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


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

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

                                HEARING

                               before the

           SUBCOMMITTEE ON INCOME SECURITY AND FAMILY SUPPORT

                                 of the

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

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                              JUNE 9, 2009

                               __________

                           Serial No. 111-24

                               __________

         Printed for the use of the Committee on Ways and Means

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                      COMMITTEE ON WAYS AND MEANS

                 CHARLES B. RANGEL, New York, Chairman

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

             Janice Mays, Chief Counsel and Staff Director

                   Jon Traub, Minority Staff Director

           SUBCOMMITTEE ON INCOME SECURITY AND FAMILY SUPPORT

                  JIM MCDERMOTT, Washington, Chairman

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

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Ways and Means are also, published 
in electronic form. The printed hearing record remains the official 
version. Electronic submissions are used to prepare both printed and 
electronic versions of the hearing record, the process of converting 
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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From the Committee homepage, http://waysandmeans.house.gov, select 
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the final page. ATTACH your submission as a Word or WordPerfect 
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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 
refuse sealed-package deliveries to all House Office Buildings. For 
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 
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files for review and use by the Committee.
      
    1. All submissions and supplementary materials must be provided in 
Word or WordPerfect format and MUST NOT exceed a total of 10 pages, 
including attachments. Witnesses and submitters are advised that the 
Committee relies on electronic submissions for printing the official 
hearing record.
      
