and may prefer that
their children be cared for at home by parents or extended family.
These families are often very isolated, particularly from the
educational system that their children will soon be entering, and from
what they and their children need to know before they enter school.
Home visiting is an ideal way to reach these families as it meets them
where they are most comfortable, in their own homes, can provide
services in their own language and can adjust to their literacy levels.
It also can be the most effective service for impacting the home
environment in ways that will not only benefit the children's
development and preparation for school but also will support them as
they continue on with their education.\3\
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\2\ Bruce Fuller, Sharon L. Kagan, Gretchen L. Caspary, and
Christiane A. Gauthier, ``Welfare Reform and Child Care Options for Low
Income Families,'' The Future of Children: Children and Welfare Reform
12.1 (2002): 97-119.
\3\ Jeanne Brooks-Gunn, ``Do You Believe in Magic? What We Can
Expect From Early Childhood Intervention,'' Social Policy Report:
Giving Child and Youth Development Knowledge Away 17.1 (2003): 3-14.
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Home visiting as a service delivery method is particularly
effective with high risk, socially and linguistically isolated
families.\4\ In The Parent-Child Home Program model, the Home Visitor's
role is specifically focused on demonstrating ways that parents/primary
caregivers can use the curricular ``tool'' of a children's book or
educational toy to interact with their young child to build language
and early literacy skills. The goal of the home visits is to increase
verbal interaction between parent and child, as both a cornerstone of
early literacy \5\ and a way to support and strengthen the attachment
between parent and child. This approach helps to mitigate potential
child abuse/neglect by increasing protective factors in the home,
supporting the children's social-emotional growth through appropriate
parent-child verbal interaction, and preparing children for school
success.\6\ Other outcomes, such as the parent pursuing their own
educational goals or improving their employment or housing situations,
often occur as a result of these intensive visits. The Program also
plays a critical role in connecting families to other programs and
support systems as requested by the participating parent, such as
referrals for evaluation for possible early childhood developmental
delays, or connections to GED or ESL programs for adult family members.
Local Program sites form partnerships with public libraries,
introducing families to library services and resources.
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\4\ Brooks-Gunn 3-14.
\5\ Lev Vygotsky, Mind in Society: The Development of Higher
Psychological Processes (Cambridge: MIT Press, 1978).
\6\ Phyllis Levenstein, Susan Levenstein, and Dianne Oliver,
``First Grade School Readiness of Former Child Participants in a South
Carolina Replication of the Parent-Child Home Program,'' Journal of
Applied Developmental Psychology 23 (2002): 331-353.
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Many Parent-Child Home Program sites have been able to hire home
visitors from the communities they are serving who speak the languages
of the families they are serving and come from the same, or similar,
cultures. These multi-cultural staffs work best when they work as a
team, on an ongoing basis, under supervision, sharing their own
cultures and helping each other understand the cultural nuances that
make a difference to the families they are serving. Often the site
coordinator or supervisor can best train her staff by seeking guidance
and cultural knowledge from the home visitors s/he is supervising.
Utilizing techniques of reflective supervision and relationship-based
practice, this information and expertise-sharing can be facilitated
over time.
Matching families and home visitors based on language and/or
culture is critical to successful outcomes with high-risk families. A
language/cultural match of home visitor to family helps to overcome the
cultural barriers often encountered when working with immigrant
families. The language match allows home visitors to fully understand
and communicate with family members. The cultural match enables home
visitors to understand nuances of behavior and address them, when
needed, from a common viewpoint.
VOICES FROM THE FIELD--``In our program, all our home visitors are
familiar with the cultures they are serving. If somebody else was doing
the home visits, I could imagine some conflicts--we understand the
language and the priorities and choices our families have. We know to
take things slow and understand that if the parents never went to
school, they don't know what sort of help and support to offer their
children.'' (Saadia Hamid, Parent-Child Home Program Coordinator,
Seattle, WA)
The issue of trust is especially important when providing a home
visitor to an immigrant or refugee family, particularly if the family
has experienced the trauma of political betrayal or war in their home
country, or is still going through a period of adjustment in a new
community in the U.S. The ability to communicate and demonstrate
understanding of these issues regarding family history and adjustment
is key to establishing a foundation of trust. The home visitor must be
well-trained and well-supervised in home visit strategies, early
childhood development, parenting, appropriate expectations, and
boundary issues; however, it is the home visitor's ability to
communicate with the family, to understand the cultural nuances of the
family's behavior and attitudes toward parenting, and to connect with
the parent/caregiver in a mature, warm, and non-judgmental way, that
provides the foundation for trust, growth, and change.
We would just like to share with you a brief anecdote demonstrating
the long-term impact of home visiting on the families, and in
particular an immigrant family. We have been fortunate to have followed
program participants through high school graduation and beyond and have
many wonderful examples of the Program's impact on children's lives.
The long-term success of the Program is clearly depicted by an
interview that was conducted recently with a program graduate from a
New York Parent-Child Home Program site, which has been implementing
the Program for over 35 years. The son of immigrants from Columbia, he
noted that of the forty native Spanish-speaking students in his grade,
only three went on to college. He observes that all these children went
through the same schools, the only difference was The Parent-Child Home
Program. He says it got him on the right track early; he entered school
ready to learn and has soared ever since. He still has vivid memories
of how confident he felt when he started kindergarten, how the books
and toys were familiar and how he was the only native-Spanish-speaking
child in his class who knew the words to London Bridge is Falling Down.
For him, the Program was a critical bridge to the rest of his education
and for his mother it was empowering. She went back to school herself,
and he noted she regularly would call his teachers to tell them to give
him more homework because what they had given him was too easy. This
young man is now a corporate lawyer in New York City, and he is the
first Program graduate to serve on The Parent-Child Home Program's
national board of directors. His story is both extraordinary and
typical of the kinds of success parents and children can achieve when
home visiting is available to reach them where they are most
comfortable and help them build the language, literacy, and social-
emotional skills they need to be successful.
The Early Support for Families Act (H.R. 2667) will ensure that
many more families in need receive home visiting services by
establishing a new mandatory federal grant program dedicated solely to
home visitation. H.R. 2667 authorizes $2 billion over 5 years in grants
to states to provide evidence-based home visitation services to support
families with young children and families expecting children. The
legislation empowers states to fund those home visitation services that
best suit the needs of their communities, while putting in place
important parameters to assure that families receive high quality
services. Programs funded through H.R. 2667 must:

We strongly support the flexibility the legislation provides to
states to select the combination of home visiting services most suited
to its needs. This flexibility is supported by a compelling body of
research demonstrating the effectiveness of a range of evidence-based
models employing a diverse and highly skilled workforce. As noted
above, The Parent-Child Home Program has documented successful outcomes
utilizing home visitors who are selected based on their personal
characteristics, such as the ability to establish a trusting
relationship, and their educational and experiential background in
early childhood development and parenting education. Parent-Child Home
Program home visitors typically live and/or have previously worked in
the same communities as Program families and share the language and
cultural background of the families with whom they are working. In
addition, The Parent-Child Home Program works with families when their
children are 16-months to 4 years; often reaching families who were not
able to access other home visiting services or picking up with the
literacy, language and school readiness focus as other home visiting
services are ending.
Recommendations
The Early Support for Families Act of 2009, H.R. 2667, establishes
a strong foundation for a new home visiting program. We do, however,
believe that there are opportunities to further strengthen the grant
program authorized by the bill. The legislation calls for states to
prioritize home visiting programs that adhere to models with the
strongest evidence, but also allows states to direct some funding to
home visiting programs that utilize models that have not yet achieved
the strongest level of evidence. We support adding more specificity to
both the standards that all programs must meet to qualify for funding;
and the standards that ``evidence-based'' programs must meet to be
given priority for funding.
In order to ensure the overall quality of the services being
provided, we believe that legislation should establish standards that
all programs must meet. All programs funded under this grant should be
home visiting programs that have been in existence for at least three
consecutive years prior to being funded under the Act, and are:

Research-based;
Grounded in empirically based knowledge related to home
visiting and child health or child development;
Linked to program-determined outcomes; and
Serving families based upon comprehensive home visitation
program standards, including standardized training, ongoing
professional development; and high quality supervision.

