    [House Hearing, 116 Congress]
    [From the U.S. Government Publishing Office]

                     STRENGTHENING PREVENTION AND TREATMENT
                           OF CHILD ABUSE AND NEGLECT

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

                                    HEARING

                                  BEFORE THE

                SUBCOMMITTEE ON CIVIL RIGHTS AND HUMAN SERVICES

                             COMMITTEE ON EDUCATION
                                   AND LABOR
                         U.S. HOUSE OF REPRESENTATIVES

                         ONE HUNDRED SIXTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                 HEARING HELD IN WASHINGTON, DC, MARCH 26, 2019

                                   __________

                               Serial No. 116-12

                                   __________

          Printed for the use of the Committee on Education and Labor

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

               Available via the World Wide Web: www.govinfo.gov
                                       or
                  Committee address: https://edlabor.house.gov

                                  __________

                        U.S. GOVERNMENT PUBLISHING OFFICE
    36-587 PDF                  WASHINGTON : 2019

    --------------------------------------------------------------------------------------

                        COMMITTEE ON EDUCATION AND LABOR

                 ROBERT C. ``BOBBY'' SCOTT, Virginia, Chairman

    Susan A. Davis, California           Virginia Foxx, North Carolina,
    Raul M. Grijalva, Arizona            Ranking Member
    Joe Courtney, Connecticut            David P. Roe, Tennessee
    Marcia L. Fudge, Ohio                Glenn Thompson, Pennsylvania
    Gregorio Kilili Camacho Sablan,      Tim Walberg, Michigan
      Northern Mariana Islands           Brett Guthrie, Kentucky
    Frederica S. Wilson, Florida         Bradley Byrne, Alabama
    Suzanne Bonamici, Oregon             Glenn Grothman, Wisconsin
    Mark Takano, California              Elise M. Stefanik, New York
    Alma S. Adams, North Carolina        Rick W. Allen, Georgia
    Mark DeSaulnier, California          Francis Rooney, Florida
    Donald Norcross, New Jersey          Lloyd Smucker, Pennsylvania
    Pramila Jayapal, Washington          Jim Banks, Indiana
    Joseph D. Morelle, New York          Mark Walker, North Carolina
    Susan Wild, Pennsylvania             James Comer, Kentucky
    Josh Harder, California              Ben Cline, Virginia
    Lucy McBath, Georgia                 Russ Fulcher, Idaho
    Kim Schrier, Washington              Van Taylor, Texas
    Lauren Underwood, Illinois           Steve Watkins, Kansas
    Jahana Hayes, Connecticut            Ron Wright, Texas
    Donna E. Shalala, Florida            Daniel Meuser, Pennsylvania
    Andy Levin, Michigan*                William R. Timmons, IV, South
    Ilhan Omar, Minnesota                    Carolina
    David J. Trone, Maryland             Dusty Johnson, South Dakota
    Haley M. Stevens, Michigan
    Susie Lee, Nevada
    Lori Trahan, Massachusetts
    Joaquin Castro, Texas
    * Vice-Chair

                       Veronique Pluviose, Staff Director
                     Brandon Renz, Minority Staff Director
                                     ------

                SUBCOMMITTEE ON CIVIL RIGHTS AND HUMAN SERVICES

                      SUZANNE BONAMICI, OREGON, Chairwoman

    Raul M. Grijalva, Arizona            James Comer, Kentucky,
    Marcia L. Fudge, Ohio                  Ranking Member
    Kim Schrier, Washington              Glenn ``GT'' Thompson,
    Jahana Hayes, Connecticut                Pennsylvania
    David Trone, Maryland                Elise M. Stefanik, New York
    Susie Lee, Nevada                    Dusty Johnson, South Dakota

                                C O N T E N T S

                                  ----------
                                                                       Page

    Hearing held on March 26, 2019...................................     1

    Statement of Members:
        Bonamici, Hon. Suzanne, Chairwoman, Subcommittee on Civil
          Rights and Human Services..................................     1
            Prepared statement of....................................     3
        Comer, Hon. James, Ranking Member, Subcommittee on Civil
          Rights and Human Services..................................     4
            Prepared statement of....................................     5

    Statement of Witnesses:
        Jackson, Dr. Yo, Ph.D, ABPP, Professor, Phychology Department
          and Associate Diector, Child Maltreatment Solutions
          Network, The Pennsylvania State University, Pennsylvania
          and Research Professor, University of Kansas...............     7
            Prepared statement of....................................    10
        King, Ms. Judy, MSW, Director, Family Support Programs,
          Washing State Department of Children, Youth, and Families,
          Olympia, WA................................................    20
            Prepared statement of....................................    22
        Thomas, Mr. Bradley, CEO, Triple P, Positive Parenting
          Program, Columbia, SC......................................    30
            Prepared statement of....................................    32
        Rose, Mrs. LaCrisha, Facilitator of the West Virginia Circle
          of Parents Network, Team for West Virginia Children, Miami,
          WV.........................................................    40
            Prepared statement of....................................    42

    Additional Submissions:
        Chairwoman Bonamici:
            Link: Strengthening National Data on Child Fatalities
              Could Aid In Prevention................................    64
            Article: The Economic Burden of Child Maltreatment in the
              United States, 2015....................................    65
        Dr. Jackson's response to question submitted for the record..    85
        Schrier, Hon. Kim, a Representative in Congress from the
          State of Washington:
            Prepared statement by Melmed, Mr. Matthew E., Executive
              Director, Zero To Three................................    73
        Scott, Hon. Robert C. ``Bobby'', a Representative in Congress
          from the State of Virginia:
            Question submitted for the record........................    84
        Trone, Hon. David J., a Representative in Congress from the
          State of Maryland:
            Link: Within Our Reach...................................    49

       STRENGTHENING PREVENTION AND TREATMENT OF CHILD ABUSE AND NEGLECT

                                  ----------

                            Tuesday, March 26, 2019

                           House of Representatives,

                Subcommittee on Civil Rights and Human Services,

                       Committee on Education and Labor,

                                Washington, DC.