    2. Copies of whole documents submitted as exhibit material will not 
be accepted for printing. Instead, exhibit material should be 
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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 
business days notice is requested). Questions with regard to special 
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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.
References
    Allen, L. & Sethi, A. (2003). An evaluation of graduates of the 
Parent-Child Home Program at Kindergarten Age. The Child and Family 
Policy Center: New York University.
    American Academy of Pediatrics, Council on Child and Adolescent 
Health. (1998). The role of home-visitation programs in improving 
health outcomes for children and families. Pediatrics, 10(3), 486-489.
    American Evaluation Association (AEA) Evaluation Policy Task Force. 
(2009). An Evaluation Roadmap for a More Effective Government. Author: 
Fairhaven, MA.
    Anisfeld, E., Sandy, J. & Guterman, N. (2004). Best Beginnings: A 
Randomized Controlled Trial of a Paraprofessional Home Visiting 
Program. Final Report submitted to the Smith Richardson Foundation and 
New York State Office of Children and Family Services. December. http:/
/www.healthyfamiliesamerica.org/research/index.shtml
    Bradley, R. & Gilkey, B. (2002). The impacts of the Home 
Instructional Program for Preschool Youngsters (HIPPY) on school 
performance in 3rd and 6th grade. Early Education 
and Development, 13(3), 302-311.
    Campbell, F. A., Ramey, C. T., Pungello, E. P., Sparling, J., & 
Miller-Johnson, S. (2002). Early Childhood Education: Young Adult 
Outcomes from the Abecedarian Project. Applied Developmental Science, 
6, 42-57.
    Chaffin, M. (2004). Is it time to rethink Healthy Start/Healthy 
Families? Child Abuse and Neglect, 28, 589-595.
    Coalition for Evidence-Based Policy. Early Childhood Home 
Visitation Program Models: An Objective Summary of the Evidence About 
Which Are Effective. Washington, D.C.: Author.
    Cohn, A. (1983). An Approach to Preventing Child Abuse. Chicago, 
IL: National Committee to Prevent Child Abuse.
    Daro, D. (1993). Child maltreatment research: Implications for 
program design. In Cicchetti, D & Toth, S. (eds.). Child Abuse, Child 
Development, and Social Policy. Norwood, NJ: Ablex Publishing 
Corporation, 331-367.
    Daro, D. (2000). Child abuse prevention: New directions and 
challenges. Journal on Motivation, Vol. 46, Nebraska Symposium on 
Motivation. Lincoln, NB: University of Nebraska Press, 161-219.
    Daro, D. & Cohn-Donnelly, A. (2002). Charting the waves of 
prevention: Two steps forward, one step back. Child Abuse and Neglect, 
26, 731-742.
    Daro, D. & McCurdy, K. (In press). Interventions to prevent child 
maltreatment. In
    Doll, L., Mercy, J., Hammond, R., Sleet, D., & Bonzo, S. (eds). 
Handbook on Injury and Violence Prevention Interventions. New York: 
Kluwer Academic/Plenum Publishers,
    DuMont, K., Mitchell-Herzfeld, S., Greene, R., Lee, E., Lowenfels, 
A., Rodriguez, M., & Dorabawila, V. (2008). Healthy Families New York 
(HFNY) randomized trial: Effects on early child abuse and neglect. 
Child Abuse and Neglect, 32, 295-315.
    Elmer, E. (1977). Fragile Families, Troubled Children: The 
Aftermath of Infant Trauma. Pittsburgh, PA: University of Pittsburgh 
Press.
    Fergusson, D., Grant, H., Horwood, & Ridder, E., (2005). Randomized 
trial of the Early Start Program of home visitation. Pediatrics, 11(6), 
803-809.
    Geeraert, L., Van den Noorgate, W., Grietens, H., and Onghena, P. 
(2004). The effects of early prevention programs for families with 
young children at risk for physical child abuse and neglect: A meta-
analysis. Child Maltreatment, 9(3), 277-291.
    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. July. Available at 
www.ced.org/projects/kids.shtml
    Guterman, N. (2001). Stopping Child Maltreatment Before It Starts: 
Emerging Horizons in Early Home Visitation Services. Sage, Thousand 
Oaks.
    Hahn, R., Bilukha, O., Crosby, A., Fullilove, M., Liberman, A., 
Moscicki, E., Snyder, S., Tuma, F., Schofield, A., Corso, Ph., & Briss, 
P. (2003). First reports evaluating the effectiveness of strategies for 
preventing violence: Early childhood home visitation. Findings from the 
Task Force on Community Prevention Services. Morbidity and Mortality 
Weekly Report, 52(RR-14), 1-9.
    Johnson, K. (2001). State-based home visitation: Strengthening 
programs through state Leadership. Washington, D.C.: National Center 
for Children in Poverty.
    Heckman, J. (2000). Policies to foster human capital. Research in 
Economics. 54, 3-56.
    Karoly, L., Kilburn, M.R., & Cannon, J. Early Childhood 
Interventions: Proven Results, Future Promise. Report prepared for the 
PNC Financial Services Group. Santa Monica, CA: Rand Corporation.
    Kauffman Foundation. (2002). Set for success: Building a strong 
foundation for school readiness based on the social-emotional 
development of young children. The Kauffman Early Education Exchange, 
1(1).
    Kempe, H. (1976). Approaches to preventing child abuse: the health 
visitor concept. American Journal of Diseases of Children, 130, 940-
947.
    Kitzman, H., Olds, D., Henderson, C., Hanks, C., Cole, R., 
Tatelbaum, R., McConnochie, K., Sidora, K., Luckey, D., Shaver, D., 
Engelhart, K., James, L., Barnard, K. (1997). Effects of prenatal and 
infancy home visitations by nurses on pregnancy outcomes, childhood 
injuries and repeated childbearing. Journal of the American Medical 
Association, 278 (22), 644-652.
    Klagholz, D. (2005). Starting Early Starting Smart: Final Report. 
Great Falls, VA: Donna D. Klagholz & Associates, LLC. http://
www.healthyfamiliesamerica.org/research/index.shtml
    LeCroy & Milligan Associates, Inc. (2005). Healthy Families Arizona 
Evaluation Report 2005. Tucson, AZ: Author. http://
www.healthyfamiliesamerica.org/research/index.shtml
    Levenstein, P., Levenstein, S. & Oliver, D. (2002). First grade 
school readiness of former child participants in a South Carolina 
replication of Parent-Child Home Program. Journal of Applied 
Developmental Psychology, 23, 331-353.
    Levenstein, P., Levenstein, S., Shiminski, J., & Stolzberg, J. 
(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.
    Love, et al., (2009). The Early Head Start Evaluation: Impacts at 
the end of the program, two years later, and the context for ongoing 
research. Poster prepared for the EHS Poster Symposium, Biennial 
Meeting of the Society for Research in Child Development, Denver, CO., 
April 2.
    Love, J et al. (2002). Making a difference in the lives of infants 
and toddlers and their families: The impacts of Early Head Start, Vol. 
I, Final Technical Report. Princeton, N.J.: Mathematica Policy 
Research, Inc., and New York, N.Y.: Columbia University's Center for 
Children and Families at Teachers College.
    McCormick, M., Brooks-Gunn, J., Buka, S., Goldman, J., Yu, J., 
Salganik, M., Scott, D., Bennett, F., Kay, L., Bernbaum, J., Bauer, C., 
Martin, C., Woods, E., Martin, A., Casey, P. (2006). Early intervention 
in low birth weight premature infants; results at 18 years of age for 
the Infant Health and Development Program. Pediatrics, 117(3), 771-
780).
    Mitchel-Herzfeld, S., Izzo, C., Green, R., Lee, E., & Lowenfels, 
A., (2005). Evaluation of Healthy Families New York (HFNY): 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. February. http://
www.healthyfamiliesamerica.org/research/index.shtml
    National Academy of Sciences. (2009). Preventing Mental, Emotional 
and Behavioral Disorders Among Young People: Progress and 
Possibilities. National Academies Press: Washington, D.C.
    Olds, D., Henderson, C., Chamberlin, R., & Tatelbaum, R. (1986). 
Preventing child abuse and neglect: A randomized trial of nurse home 
visitation. Pediatrics, 78(1), 65-78.
    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 
course, child abuse and neglect and children's arrests: Fifteen-year 
follow-up of a randomized trial. Journal of the American Medical 
Association, 278(8), 637-643.
    Olds, D., Robinson, J., O'Brien, R., Luckey, D., Pettitt, L., 