In addition to meeting the criteria listed above, we recommend that
home visiting models achieve the following research standard in order
to be considered programs with ``the strongest evidence of
effectiveness:''
[the model must] Have demonstrated significant positive outcomes
for children and families consistent with the outcomes being sought
(for the populations being served) when evaluated using well-designed
and well-conducted rigorous evaluations, including but not limited to
randomized controlled trials, that provide valid estimates of program
impact and demonstrate replicability and generalizability to diverse
communities and families.
We are pleased to be part of a national coalition of national home
visiting organizations and advocates for early childhood and family
support services that have been working together for a number of years
to achieve federal home visiting legislation and are pleased to support
The Early Support for Families Act.
Thank you for holding this hearing and for introducing The Early
Support for Families Act which will provide funding to support vital
services for children and families who would otherwise miss their
opportunities to experience healthy development and quality parent-
child interaction and to enter school prepared and ready to be
successful. Thank you for your support for ensuring that all parents
struggling to help their children succeed receive the support they need
to bring parent-child interaction, a supportive home environment,
healthy development, and the joys of reading, playing, learning, and
school success into their children's lives. Providing families with
high quality, research-validated home visiting services is a critical
component of successful school readiness, early childhood education,
and parent support efforts. It is truly a cost-effective way to ensure
that all children and their parents have the opportunity to be
successful.
Thank you for the opportunity to submit testimony.
The Parent-Child Home Program
Contact:
Sarah E. Walzer
Executive Director
The Parent-Child Home Program, Inc.
Garden City, NY

Statement of The Pew Center on the States
Pew Center on the States appreciates the opportunity to submit
written testimony in support of quality, evidence-based home visiting
programs. We fully support President Obama's budget recommendation to
help states implement, expand and establish quality voluntary home
visiting models, and commend this Subcommittee for convening a panel of
experts in order to raise awareness of the major issues surrounding
home visitation. Pew would like to recognize Chairman McDermott and
Representatives Davis (IL), and Platts (PA) for their continued
leadership on this very important strategy that can help ensure that
new and expectant families are given the tools that they need to become
healthy, productive citizens.
HIGH-LEVEL OVERVIEW
Strong families create strong communities. Federal guidance and
support can help lead, refine and focus state efforts so that state and
federal investments in home visiting have measurable, positive
outcomes. In this testimony we outline recommended principles for
establishing a federal evidence-based home visiting policy, including:

1. Rigorous research findings should guide federal home visiting
resource allocation.
2. Federal guidance and federal funding are critical to strengthen
and expand evidence-based state home visiting programs.
3. States should have flexibility to utilize public health
insurance as part of home visiting finance strategy.

