    [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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    52-502 PDF                       WASHINGTON : 2010

    For sale by the Superintendent of Documents, U.S. Government Printing
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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
    between various electronic formats may introduce unintentional errors
    or omissions. Such occurrences are inherent in the current publication
    process and should diminish as the process is further refined.

                                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

                                  ----------

                             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.

    DETAILS FOR SUBMISSION OF WRITTEN COMMENTS:

        Please Note: Any person(s) and/or organization(s) wishing to submit
    for the hearing record must follow the appropriate link on the hearing
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    ``Committee Hearings''. Select the hearing for which you would like to
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    the final page. ATTACH your submission as a Word or WordPerfect
    document, in compliance with the formatting requirements listed below,
    by close of business Tuesday, June 23, 2009. Finally, please note that
    due to the change in House mail policy, the U.S. Capitol Police will
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    questions, or if you encounter technical problems, please call (202)
    225-1721.

    FORMATTING REQUIREMENTS:

        The Committee relies on electronic submissions for printing the
    official hearing record. As always, submissions will be included in the
    record according to the discretion of the Committee. The Committee will
    not alter the content of your submission, but we reserve the right to
    format it according to our guidelines. Any submission provided to the
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    written comments must conform to the guidelines listed below. Any
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        1. All submissions and supplementary materials must be provided in
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    Committee relies on electronic submissions for printing the official
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        2. Copies of whole documents submitted as exhibit material will not
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        3. All submissions must include a list of all clients, persons,
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        The Committee seeks to make its facilities accessible to persons
    with disabilities. If you are in need of special accommodations, please
    call 202-225-1721 or 202-226-3411 TTD/TTY in advance of the event (four
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        Note: All Committee advisories and news releases are available on
    the World Wide Web at http://waysandmeans.house.gov.

        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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    and Behavioral Disorders Among Young People: Progress and
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        Olds, D., Henderson, C., Chamberlin, R., & Tatelbaum, R. (1986).
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        Olds, D., Henderson, C.R., Kitzman, H., & Cole, R. (1995). Effects
    of prenatal and infancy nurse home visitation on surveillance of child
    maltreatment. Pediatrics, 95(3), 365-372.
        Olds, D., Eckenrode, J., Henderson, C., Cole., R., Eckenrode, J.,
    Kitzman, H., Luckey, D., Pettitt, L., Sidora, K., Morris, P., & Powers,
    J. (1998). Long-term effects of home visitation on maternal life
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        Olds, D., Robinson, J., O'Brien, R., Luckey, D., Pettitt, L.,
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    A. (2002). Home visiting by paraprofessionals and by nurses: a
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        Pfannenstiel, J., Seitz, V., & Zigler, E. (2002). Promoting school
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        Seitz, V., Rosenbaum, L. & Apfel, N. (1985). Effects of family
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        Shonkoff, J. & Phillips, D. (2000). From Neurons to Neighborhoods:
    The Science of Early Childhood Development. National Academy Press,
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        Sweet, M., and Appelbaum, M. (2004). Is home visiting an effective
    strategy? A meta-analytic review of home visiting programs for families
    with young children. Child Development, 75, 1435-1456.
        Reynolds, A., Temple, J., Robertson, D., & Mann, E. (2001). Long-
    term effects of an early childhood intervention on educational
    achievement and juvenile arrest: A 15-year follow-up of low-income
    children in public schools. JAMA, 285(18), 2339-2346.
        U.S. Department of Health and Human Services, U.S. Advisory Board
    on Child Abuse and Neglect. (1990). Child Abuse and Neglect: Critical
    First Steps in Response to a National Emergency. Washington, DC: U.S.
    Government Printing Office, August.
        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.
        Wagner, M. & Spiker, D., (2001). Multisite Parents as Teachers
    Evaluation: Experience and Outcomes for Children and Families. Menlo
    Park, CA: SRI, International. Available at www.sri.com/policy/cehs/
    early/pat.html
        Wasserman, M. (2006). Issue Brief: Implementation of Home
    Visitation Programs: Stories from the States. Chicago: Chapin Hall
    Center for Children.
        Williams, Stern & Associates. (2005). Health Families Florida:
    Evaluation Report January 1999-December 2003. Miami, FL: Author. http:/
    /www.healthyfamiliesamerica.org/research/index.shtml
        Zigler, E., Pfannenstiel, J.C., & Steitz, V. (2008). The Parents as
    Teachers program and school success: A replication and extension.
    Journal of Primary Prevention, 29, 103-120.