Henderson, C., Ng, R., Sheff, K., Korfmacher, J., Hiatt, S., 7 Talmi, 
A. (2002). Home visiting by paraprofessionals and by nurses: a 
randomized, controlled trial. Pediatrics, 110:3 (September), 486-496.
    Pfannenstiel, J., Seitz, V., & Zigler, E. (2002). Promoting school 
readiness: The role of the Parents as Teachers program. NHSA Dialog: A 
Research to Practice Journal for the Early Intervention Field, 6, 71-
86.
    Seitz, V., Rosenbaum, L. & Apfel, N. (1985). Effects of family 
support intervention: A ten-year follow-up. Child Development, 56, 376-
391.
    Schweinhart, L. (2004). The High/Scope Perry Preschool Study 
through age 40: summary, conclusions and frequently asked questions. 
http://www.highscope.org/Research/PerryProject/PerryAge40SumWeb.pdf.
    Shonkoff, J. & Phillips, D. (2000). From Neurons to Neighborhoods: 
The Science of Early Childhood Development. National Academy Press, 
Washington, D.C.
    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
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Nurse-Family Partnership
    Under the Nurse-Family Partnership program, nurses conduct a series 
of home visits to low-income, first-time mothers, starting during 
pregnancy and continuing through the child's second birthday. Some NFP 
research cites reductions in smoking, but there are few references to 
use of alcohol or other drugs. In one of the most recent evaluations of 
NFP, conducted by the program's original designers, substance use by 
mothers was assessed and summarized:
    Earlier reported impacts of the Elmira program on `maternal 
behavioral problems due to substance abuse' [was] . . . no longer 
statistically significant in the new analysis.\10\
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    \10\ http://www.nursefamilypartnership.org /content/
index.cfm?fuseaction=showContent&contentID=4&navID=4
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Parents as Teachers
    Although Parents as Teachers (PAT) models emphasize equipping 
parents to understand child development and include developmental 
screening, there is no reference to prenatal exposure or substance 
abuse-related outcomes in the research summaries published by 
(PAT).\11\ However, a recently issued guide to working with children 
with special needs briefly discusses fetal alcohol effects.
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    \11\ http://www.parentsasteachers.org /atf/cf/%7B00812ECA-A71B-
4C2C-8FF3-8F16A5742EEA%7D/ Research--Quality--Booklet.pdf
---------------------------------------------------------------------------
Why substance abuse must be addressed
Because substance abuse affects developmental outcomes and school 
        readiness
    Home visitation programs often cite school readiness as a major 
goal. In seeking to serve children and families with high risk factors, 
the overlapping group of children living with substance-abusing parents 
and those who were prenatally exposed are at considerably greater risk 
for developmental delays, behavior problems, and difficulties as they 
enter school. A recent study of children whose school attendance is 
substandard noted that parental substance abuse can be a contributing 
factor in poor attendance; \12\ again, one in eleven children lives in 
a family where substance abuse is serious enough to be classified as 
alcoholism or chemical dependency. But with the exception of the above-
mentioned HFA program that was linked to Starting Early, Starting 
Smart, there are few examples of home visitation models that directly 
address these risks.
---------------------------------------------------------------------------
    \12\ H. Chang, and M. Romero, (2008) Present, Engaged, and 
Accounted For: The Critical Importance of Addressing Chronic Absence in 
the Early Grades. National Center for Children in Poverty. N. Connors, 
et al. 2004. Children of Mothers with Serious Substance Abuse Problems: 
An Accumulation of Risks. American Journal of Drug and Alcohol Abuse 
30(1): 85-100. http://www.nccp.org/publications/pub_837.html
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    As the exception makes clear, that gap is not for lack of models. 
Home visitation programs that are formally linked with center-based 
early childhood education can address the substance abuse issues by 
using one of the two widely recognized programs designed for linking 
substance abuse services and early care and education: Starting Early, 
Starting Smart or the Free to Grow model developed by the Head Start 
program. Both of these are promising approaches that should be 
encouraged further as means of improving the focus of early childhood 
programs on substance abuse effects impacting millions of children.
Because substance abuse is intergenerational
    Because substance use disorders are inherently intergenerational, 
with a genetic component, a component that is affected by multi-
generational family patterns, and effects of both organic and 
environmental exposure on children, family-centered home visitation 
must provide services to parents and children that specifically address 
substance use disorders.
Because home visitation addresses other problems that co-occur with 
        substance use disorders.
    To address mental illness, family stress, domestic violence, and 
other conditions that co-occur with substance use disorders as though 
they were each separable ignores the reality of co-occurring disorders. 
It is not possible to neatly separate the mental health and family 
violence portions of family risk factors from substance abuse.
    Approximately one half of the people who have one of these 
conditions--a mental illness or a substance abuse disorder--also have 
the other condition. The proportion of co-morbidity may be even higher 
in adolescent populations . . . Availability of integrated treatment 
for mental health and substance abuse problems is currently the 
exception rather than the rule.\13\
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    \13\ California Mental Health Services Oversight and Accountability 
Commission Report: Co-Occurring Disorders, March 2007.
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Because home visitation appears to benefit higher-risk families more 
        than lower-risk ones
    The finding that ``home visiting appears to carry more benefits for 
high-risk families than for low-risk ones'' \14\ raises the issue of 
which risks are being addressed. Combined with the finding that high--
quality programs are more likely to assess family needs and link them 
with community resources, this suggests that identifying substance 
abuse as it affects both parents and children is a necessary component 
of addressing major risk factors to promote strong families and healthy 
child development.
---------------------------------------------------------------------------
    \14\ ``Home Visiting: Strengthening Families by Promoting Parenting 
Success,'' Policy Brief No. 23, National Human Services Assembly. 
November 2007.
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    Identifying those parents needing treatment would also help to 
reduce the sizable gap between those needing and those receiving 
treatment. Based on the National Survey on Drug Use and Health (NSDUH) 
data, in 2007 of the 23.2 million persons over 12 who needed treatment 
for illicit drug or alcohol use, only 2.4 million received treatment.
    To the extent that home visitation programs have been shown to have 
the highest payoff for families with higher at-risk profiles, the 
families affected by co-occurring substance abuse, mental illness, and 
domestic violence-related trauma are those that would benefit most from 
home visitation programs designed to respond to these challenges.
Legislative Options
    The legislation emerging from Congress can build upon these lessons 
drawn from the recent history of home visitation, in recognizing the 
importance of substance abuse as a critical risk factor. We thank 
Chairman McDermott for your leadership in this critical area through 
your sponsorship of the Early Support for Families Act of 2009 (H.R. 
2667) along with Representatives Danny Davis and Todd Platts. We also 