Below are a description of Pew's home visiting initiative and
federal policy recommendations.
BACKGROUND:
The Pew Center on the States Home Visiting Campaign
Responsible and responsive parenting is not just good for children,
it's good for society. Recent research has proven the common sense
notion that experiences in early childhood--good or bad, starting even
before a baby is born--can last a lifetime. Families who create a
nurturing, safe and healthy environment endow their children with
protective factors that set them on a path toward lifelong success.
Public investments that help strengthen new and expectant families
yield long-term benefits by eliminating need for costly remedial
services associated with poor childhood development.
The Pew Charitable Trusts applies the power of knowledge to solve
today's most challenging problems. The Pew Center on the States, a
division of the Pew Charitable Trusts, advances effective policy
approaches to critical issues facing states by raising issue awareness
and advancing effective policy solutions through research, advocacy and
technical assistance. Pew's home visiting campaign, led by Project
Director John Schlitt, was created to provide states with an in-depth,
data-driven look into the urgent need to expand access to quality,
evidence-based home visiting programs for new and expectant low-income
families.
In January 2009, Pew launched a national campaign to increase low-
income families' access to quality, proven home visiting programs. This
five-year effort includes a dual focus on research and advocacy.
Home Visiting Research Agenda
In partnership with the Doris Duke Charitable Foundation, we will
consider and commission research to help policymakers answer critical
questions about the ever expanding home visiting evidence base. This
research will include a 50-state report of home visiting policies,
programs and funding to be published in 2010 as a baseline for marking
states' progress, and to provide policymakers with an in-depth, data-
driven look into the urgent need to expand access to quality, research-
based home visiting programs to low-income families.
State Policy Advocacy Campaigns
Simultaneously, Pew will engage in advocacy campaigns in 4-6 states
to encourage public investment in proven home visiting services that
help low-income parents fulfill their role as their child's first and
best teacher. We will prioritize our work in states that have committed
to assuring expansion of quality home visiting programs to all eligible
low-income families.
The Case for Home Visiting
Policymakers and other leaders across the country should be
concerned about the widespread, resonating effects of negative
experiences, maltreatment, and neglect in childhood. A 2008 report from
the Centers for Disease Control and Prevention (CDC) states that
intense, repeated negative experiences can disrupt early brain
development to the point of permanently impairing the nervous and
immune systems and, in extreme cases, cause the child to develop a
smaller brain.\i\ Similarly, researchers from the National Scientific
Council on the Developing Child at Harvard University have shown that
when a child is exposed to intense stress early in life--due to abuse,
neglect or prolonged lack of nurturing--high levels of hormones
produced in the brain can lead to increased chances for cognitive and
emotional deficits.\ii\
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\i\ Middlebrooks JS and Audage NC ``The Effects of Childhood Stress
on Health Across the Lifespan.'' Centers for Disease Control and
Prevention, National Center for Injury Prevention and Control (2008).
\ii\ National Scientific Council on the Developing Child.
``Excessive Stress Disrupts the Architecture of the Developing Brain.
Working Paper No. 3'' (2005) http://www.developingchild.net/pubs/wp/
Stress_Disrupts_Architecture_Developing_Brain.pdf. (Accessed June 17,
2009).
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Federal, state and local leaders are challenged with addressing the
social and financial effects of maltreatment and negative childhood
experiences. As they seek to build a healthy, productive citizenry, our
leaders are increasingly aware of the growing costs of bad outcomes for
adolescents and adults--in criminal justice, health care, foster care
and more--and of the direct relationship between interventions in the
earliest stages of life and children's chances of becoming successful
adults.
Child maltreatment and neglect is a serious issue that warrants
public attention. Both men and women who reported experiencing multiple
types of abuse during early childhood were more likely to be a part of
unintended pregnancies before the age of twenty. Children born to
teenage mothers have higher health care costs and are more likely to
become part of the foster care and juvenile justice systems. A report
by the National Campaign to Prevent Teen Pregnancy, authored by the
chairman of the economics department at the University of Delaware,
showed that the taxpayers' tab for teen childbearing in 2006 alone was
calculated at over $9 billion.\iii\ Children born at low birth weight
and without health insurance experience dramatically poorer health as
adults, a result that is likely to generate significant costs in terms
of medical care and lower productivity.\iv\
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\iii\ Hoffman, S, ``By the Numbers: The Public Costs of Teen
Childbearing'' (2006). National Campaign to Prevent Teen and Unplanned
Pregnancy. Available online at: http://www.thenationalcampaign.org/
resources/reports.aspx#costs.
\iv\ Lewit, EM., et al, ``The Direct Cost of Low Birth Weight,''
The Future of Children, 5 (1), (1995). http://www.futureofchildren.org/
information2826/information_show.htm?doc_id=79879 (Accessed June 17,
2009).
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Low birth weight, child abuse and neglect, school failure and
incarceration are devastating to families, put a tremendous strain on
state budgets and are often preventable. A preponderance of evidence
supports the fact that an ounce of prevention may be worth much more
than a pound of cure. Early intervention is absolutely necessary if we
want to ensure the health, stability, and vitality of our children, our
families, our communities and our nation.
Quality, Evidence-Based Home Visiting Works
Quality evidence-based home visiting programs offer families a
social support network that--when properly implemented and matched to
family need--can dramatically decrease negative outcomes. Pairing new
and expectant families with trained professionals to provide parenting
information, resources and support during pregnancy and throughout
their child's first three years serves to strengthen parent-child
relationships, increase early language and literacy skills and reduce
child abuse and neglect--significant outcomes that can help ease the
strain on state budgets.\v\ Economists have calculated a pay-off of up
to $5.70 on each dollar invested in the Nurse Family Partnership, a
high-quality home visitation program serving at-risk families.\vi\
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\v\ See, for example, Sweet, MA and Appelbaum, M ``Is home visiting
an effective strategy? A meta-analytic review of home visiting programs
for families with young children.'' Child Development 75(5):1435-1456,
(2005).; U.S. Department of Health and Human Services. Youth Violence:
A Report of the Surgeon General. Washington, DC: Department of Health
and Human Services, (2001).; Kendrick D, et al. ``Does home visiting
improve parenting and the quality of the home environment? A systematic
review and meta-analysis.'' Archives of Disease in Childhood,
82(6):443-451. (2000).
\vi\ Karoly, Lynn A., et al. Investing in Our Children: What We
Know and Don't Know about the Costs and Benefits of Early Childhood
Interventions. (Santa Monica, CA: RAND, 1998).
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That said, not all home visiting efforts are created equal:
research shows that poorly designed and inconsistently implemented
programs will not offer the same return on a state's investment, nor
necessarily result in positive outcomes for families. The most
significant cost-savings from home visiting occur when low-income
families are served by proven programs that employ well-trained
professional home visiting staff.
DETAILED RECOMMENDATIONS
Pew believes that public investments in social capital should be
backed by strong evidence--that is, programs should show evidence of
effectiveness supported with rigorous, well designed evaluations of
program implementation and outcomes.
Particularly in difficult economic times, when stress on families
and state budgets is heightened, states can benefit greatly from
federal leadership and support in creating and implementing effective
home visiting programs. States need support in order to set quality
standards for home visiting programs, monitor and assess program
fidelity and track program resources and outcomes.
While states will choose to implement home visiting models that
best fit their individual needs, they face several universal challenges
in attempting to identify and support quality, evidence-based home
visiting programs. Such challenges provide an opportune moment for
federal leadership in setting standards for public investment in home
visiting.
To determine what warrants substantial public investment in large-
scale implementation or program replication, Pew supports prioritized
funding to programs that have demonstrated positive outcomes with
randomized controlled trial or rigorous quasi-experimental design with
equivalent comparison groups. While programs with the strongest
evidence are best positioned for scaled-up implementation, additional
support is needed to help promising programs meet the high evidentiary
standard necessary for large-scale investments.
The state of Washington, for example, uses evidentiary standards to
prioritize funding allocations for home visiting programs. The state
adopted criteria for assessing home visiting evaluation research on
child abuse and neglect prevention outcomes and then established three
levels: best, good and promising. This evidence-based approach allows
the state to:

Prioritize program funding to programs proven to yield the
highest return on investment;
Support research for promising programs with a sound
theoretical basis but lower evidentiary standards to determine program
efficacy; and
Continuously monitor programs for quality improvement.

Pew proposes the following to guide state and federal investment in
the home visiting arena:

1. Rigorous research findings should guide federal home visiting
resource allocation.
Only high-quality, evidence-based home visiting programs
will garner significant cost-savings in the future, as well as an
improved quality of life for our children.
Federal policy should support states in implementing
evidence-based programs.
Federal policy should establish standards for state
evaluations to rigorously assess home visiting child and family
outcomes that document program impacts.
Priority should be given to models that meet the highest
evidentiary standards and ensure fidelity in implementation.
Federal and state policy should support rigorous
evaluation of promising programs that may not fully meet the standard
of evidence needed to warrant large-scale investments.
2. Federal guidance and federal funding are critical to strengthen
and expand state home visiting programs.
The federal government should provide states with
financial support to strengthen and expand effective home visiting.
States should be supported in their critical role of
ensuring that communities implement evidence-based home visiting
programs with fidelity. Specifically, federal funding should support
state infrastructure for: 1) the coordination of home visiting policies
and resources across state public health, child welfare, and early
education programming for new and expectant parents; 2) evaluation and
monitoring of quality and outcome performance measures; 3) program
implementation support; and 4) home visiting staff training.
A significant secondary outcome of a federal home visiting
initiative should be to influence the quality of all home visiting
services across the states, whether federally funded or not. States can
establish uniform quality standards and performance measures for all
home visiting programs such as well tested parent education curricula,
target populations, core process and outcome data elements, staff
qualifications, service duration and frequency, training, intake and
referral.
3. States should have flexibility to utilize public health
insurance as part of home visiting finance strategy.
Public health insurance for low-income families should
cover home visiting services to help new and expectant families
appropriately access medical, mental health and dental services,
monitor the health and wellbeing of mom and baby, and identify early
any potential developmental delays. As federal policymakers look toward
healthcare reform and modernization, they should include Medicaid and
SCHIP provisions that support home visitation as a preventive program.