        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

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        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.
        [The information follows:]

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        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
    ---------------------------------------------------------------------------
        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
    ---------------------------------------------------------------------------
    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\
    ---------------------------------------------------------------------------
        \10\ http://www.nursefamilypartnership.org /content/
    index.cfm?fuseaction=showContent&contentID=4&navID=4
    ---------------------------------------------------------------------------
    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.
    ---------------------------------------------------------------------------
        \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\
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
        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
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
         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
    ---------------------------------------------------------------------------
        \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
    ---------------------------------------------------------------------------
    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
    ---------------------------------------------------------------------------
        \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
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
         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
    ---------------------------------------------------------------------------
        \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
    ---------------------------------------------------------------------------
    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
    ---------------------------------------------------------------------------
        \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
    ---------------------------------------------------------------------------
        \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
    ---------------------------------------------------------------------------
    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
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
         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
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
    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).

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        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.
    ---------------------------------------------------------------------------
        \i\ Monica of Lifelink in Bensenville, Illinois. (2008, November
    21). Home Visitors Celebration Lunch: Recognizing Success and
    Achievement.
    ---------------------------------------------------------------------------
        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.
    ---------------------------------------------------------------------------
        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.
    ---------------------------------------------------------------------------
    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
    ---------------------------------------------------------------------------
        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.
    ---------------------------------------------------------------------------
        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\
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
        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.
    ---------------------------------------------------------------------------
    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.
    ---------------------------------------------------------------------------
        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.
    ---------------------------------------------------------------------------
        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\
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
        \11\ Kay Johnson, State-based Home Visiting: Strengthening Programs
    through State Leadership. New York, NY: National Center for Children in
    Poverty, 2009.
    ---------------------------------------------------------------------------
        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\
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
        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.
    ---------------------------------------------------------------------------
        \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).
    ---------------------------------------------------------------------------
        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\
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
        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.
    ---------------------------------------------------------------------------
        \7\ Wang, CT, & Holton, J (2007). Total estimated cost of child
    abuse and neglect in the United States. Chicago, IL: Prevent Child
    Abuse America.
    ---------------------------------------------------------------------------
        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\
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
          A large, randomized control trial found less physical and
    psychological abuse for parents receiving home visitation services than
    control parents at one year.\9\
    ---------------------------------------------------------------------------
        \9\ Mitchell-Herzfeld et al. (2005). Evaluation of Healthy Families
    New York: First year program impacts. Office of Children and Family
    Services.
    ---------------------------------------------------------------------------
          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\
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
          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\
    ---------------------------------------------------------------------------
        \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\
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
        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\
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
        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\
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
         Participation in Parents as Teachers helps to close the
    achievement gap between children living in poverty and those from non-
    poverty households.\ii\
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
         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\
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
         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\
    ---------------------------------------------------------------------------
        \iv\ Pfannenstiel, J., Lambson, T., & Yarnell, V. (1991). Second
    wave study of the Parents as Teachers program. Overland Park, KS:
    Research & Training Associates.
    ---------------------------------------------------------------------------
         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\
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
         PAT parents were more involved in children's school
    activities and engaged their children more in home learning activities,
    especially literacy-related activities.\vi\
    ---------------------------------------------------------------------------
        \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\
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
        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.
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
        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:
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
        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\
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
        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\
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
        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.
    ---------------------------------------------------------------------------
        \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).
    ---------------------------------------------------------------------------
        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.
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
        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\
    ---------------------------------------------------------------------------
        \1\  ``A Policy Primer: Quality Pre-Kindergarten,'' Trust for Early
    Education, Fall 2004.
    ---------------------------------------------------------------------------
        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\
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
        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.
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
        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:

         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.

        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\
    ---------------------------------------------------------------------------
        \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).
    ---------------------------------------------------------------------------
        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\
    ---------------------------------------------------------------------------
        \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).
    ---------------------------------------------------------------------------
        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\
    ---------------------------------------------------------------------------
        \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).
    ---------------------------------------------------------------------------
        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\
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
        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\
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
        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\
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
        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\
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
        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\
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
        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\
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
        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.
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
        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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