commend Representatives Davis and Platts for their sponsorship of 
similar legislation, the Education Begins at Home Act of 2009 (H.R. 
2205). These important pieces of legislation offer a significant 
opportunity to States and Tribes to create and expand early childhood 
home visitation programs. However as currently drafted, the Early 
Support for Families Act of 2009 (H.R. 2667) does not specifically 
mention nor speak to the issue of substance abuse. Similarly, in the 
Education Begins at Home Act of 2009 (H.R. 2205), substance abuse is 
mentioned only once as one of the agencies that should be collaborating 
with the central program organization. It is left out of lists of 
several risk factors, is left out of a list of agencies to which 
families should be referred for services, and is left out of a list of 
technical assistance topics.
    To ensure that substance abuse is given appropriate attention in 
home visitation models, we offer the following recommendations on 
provisions that could be included in legislation:
    1. Require that state or local plans for home visitation programs 
that are developed also include the prevalence of substance abuse in a 
formal needs assessment and indicate how substance abuse agencies will 
be actively engaged in program design and services effectively 
coordinated, how the training of home visitation personnel will include 
training on proper risk and safety assessment techniques that include 
substance use, and include information on the program's outcomes 
including how effective the program model has been in conducting risk 
assessments, the number of parents (when appropriate and necessary) 
referred for treatment, and the outcomes of treatment for those 
referred.
    2. Require that home visitation programs that begin with prenatal 
visits include a proven risk assessment and safety model that 
identifies substance use and links pregnant women with treatment 
services in effective agencies that are full partners with the home 
visitation programs.
    3. Require that parents with substance use disorders receive 
continuing care following treatment.
    4. Require that children of substance-abusing parents receive 
developmental screening and are given eligibility for intervention 
services in the case of developmental delays, linked with Individuals 
with Disabilities Education Act (IDEA) eligibility.
    5. Require that any set-asides for training and technical 
assistance also require funds to support the development and 
dissemination of risk and safety assessment protocols that at a minimum 
address substance abuse to expand the capacity of existing and 
promising home visitation models in addressing substance abuse among 
these high-risk families.
    6. Require that the Secretary of the U.S. Department of Health and 
Human Services in administrating this home visitation program to States 
and Tribes implement a multi-agency approach including participation by 
the Administration for Children and Families, the Substance Abuse and 
Mental Health Services Administration, the Health Resources and 
Services Administration, as well as any other agencies the Secretary 
determines may be appropriate to ensure a coordinated system of family 
support is implemented.
    Again, we thank the Committee for holding this important hearing 
and for the opportunity to submit this statement for the record. We 
look forward to working with you as this legislation moves forward to 
ensure that the promise of home visitation is realized for low-income 
families, and in particular, that home visitation strategies seek to 
improve the lives of families and children impacted with substance use 
disorders.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[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.
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The Education Continuum: Beginning Earlier with Home Visiting Programs
    Although the continuum of education has traditionally been P-12 
(kindergarten through high school), brain research makes it clear that 
age five is much too late to first offer educational supports to the 
child and family. A child's experiences before entering kindergarten 
may hinder or promote her chances of successfully finishing high school 
and reaching college. Recognizing the need to expand the education 
continuum to include much, much younger ages, professionals around the 
country began developing programs, known as ``Home Visiting Programs,'' 
to fill the early childhood gap and to support parents of young 
children.
    For all programs, participation is entirely voluntary; program 
models are generally designed to include weekly or biweekly home 
visits, which last two to five years. By having nurses or 
paraprofessionals visit families in their homes, home visiting programs 
reduce the obstacles that may otherwise prevent a family from accessing 
services. Seven nationally recognized home visiting programs are Early 
Head Start, Healthy Families America, Nurse-Family Partnership, Parents 
as Teachers, the Parent-Child Home Program, Parents Too Soon, and Home 
Instruction for Parents of Preschool Youngsters (HIPPY). HIPPY and 
Parents as Teachers are universal access programs, while the others 
target teen mothers, single mothers, low-income parents, or families 
with some other significant risk factor.
    Several home visiting programs are designed to engage families when 
children are at their earliest ages--during pregnancy and infancy. Home 
visitors provide or link women to prenatal care and assist the family 
with establishing a medical home and making and attending the baby's 
well-being appointments. Doulas may work with a mother to prepare for 
delivery and begin breastfeeding. Furthermore, home visitors talk with 
parents about caring for the baby, discuss the child's developmental 
stages, and help moms and dads develop practical and appropriate 
parenting skills and strategies. Overall, these programs emphasize the 
importance of family health, economic self-sufficiency, and parenting 
skills--factors that significantly affect the home environment and the 
child's developmental foundation.
    As children reach the toddler and preschool years, home visiting 
programs build on healthy development and empower parents to be their 
child's first and most important teacher. Arriving with an educational 
toy or book, visitors teach or model parent-child interactions that 
stimulate brain development, and they encourage parents to take 
advantage of preschool. Reading, talking with the child, and promoting 
age-appropriate exploration and choices contribute to the development 
of the child's burgeoning vocabulary, self-confidence, and ability to 
reason. Parent involvement in nurturing verbal, reasoning, and social 
skills in the informal home environment is critical to preparing 
children to learn in the more formal school environment. These programs 
also provide parents with information about their child's development 
and related capabilities and limitations.
Illinois' commitment to Home Visiting
    As a state, Illinois has long recognized the benefits associated 
with home visitation and has been investing in programs since 1982. On 
average, these programs serve 15,880 children each year in Illinois 
through the Healthy Families, Parents as Teachers, Parents too Soon, 
and Nurse Family Partnership models.vi However, especially 
in these difficult economic times, the current level of programming is 
not meeting the need for home visiting. As financial pressures increase 
for a family, so does the risk of child abuse and the need for 
preventive services. Including children receiving Medicaid assistance, 
Illinois currently serves only 48 percent of the 35,000 infants born 
each year who are most likely to benefit developmentally and 
academically from home visitation.vii There are still many 
children and families yet to be served.
---------------------------------------------------------------------------
    \vi\ Ibid
---------------------------------------------------------------------------
    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 [email protected].