Conclusion
Voluntary evidence-based home visiting programs are proven to
strengthen parent-child relationships, increase early language and
literacy skills and reduce child abuse and neglect--positive outcomes
that can help ease the strain on state budgets.
Pew's Home Visiting Initiative will advance nonpartisan, pragmatic
state policy solutions in home visiting. We would be pleased to serve
as a resource to your committee as this issue moves forward. We
sincerely thank the Subcommittee for the opportunity to submit
testimony in full support of federal funding for quality voluntary
evidence-based home visiting programs.

Statement of Voices for America's Children
Chairman McDermott, Ranking Member Linder and all members of the
subcommittee, Voices for America's Children thanks you for the
opportunity to submit comments for the June 9th hearing examining
proposals to provide federal funding for early childhood home
visitation programs. This hearing, and the associated legislation,
continues the subcommittee's efforts to ensure that all children are
safe, free from harm, healthy and able to thrive in their homes and
communities.
Voices for America's Children (Voices) is a national child advocacy
organization committed to speaking up for the lives of children at all
levels of government. Comprised of 60 multi-issue member organizations
across 45 states the Voices network seeks the promotion of effective
public policies that improve the lives of children at the local, state
and national level. It is the vision for Voices that all public
policies must further the positive and healthy development of all
children.
To achieve this vision requires:

Equity and Diversity: All children achieve their full
potential in a society that closes opportunity gaps and recognizes, and
values, diversity;
Health: All children receive affordable, comprehensive,
high-quality health care;
School Readiness: All children, and their parents, receive
the services and supports to enable them to start school prepared for
success;
School Success: All children have an equal opportunity to
attend an adequately and equitably financed public school meeting
rigorous academic standards aligned with the needs of the 21st Century
workforce;
Safety: All children are safe in their homes and
communities from all forms of abuse, neglect, exploitation and
violence, avoid risky behaviors, and contribute to community well-
being; and
Economic Stability: All children live in families that can
provide for their needs and make investment in their future.