                                 
                       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.
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Home Visiting within a Comprehensive Early Childhood Program: The Early 
        Head Start Example
    Comprehensive programs serving families with young children may 
incorporate a strong home-based component even though they are not 
described as home visiting programs; one such model is Early Head Start 
(EHS). EHS programs can use a home-based approach, a center-based 
approach, or a combination of the two. The Early Head Start evaluation 
results for home-based programs showed that, when compared to a control 
group, parents in the programs demonstrated more positive impacts with 
regard to providing more stimulating environments, gaining a greater 
knowledge of child development, and reporting less parental stress. 
Children in the program showed stronger vocabulary development at age 
24 months compared with control group children, were more engaged with 
their parents during play at this age, and, in programs that fully 
implemented the Head Start Program Performance Standards, showed 
positive impacts on child cognitive and language development at age 36 
months.\6\
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    \6\ U.S. Department of Health and Human Services, Administration 
for Children and Families, Research to Practice: Early Head Start Home-
Based Services. U.S. Department of Health and Human Services, 2003, 
http://www.acf.hhs.gov.
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    It is important to note, however, that other approaches to 
supporting parenting and early childhood development can have a 
positive impact as well. Center-based programs, by themselves, have 
proven to have impacts on child cognitive development at both 24 and 36 
months of age, as well as on other child and parenting outcomes, but 
without a consistent pattern.\7\ On the other hand, Early Head Start 
programs using a mixed approach, a combination of center- and home-
based approaches, showed strong impacts at both 24 and 36 months for 
parenting and child outcomes. In fact, the national evaluation found 
the strongest pattern of impacts on children and families in mixed-
approach programs.\8\
---------------------------------------------------------------------------
    \7\ Ibid., fn. 3.
    \8\ U.S. Department of Health and Human Services, Administration 
for Children and Families, Early Head Start Benefits Children and 
Families. U.S. Department of Health and Human Services, 2002, http://
www.acf.hhs.gov.
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    One issue that surfaced in the examination of Early Head Start when 
services are delivered through the home is that families with more risk 
factors (e.g. teen parents, parents with depressive symptoms, parents 
with high school diplomas) tended to have visits that spent more time 
on parent-development needs with less time aimed at child-focused 
activities. More time spent on child-focused activities was associated 
with better outcomes in the areas of cognitive and language development 
and increased parental ability to support development. This finding 
underscores the idea that program models must be prepared to tailor 
services such that the needs of children and parents are carefully 
balanced. Programs that are serving families with high needs require 
staff who are capable of addressing such needs while also being able to 
maintain a strong focus on the child and the parent-child relationship. 
It is also quite possible that these children might benefit from 
center-based services to further enhance development and support 
families.
Translating Research into Practice: Recommendations for a New Home 
        Visiting Initiative
    ZERO TO THREE is pleased to see that the Administration and Members 
of Congress have continued to shine a spotlight on high quality home 
visiting initiatives. As stated earlier, home visiting is an important 
way to deliver services within a prenatal-to five-system of early 
childhood development. In considering legislation to promote a two-
tiered mandatory funding approach to creating and expanding home 
visiting programs in the states, we recommend that the Subcommittee 
take into account the following recommendations based on the science of 
early childhood development:
    1. Integrate home visiting programs into a broader state early 
childhood system and infrastructure, and emphasize coordination among 
home visiting programs. As policymakers work to expand access and 
improve home visiting services for young children and their families, 
they should ensure that services are not established in isolation, but 
are integrated into a broader state early childhood system that 
incorporates a strategy to reach all vulnerable young children in a 
coordinated way. Such a system should reach children in a variety of 
settings and include professional development, training, and technical 
assistance for providers; data collection; program standards; and 
quality assurance and improvement efforts. Thirty-two states are 
currently operating a statewide home visiting program, yet only 18 
states link these home visiting programs to other supports for early 
childhood development at the state level.\9\ Representatives of home 
visiting programs should work with other such programs within the state 
and participate in community and statewide collaborative groups to 
improve the coordination of services for young children and their 
families across agencies and programs, particularly since some programs 
have been known to work better for families with certain risk factors.
---------------------------------------------------------------------------
    \9\ National Center for Children in Poverty, United States Early 
Childhood Profile. National Center for Children in Poverty, 2007, 
www.nccp.org.
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    Federal legislation establishing state home visiting programs 
should ensure that such linkages occur by requiring that they be part 
of the planning and implementation efforts of the State Advisory 
Councils on Early Childhood Education and Care, created by the 
Improving Head Start for School Readiness Act of 2007, as well as other 
state-specific early childhood oversight boards. Governors should 
appoint home visiting representatives to the Councils. The Councils are 
tasked with, among other things, conducting a periodic statewide needs 
assessment concerning the quality and availability of early childhood 
education and development programs; identifying opportunities for, and 
barriers to, collaboration and coordination among federally-funded and 
state-funded child development, child care, and early childhood 
education programs and services; and developing recommendations for 
increasing the overall participation of children in existing early 
childhood education programs. Given their role in coordinating and 
planning state-level activities for very young children, home visiting 
representatives are a logical fit with the Councils' activities.
    2. Develop a continuum of care for young children and their 
families by coordinating home visiting efforts with other child 
development services in the community. No one single home visiting 
program, by itself, is a silver bullet for all children, all families, 
and all communities. Connecting home visiting efforts, particularly 
those focused on children's well-being and healthy development, with 
other child and family services at the community level will help to 
ensure that young children and parents have the comprehensive support 
they need. In instances when parents and children have needs that are 
not addressed by the home visiting program in which they are enrolled, 
they should be linked to other resources available in their community, 
such as high quality child care programs and comprehensive early 
childhood programs such as Early Head Start, early intervention 
programs, health assistance programs, and mental health services.
    3. Ensure that all home visiting initiatives incorporate known 
elements of effectiveness and use a model appropriate to the needs of 
the targeted population. There is growing consensus on a list of key 
elements of effective home visiting models that are most likely to 
achieve outcomes for young children and their families. This list 
includes:

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

    Policymakers should ensure that a new home visiting initiative 
incorporates these key elements focused on effective design and 
implementation to ensure high quality and effective service delivery. 
Additionally, as services are expanded within states, policymakers 
should ensure that program models are implemented with families that 
exhibit characteristics similar to those for whom the program has been 
tested. Not all families will need the same level or intensity of 
services. In a review of state-based home visiting initiatives, 31 
states operating 55 programs reported using different approaches for 
different families, providing more intensive services to families with 
greater risks and needs.\11\ We must ensure that the most at-risk 
families receive the most intense supports available, while ensuring 
appropriate services for those with fewer risks for poor developmental 
outcomes.
---------------------------------------------------------------------------
    \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.
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    Voluntary home visitation is an effective and cost-efficient way to 
ensure that all children have the opportunity to grow up healthy, safe, 
ready to learn and able to become productive members of society. 
Investing in this research-proven approach now will mean savings down 
the road in costs associated with health, education, child maltreatment 
and criminal justice. The McDermott-Davis-Platts bill would support 
rigorously evaluated programs that utilize nurses, social workers, 
other professionals and paraprofessionals to visit families, especially 
lower-income families, on a voluntary basis. We look forward to adding 
our collective voice to support this initiative as it moves toward 
enactment in Congress.
An Imperative for Prevention
    According to the most recent data released in April this year by 
the U.S. Department of Health and Human Services (HHS),\3\ over 3 
million referrals of possible child abuse and neglect cases were made 
to state child protective services (CPS) agencies in the United States 
in 2007. Close to 2 million of those referrals were accepted by CPS for 
an investigation or assessment, resulting in some 800,000 children 
found to be victims of child abuse and neglect.
---------------------------------------------------------------------------
    \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\
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    \4\ Felitti, VJ, Anda, RF, Nordenberg, D, Williamson, DF, Spitz, 
AM, Edwards, V, Koss, MP, & Marks, JS. (1998). The relationship of 
adult health status to childhood abuse and household dysfunction. 
American Journal of Preventive Medicine, 14, 245-258.
    \5\ C.S. Widom & M.A. Ames (1994). Criminal Consequences of 
Childhood Sexual Victimization. Child Abuse and Neglect. Washington, 
DC: National Institute of Justice.
    \6\ S.R. Morgan (1976). The Battered Child in the Classroom. 
Journal of Pediatric Psychology.
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    Home visiting programs link families to health care resources and 
focus on healthy outcomes. Through a strong emphasis on prenatal care 
significant costs associated with pre-term births, and developmental 
disabilities are reduced. Linking families to consistent primary care 
and immunizations means reduced emergency room costs and reduction in 
chronic illness.
    Current child welfare expenditures are heavily skewed toward 
spending on foster care and adoption subsidies. For every federal 
dollar spent on out-of-home care, the federal government spends just 
fifteen cents on prevention and child protection. Implementing proven, 
effective strategies to prevent child abuse and neglect can save on the 
high cost of doing nothing until intervention later is inevitable. 
According to a study conducted by Prevent Child Abuse America,\7\ the 
direct costs of child maltreatment for foster care services, 
hospitalization, mental health treatment, and law enforcement amount to 
more than $33 billion annually. Indirect costs of over $70 billion 
include expenditures related to chronic health problems, special 
education, and the criminal justice system as well as loss of 
productivity--for an expenditure of close to $104 billion per year.
---------------------------------------------------------------------------
    \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\
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    \8\ Wagner, M.M. & Clayton, S.L. (1999). The Parents as Teachers 
Program: Results from Two Demonstrations. The Future of Children: Home 
Visiting: Recent Program Evaluations, 9(1), 91-115.
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      A large, randomized control trial found less physical and 
psychological abuse for parents receiving home visitation services than 
control parents at one year.\9\
---------------------------------------------------------------------------
    \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\
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    \10\ Berkenes, J.P. (2001), HOPES Healthy Families Iowa FY 2001 
Services Report; Klagholz & Associates (2000), Healthy Families 
Montgomery Evaluation Report Year IV; Greene et al. (2001), Evaluation 
Findings of the Healthy Families New York Home Visiting Program; 
Katzev, A., Pratt, C. & McGuigan, W. (2001), Oregon Healthy Start 1999-
2000, Status Report.
    \11\ Williams, Stern & Associates (2005). Healthy Families Florida 
Evaluation Report, January 1, 1999-December 31, 2003.
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      Babies of parents enrolled prenatally in home visitation 
services have shown fewer birth complications in one randomized control 
trial and higher birth weights in another randomized control trial.\12\
---------------------------------------------------------------------------
    \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.
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    Funds directed to programs in Indian Country not only target a 
population that is younger than average, but also target a population 
that is relatively poorer. American Indians and Alaskan Natives are 
twice as likely to live in poverty as members of the general 
population.\4\ Children within that population are also more likely to 
face other problems. According to the Administration on Children, Youth 
and Families, roughly 14.2 out of every 1000 American Indian or Alaska 
Native children are victimized or maltreated.\5\
---------------------------------------------------------------------------
    \4\ Id. at 12 (finding that more than 25% of American Indian and 
Native Alaskan people lived in poverty, compared to 12.7% of the U.S. 
population as a whole).
    \5\ Administration on Children, Youth and Families, Child 
Maltreatment Study 2007, p. 25.
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    The funds this bill would make available could be used to establish 
new programs, to strengthen current home visitation programs, or to 
utilize existing programs. There is a major health home visitation 
program in Indian Country--the Community Health Representative (CHR) 
program. The program does not provide the services envisioned under 
H.R. 2667, but is an example of a successful home visitation program 
operating throughout Indian Country. The CHR programs are funded and 
overseen by the Indian Health Service, pursuant to the Indian Health 
Care Improvement Act (as amended, Public Law 100-713, dated November 
23, 1988). This program trains community members as health 
paraprofessionals and provides funding to deliver health services 
through integrated home visitation programs. These services are 
culturally competent and community-based and offer a model that can be 
helpful in the context of providing in-home services to young children 
and their families as envisioned in this legislation.
     The CHR program illustrates how service providers that value human 
interaction and supportive relationships may yield better results than 
traditional delivery methods. These home visitation programs include a 
broad range of services, from patient care and case management to 
health education and transportation. Paraprofessionals trained under 
the CHR program also engage in injury prevention activities and educate 
patients about best health practices. Though not targeted specifically 
for children, these programs are proven models that advance self-
determination and deliver healthcare services to underserved households 
who often live in very rural, geographically isolated areas where 
health services in general are not always easily accessible. They also 
raise community awareness of ongoing health issues in tribal 
communities and the steps that are being taken to address them. Whether 
used as a model on which to create a home visitation program or an 
initial foundation from which to build, the success of the CHR program 
is clear evidence that home visitation programs targeting children will 
be effective in tribal communities.
    While the CHR program holds promise for home visitation programs 
envisioned in H.R. 2667, the legislation specifically identifies the 
need to use evidence-based models, especially those with the strongest 
evidence of effectiveness. Because research dollars and projects often 
do not reach Indian Country it would be helpful to add a provision that 
directs the Secretary of DHHS to collaborate and consult with tribes 
and tribal organizations that have experience in this area. They could 
evaluate the inclusion of tribal populations in current home visitation 
models, assess the ability to adapt existing mainstream models for 
implementation in tribal communities, identify tribal home visitation 
programs that are working well in Indian Country, and develop 
recommendations on how to strengthen the development and dissemination 
of tribal home visitation models. Such a provision would help advance 
the purposes of the bill and ensure that tribal home visitation 
programs benefit from evidence-based approaches too.
    The home visitation programs envisioned in this bill would benefit 
American Indian and Alaska Native children and the young family 
households in which they are being raised. As a source of services and 
education, these programs are tools that Native families can use to 
improve well-being, help prevent child abuse and neglect and advance 
their children's development.
    We thank Chairman McDermott and the Members of this Subcommittee 
for their active interest in the welfare of children, and look forward 
to working with you on this and related legislation. And we thank you 
once again for the enactment last year of the Fostering Connections to 
Success Act (PL 110-351) which brought long overdue eligibility for 
tribal governments to administer the Title IV-E Foster Care and 
Adoption Assistance programs.
    If you have questions or comments regarding this testimony, please 
contact NICWA Government Affairs Director, David Simmons at 
[email protected] or AAIA Executive Director, Jack Trope at 
[email protected].