The opportunity of home visiting, and of the Early Support for
Families Act, is a strong avenue to assist in achieving this vision.
Voices applauds the efforts of Chairman McDermott, along with
committee member Danny Davis and Representative Todd Russell Platts in
crafting legislation that advances with President Obama's announced
commitment to reach 450,000 families with evidence-based home
visitation services within the next decade when fully implemented.
Representatives Davis and Platts should also be acknowledged for their
continued efforts and commitment in previous congressional sessions
championing the Education Begins At Home Act--the precursor to the
Early Support for Families Act. This bipartisan effort, along with
Senators Kit Bond, Patty Murray and former Senator Hillary Rodham
Clinton served as the galvanizing forces for this new opportunity.
Voices for America's Children (Voices) salutes Chairman McDermott,
and other committee members, for maintaining their commitment in noting
that ``more needs to be done'' following the passage of the Fostering
Connections to Success and Increasing Adoptions Act (P.L. 110-351) that
is now providing permanency options for thousands of children currently
in foster care. The legislation now pending before the subcommittee,
The Early Support for Families Act (H.R. 2667) seeks to improve the
lives of children and families before they are in harm's way, and allow
for optimal development of health and early learning. Voices
enthusiastically supports the offered legislation for the opportunity
of mandatory funding for the establishment, or expansion, of high
quality evidence-based home visitation programs that will make lasting
impacts on children, families and communities.
As the Congress continues efforts to fulfill the president's goal
of ensuring that every child enters school ready to succeed, effective
home visiting must be a part of this picture, though must not be the
only component. These supports must be provided in conjunction, and
coordination with Head Start and Early Head Start, the Child Care
Development Block Grant, and high quality Pre-K opportunities for
children, and assurances must be made that these programs are funded at
levels to dramatically increase outreach and service delivery.
Home visiting services provided in isolation will not achieve the
goal of ensuring that every child has a safe start in life and enters
school ready to learn.
Voluntary home visiting provides early education and support to
families where they are--in their homes and communities--in a non-
threatening environment allowing for optimal outcomes. The growth of
home visiting services over the past two decades is driven through a
solid evidence base, and community focus, as an effective early-
intervention strategy to enhance child well-being. The president's
initiative, and the offered legislation, begins to follow through on
recommendations initially developed by the United States Advisory Board
on Child Abuse and Neglect in 1991 calling for voluntary, universal
home visiting for every family in the country. As part of their
findings, the Advisory Board noted that ``no other single intervention
has the promise of home visitation.'' \1\
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\1\ U.S. Department of Health and Human Services, U.S. Advisory
Board on Child Abuse and Neglect (1991). Creating caring communities:
Blueprint for an effective federal policy for child abuse and neglect.
Washington, DC: U.S. Government Printing Office.
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As the Congress undertakes health reform this year, Voices urges
all members to make children paramount in this debate while
acknowledging that child maltreatment is a major public health concern.
The Adverse Childhood Experiences Study (ACES), with 17,000
participating adults, finds that adults with exposure to adverse
childhood experiences including abuse, physical or emotional neglect,
or household dysfunction, are more likely to have negative health
outcomes as adults. These outcomes include greater likelihood of
alcoholism and illicit drug use, risk for intimate partner violence,
sexual promiscuity, smoking, suicide attempts and unintended
pregnancies.\2\
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\2\ Felitti, V.J., Anda, R.F., et al. (1998). Relationship of
childhood abuse and household dysfunction to many of the leading causes
of death in adults. American Journal of Preventative Medicine, 14 (4);
245-58.
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Investing in home visiting was also recommended by the United
States Centers for Disease Control and Prevention (CDC) Task Force on
Community Prevention Services as an effective strategy to combat child
maltreatment.\3\ Just last year, the CDC's National Center for Injury
Prevention and Control cited home visiting as an effective strategy for
the prevention of adverse childhood experiences.\4\
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\3\ Hahn, R.A. (2003). First reports evaluating the effectiveness
of strategies for preventing violence: Early childhood home visitation.
Morbidity and Mortality Weekly Report. 52(RR14);1-9. Atlanta, GA:
Centers for Disease Control and Prevention.
\4\ Middlebrooks, J.S., Audage, N.C., The effects of childhood
stress on health across the lifespan. Atlanta, GA. Centers for Disease
Control and Prevention, National Center for Injury Prevention and
Control.
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The evidence surrounding the effectiveness of home visiting
services continues to grow since the initial Advisory Board report was
released in 1991. Analysis of home visiting programs have shown less
occurrence of child maltreatment, family engagement in positive
parenting practices for optimal child development, and stable,
nurturing environments for children.\5\
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\5\ Daro, D. (2009). Home visitation: The cornerstone of effective
early intervention. Public testimony provided to the U.S. House Ways
and Means Subcommittee on Income Security and Family Support on
proposals to provide federal funding for early childhood home
visitation programs. June 9, 2009.
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Longitudinal studies of programs also demonstrate a reduction in
later adverse experiences for children including juvenile crime
delinquency and substance abuse use, as well as improvements in school
performance and increased graduation rates.\6\ Other studies show that
participating children demonstrate improved early literacy, language
development, problem solving, social awareness and competence, and