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

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

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

     Parents as Teachers children showed better school 
readiness at the start of kindergarten, higher reading and math 
readiness at the end of kindergarten, higher kindergarten grades, and 
fewer remedial education placements in first grade.\i\
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    \i\ Drazen, S., & Haust, M. (1995). The effects of the Parents and 
Children Together (PACT) program on school achievement. Binghamton, 
NY.; Drazen, S. & Haust, M. (1996). Lasting academic gains from an 
early home visitation program. Paper presented at the annual meeting of 
the American Psychological Association, August 1996.
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     Participation in Parents as Teachers helps to close the 
achievement gap between children living in poverty and those from non-
poverty households.\ii\
---------------------------------------------------------------------------
    \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.
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     In another randomized trial, adolescent mothers in an 
urban community who participated in Parents as Teachers scored lower on 
a child maltreatment precursor scale than mothers in the control group. 
These adolescent mothers showed greater improvement in knowledge of 
discipline, showed more positive involvement with children, and 
organized their home environment in a way more conducive to child 
development.\iv\
---------------------------------------------------------------------------
    \iv\ Pfannenstiel, J., Lambson, T., & Yarnell, V. (1991). Second 
wave study of the Parents as Teachers program. Overland Park, KS: 
Research & Training Associates.
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     Children participating in Parents as Teachers were much 
more likely to be fully immunized for their given age, and were less 
likely to be treated for an injury in the previous year.\v\
---------------------------------------------------------------------------
    \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\
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    \1\ Felitti V, Anda R, Nordenberg D, Williamson D, Spitz A, Edwards 
V, et al. Relationship of Childhood Abuse and Household Dysfunction to 
Many of the Leading Causes of Death in Adults. American Journal of 
Preventive Medicine 1998;14(4):245-58.
    \2\ Springer, K.W., Sheridan, J., Kuo, D., & Carnes, M. (2007). 
Long-term Physical and Mental Health Consequences of Childhood Physical 
Abuse: Results from a Large Population-based Sample of Men and Women. 
Child Abuse & Neglect, 31, 517-530.
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    As ACE and similar studies demonstrate, getting prevention right 
early is less costly to the nation, and to individuals, than trying to 
fix things later. Prevent Child Abuse America estimates that 
implementing effective policies and strategies to prevent child abuse 
and neglect can save taxpayers $104 billion per year. The cost of not 
doing so includes more than $33 billion in direct costs for foster care 
services, hospitalization, mental health treatment, and law 
enforcement. Indirect costs of over $70 billion include loss of 
productivity, as well as expenditures related to chronic health 
problems, special education, and the criminal justice system.\3\ An 
international study by the United Nations Children's Fund (UNICEF, 
February 2007) placed the United States next to last on child well-
being, among the 21 wealthiest nations in the world. Although only one 
indicator of child well-being, rates of child abuse and neglect are 
ultimately tied to a nation's investment in its children.
---------------------------------------------------------------------------
    \3\ (1) Wang, CT, & Holton, J (2007). Total estimated cost of child 
abuse and neglect in the United States. Chicago, IL: Prevent Child 
Abuse America. http://www.preventchildabuse.org/about_us/
media_releases/pcaa_pew_economic_impact_study_final.pdf.
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    This is where an investment in home visitation, as contemplated by 
HR 2667, provides the country with a great opportunity to enhance child 
development, support communities, reduce child abuse and neglect, and 
ultimately have a profound impact on the health and productivity of 
future generations.
Role of Early Childhood Home Visitation
    All expectant parents and parents of newborns have common questions 
about their child's development. Early childhood home visitation 
provides a voluntary and direct service in which highly trained home 
visitors can help parents understand, recognize and promote age 
appropriate developmental activities for children; meet the emotional 
and practical needs of their families; and improve parents' capacity to 
raise successful children.
    Research has shown that voluntary home visitation is an effective 
and cost-efficient strategy for supporting new parents and connecting 
them to helpful community resources. Quality early childhood home 
visitation programs lead to proven, positive outcomes for children and 
families, including improved child health and development, improved 
parenting practices, improved school readiness, and reductions in child 
abuse and neglect.
Healthy Families America
    Healthy Families America is Prevent Child Abuse America's 
nationally recognized, signature home visitation program. Through 
Healthy Families America, well-respected, extensively trained 
assessment workers and home visitors provide valuable guidance, 
information and support to help parents be the best parents they can 
be. Healthy Families America focuses on three equally important goals 
to: 1) promote positive parenting; 2) encourage child health and 
development; and 3) prevent child abuse and neglect.
    A review of 34 studies in 25 states, involving over 230 Healthy 
Families America programs allows us to say with confidence and 
conviction that the benefits of Healthy Families America are proven, 
significant, and impact a wide range of child and family outcomes.\4\ 
In particular, Healthy Families America:
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    \4\ Study designs include 8 randomized control trials and 8 
comparison group studies. More information on the studies can be found 
in the Healthy Families America Table of Evaluations at ** 
www.healthyfamiliesamerica.org/research/index.shtml.
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    Improves Parenting Attitudes. Healthy Families America families 
show positive changes in their perspectives on parenting roles and 
responsibilities.
    Increases Knowledge of Child Development. Healthy Families America 
parents learn about infant care and development; including child care, 
nutrition, and effective positive discipline.
    Supports a Quality Home Environment. Healthy Families America 
parents read to their children at early ages, provide appropriate 
learning materials, and are more involved in their child's activities, 
all factors associated with positive child development.
    Promotes Positive Parent-Child Interaction. Healthy Families 
America parents demonstrate better communication with, and 
responsiveness to, their children. This interaction is an important 
factor in social and emotional readiness to enter school.
    Improves Family Health. Healthy Families America improves parents' 
access to medical services, leading to high rates of well-baby visits 
and high immunization rates, and helps increase breast feeding, which 
is linked to many benefits for both babies and moms. Healthy Families 
America has also been found to significantly reduce low birthweight 
deliveries.\5\ By one estimate, each normal birth that occurs instead 
of a very low birthweight birth saves $59,700 in the first year of 
care.\6\
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    \5\ Eunju Lee, PhD, Susan D. Mitchell-Herzfeld, MA, Ann A. 
Lowenfels, MPH, Rose Greene, MA, Vajeera Dorabawila, PhD, Kimberly A. 
DuMont, PhD (2009). Reducing Low Birth Weight Through Home Visitation: 
A Randomized Controlled Trial. American Journal of Preventive Medicine, 
36, 2,154-160.
    \6\ Rogowski, J. (1998). Cost-effectiveness of Care for Very Low 
Birth Weight Infants. PEDIATRICS Vol. 102 No. 1 July 1998, pp. 35-43.
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    Prevents Child Abuse and Neglect. Healthy Families America has a 
significant impact on preventing child maltreatment, particularly 
demonstrated in recent randomized control trials.
    In addition to our stewardship of Healthy Families America, Prevent 
Child Abuse America partners with other effective home visiting models 
working in communities across the country to create nurturing 
environments for children. Our national home visiting partners include 
Home Instruction for Parents of Preschool Youngsters (HIPPY USA), the 
Nurse-Family Partnership, The Parent-Child Home Program, and Parents as 
Teachers.
    Together, we have accepted the responsibility to improve the home 
visitation field. Together, we share research findings and best 
practices, and together, we work toward common goals, and create areas 
for cross-program cooperation and learning that strengthens the home 
visit field as a whole, as well as enhances individual programs. At the 
local level, Healthy Families programs partner with other home visiting 
models to reach a broader population of families, to ensure that 
families are receiving the home visiting service model best suited to 
their needs, and to maximize limited resources.
The Need for Reliable Funding and a Coordinated Approach
    Despite the many proven benefits of home visitation, home 
visitation services across the country struggle with unreliable and 
unsustainable funding. The current patchwork of funding results in a 
home visitation system that serves only a small percentage of families. 
By one estimate, approximately 400,000 children and families 
participate in home visitation services each year.\7\ A report by the 
National Center for Children in Poverty estimates 42% of young children 
(more than 10 million children in 2005) experience one or more risk 
factors associated with poor health and educational outcomes, and 10% 
(nearly 2.4 million children) experience three or more risk factors.\8\
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    \7\ Gomby, D. (2005). Home Visitation in 2005: Outcomes for 
Children and Parents. Invest in Kids Working Paper No. 7. Committee for 
Economic Development: Invest in Kids Working Group. Available at 
www.ced.org/projects/kids.shtml.
    \8\ Stebbins, Helene, & Knitzer, Jane (2007). State Early Childhood 
Policies: Improving the Odds. NY: National Center for Children in 
Poverty.
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    The Early Support for Families Act (HR 2667) will address the home 
visiting funding crisis by establishing a new federal mandatory grant 
program dedicated solely to home visitation. HR 2667 authorizes $2 
billion over 5 years in grants to states to provide evidence-based home 
visitation services to support families with young children and 
families expecting children. The legislation empowers states to fund 
home visitation services that best suit the needs of their communities, 
while putting important parameters in place to assure quality of 
services. Programs funded through the new grant must:

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

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

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

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

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

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

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

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

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

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

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

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

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

Robin Roberts

                                 

                     Statement of Stephanie Gendell

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

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

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

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

     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).
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    Low birth weight, child abuse and neglect, school failure and 
incarceration are devastating to families, put a tremendous strain on 
state budgets and are often preventable. A preponderance of evidence 
supports the fact that an ounce of prevention may be worth much more 
than a pound of cure. Early intervention is absolutely necessary if we 
want to ensure the health, stability, and vitality of our children, our 
families, our communities and our nation.
Quality, Evidence-Based Home Visiting Works
    Quality evidence-based home visiting programs offer families a 
social support network that--when properly implemented and matched to 
family need--can dramatically decrease negative outcomes. Pairing new 
and expectant families with trained professionals to provide parenting 
information, resources and support during pregnancy and throughout 
their child's first three years serves to strengthen parent-child 
relationships, increase early language and literacy skills and reduce 
child abuse and neglect--significant outcomes that can help ease the 
strain on state budgets.\v\ Economists have calculated a pay-off of up 
to $5.70 on each dollar invested in the Nurse Family Partnership, a 
high-quality home visitation program serving at-risk families.\vi\
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    \v\ See, for example, Sweet, MA and Appelbaum, M ``Is home visiting 
an effective strategy? A meta-analytic review of home visiting programs 
for families with young children.'' Child Development 75(5):1435-1456, 
(2005).; U.S. Department of Health and Human Services. Youth Violence: 
A Report of the Surgeon General. Washington, DC: Department of Health 
and Human Services, (2001).; Kendrick D, et al. ``Does home visiting 
improve parenting and the quality of the home environment? A systematic 
review and meta-analysis.'' Archives of Disease in Childhood, 
82(6):443-451. (2000).
    \vi\ Karoly, Lynn A., et al. Investing in Our Children: What We 
Know and Don't Know about the Costs and Benefits of Early Childhood 
Interventions. (Santa Monica, CA: RAND, 1998).
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    That said, not all home visiting efforts are created equal: 
research shows that poorly designed and inconsistently implemented 
programs will not offer the same return on a state's investment, nor 
necessarily result in positive outcomes for families. The most 
significant cost-savings from home visiting occur when low-income 
families are served by proven programs that employ well-trained 
professional home visiting staff.
DETAILED RECOMMENDATIONS
    Pew believes that public investments in social capital should be 
backed by strong evidence--that is, programs should show evidence of 
effectiveness supported with rigorous, well designed evaluations of 
program implementation and outcomes.
    Particularly in difficult economic times, when stress on families 
and state budgets is heightened, states can benefit greatly from 
federal leadership and support in creating and implementing effective 
home visiting programs. States need support in order to set quality 
standards for home visiting programs, monitor and assess program 
fidelity and track program resources and outcomes.
    While states will choose to implement home visiting models that 
best fit their individual needs, they face several universal challenges 
in attempting to identify and support quality, evidence-based home 
visiting programs. Such challenges provide an opportune moment for 
federal leadership in setting standards for public investment in home 
visiting.
    To determine what warrants substantial public investment in large-
scale implementation or program replication, Pew supports prioritized 
funding to programs that have demonstrated positive outcomes with 
randomized controlled trial or rigorous quasi-experimental design with 
equivalent comparison groups. While programs with the strongest 
evidence are best positioned for scaled-up implementation, additional 
support is needed to help promising programs meet the high evidentiary 
standard necessary for large-scale investments.
    The state of Washington, for example, uses evidentiary standards to 
prioritize funding allocations for home visiting programs. The state 
adopted criteria for assessing home visiting evaluation research on 
child abuse and neglect prevention outcomes and then established three 
levels: best, good and promising. This evidence-based approach allows 
the state to:

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

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

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

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

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

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

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

                                 
                Prepared Child Welfare League of America

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                          Prepared Fight Crime

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                        Prepared Sharon Sprinkle

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