basic skill development.\7\
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\6\ Ibid.
\7\ Administration for Children and Families (2003). Research to
practice: Early head start home-based services. Washington, DC:
Department of Health and Human Services; New York University Study on
School Readiness of Parent-Child Home Program Participants (2003);
Coleman, M., Rowland, B., & Hutchins, B., (1997) Parents-As-Teachers:
Policy implications for early school intervention. Paper presented at
the 1997 annual meeting of the National Council of Family Relations,
Crystal City, VA, Nov. 1997.
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Home visiting services also demonstrate cost savings across a
number of social factors. Significant savings are found through reduced
Medicaid expenditures, reduction in the need for special education
services,\8\ stronger birth outcomes \9\ and reduction in low birth-
weight babies,\10\ and substantial increased work potential.\11\
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\8\ Hevesi, A.G., (2001). Building foundations: Supporting parental
involvement in a child's first years. Report from the New York Office
of the Comptroller; Lazar, I., Darlington, R., Murray, H., et al.
(1982). Lasting effects of early education: A report from the
consortium for longitudinal studies. Monographs of the Society for
Research in Child Development, 47, 2/3; Pfannenstiel, J., Lambson, T.,
& Yaarnell, V. (1991). Second wave of the parents as teachers program.
Overland Park, KS: Research and Training Associates.
\9\ Mitchel-Herzfeld, S., Izzo, C., Green, R., Lee, E. & Lowenfels,
A. (2005). Evaluation of healthy families New York: First year program
impacts. Albany, NY: Office of Child and Family Services, Bureau of
Evaluation and Research and the Center for Human Services Research,
University of Albany.
\10\ Eunju, L., Mitchell-Herzfeld, S., Lowenfels, A.A., Green, R.,
et al. (2009). Reducing low birth weight through home visitation: A
randomized controlled trial. American Journal of Preventative Medicine,
36, (2), 154-160; Rogowski, J. (1998). Cost-effectiveness of care for
very low birth weight infants. PEDIATRICS, 102, 1, 35-43.
\11\ Hevesi, A.G., (2001). Building foundations: Supporting
parental involvement in a child's first years. Report from the New York
Office of the Comptroller; Bartik, T.J., (2008). The economic
developments of early childhood. Partnership for America's Economic
Success: Washington, DC.
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Analysis from Prevent Child Abuse America estimates that the
combined direct and indirect costs of child maltreatment alone exceed
$104 billion each year. This includes more than $33 billion in direct
costs associated with foster care, hospitalization, mental health
services and law enforcement. Another $70 billion is spent each year
for indirect costs including the loss of work productivity, chronic
health problems, special education, and involvement within the criminal
justice system.\12\ For every federal dollar spent for children in out
of home care, a meager 15 cents of federal supports is focused on child
maltreatment prevention and protection. With the current federal child
welfare financing system providing little in opportunities to provide
primary prevention activities, and with greater supports only available
only after a child is removed, the opportunity for states to access the
proposed supports included within the Early Support for Families Act
will serve as the greatest mandatory investment in child abuse
prevention services in federal history.
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\12\ Wang, C.T. and Holton, J. (2007). Total estimated costs of
child abuse and neglect in the United States. Chicago, IL: Prevent
Child Abuse America.
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Voices supports provisions within the Early Support for Families
Act that will provide up to $2 billion of mandatory funding when fully
implemented. These funds, to be administered through the creation of a
new Title IV-B, Subpart 3, would provide state-based grants for the
expansion, or establishment of evidence-based home visitation programs
following the completion of a statewide needs assessment.
As efforts to adopt the legislation advance through Congress,
potentially as part of the health reform debate, Voices hopes that the
funding for programs determined to meet the ``strongest evidence of
effectiveness'' are determined through those programs who have
continued to demonstrate significant positive outcomes for children and
families that are consistent with the outcomes being sought as measured
through findings of well-designed rigorous evaluations. In order to
maintain the development of high-quality programs, Voices also hopes
that those programs seeking federal supports meet, at a minimum, core
requirements related to prenatal health or positive child healthy
development, promote appropriate social emotional development, enhance
school readiness and academic success, increase family stability or
economic stability, lead to reductions in child maltreatment or
involvement within the juvenile justice system, or other demonstrated
outcomes that improves a child's well-being.
These programs should also ensure that ongoing, organized training
and professional development is provided for employees, and that the
models themselves are continually seeking to improve program delivery.
To achieve the president's commitment of promoting to the highest
available standard for the programs involved, Voices also hopes that
efforts are made that allow continued training and technical assistance
are available via the Department of Health and Human Services to assist
states in their implementation efforts. Voices also seeks a set aside
of federal monies to assist states in their ongoing program development
and evaluation of funded programs.
On behalf of child advocates across the county, and the children
and families we speak for, Voices again applauds the efforts to date to
establish a new federal program dedicated for high quality home
visitation programs with associated mandatory funding. Voices looks
forward to working with the committee, and all members of congress, to
ensure adoption of this critically important legislation. Please let us
know if we may be of any assistance in this endeavor.

Prepared Child Welfare League of America

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Prepared Fight Crime

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Prepared Sharon Sprinkle

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