                                  ----------

        The subcommittee met, pursuant to notice, at 2:45 p.m., in
    room 2175, Rayburn House Office Building, Hon. Suzanne Bonamici
    [chairwoman of the subcommittee] presiding.
        Present: Representatives Bonamaci, Schrier, Hayes, Trone,
    Lee, Scott, Comer, Thompson, Stefanik, Johnson, and Foxx.
        Also present: Representative Langevin.
        Staff present: Alli Tylease, Chief Clerk; Jacque Mosely
    Chevalier, Director of Education Policy; Paula Daneri,
    Education Policy Fellow; Christian Haines, General Counsel,
    Education; Alison Hard, Professional Staff Member; Ariel Jona,
    Staff Assistant; Stephanie Lalle, Deputy Communications
    Director; Max Moore, Office Aide; Banyon Vassar, Deputy
    Director of Information Technology; Cyrus Artz, Minority
    Parliamentarian; Marty Boughton, Minority Press Secretary;
    Courtney Butcher, Minority Coalitions and Members Services
    Coordinator; Bridget Handy, Minority Legislative Assistant;
    Blake Johnson, Minority Staff Assistant; Amy Raaf Jones,
    Minority Director of Education and Human Resources Policy;
    Hannah Matesic, Minority Director of Operations; Kelley McNabb,
    Minority Communications Director; Jake Middlebrooks, Minority
    Professional Staff Member; Mandy Schaumburg, Minority Chief
    Counsel and Deputy Director of Education Policy; and Meredith
    Schellin, Minority Deputy Press Secretary and Digital Advisor.
        Chairwoman Bonamici. The subcommittee on Civil Rights and
    Human Services will come to order. Welcome everyone. I note
    that a quorum is present and apologize for the late start. We
    were voting.
        I ask unanimous consent that Mr. Langevin of Rhode Island
    be permitted to participate in today's hearing with the
    understanding that his questions will come only after all
    members of the subcommittee on Civil Rights and Human Services
    on both sides of the aisle who are present have had an
    opportunity to question the witnesses.
        Without objection. So ordered.
        The committee is meeting today in a legislative hearing to
    hear testimony on strengthening prevention and treatment of
    child abuse and neglect. Pursuant to committee rule 7(c),
    opening statements are limited to the chair and ranking member.
    This allows us to hear from our witnesses sooner and provide
    all members with adequate time to ask questions. I recognize
    myself now for the purpose of making an opening statement.
        We are here today to discuss our responsibility to protect
    the health and safety of our Nation's children. Child abuse and
    neglect, collectively, child maltreatment are quiet nationwide
    tragedies that unfold every day in communities across the
    country.
        In 2017, state child protection services agencies received
    a total of 4.1 million referrals of possible child abuse or
    neglect involving 7.5 million children. All together, child
    maltreatment affects as many as one in seven children. Victims
    of child maltreatment typically suffer both immediate and
    lasting harm. In the short-term, maltreatment can result in
    significant physical injuries in addition to emotional and
    psychological disruption, and the effects can last over a
    lifetime.
        Emotional and psychological abuse can hinder not only
    social growth but also the physical growth of the brain itself.
    As adults, victims of child maltreatment can suffer from
    inhibited memory processing and struggle to control their
    emotions and behaviors. As a result, they are 7 percent more
    likely to drop out of high school and nine times more likely to
    be involved with the juvenile justice system than their peers.
    The trauma suffered by these children and families will stay
    with them for a lifetime, and in Congress, we should always
    look for ways to support trauma informed care.
        In addition to the high personal costs, child maltreatment
    also carries devastating societal costs. Research shows that
    the long-term effects can have lifetime costs of more than
    $800,000 per child all together. This is a public health crisis
    that costs more than $400 billion each year.
        Since the passage of the Child Abuse Prevention and
    Treatment Act, or CAPTA, more than 3 decades ago we have made
    progress toward reducing cases of child maltreatment. In fact,
    from 1990 to 2009, rates steadily declined and then plateaued
    through 2012. Despite that, we face new challenges in our
    efforts to address child maltreatment. Since 2013, the rate at
    which children are abused and neglected has steadily increased,
    and with it, tragically, the rate of child deaths has also gone
    up. In the year 2017, child deaths from maltreatment reached an
    all-time high; 1,720 children lost their lives.
        Evidence suggests that the opioid crisis is giving rise to
    new challenges in protecting vulnerable children. In my home
    state of Oregon, I have met with parents, healthcare
    professionals, community leaders, veterans, and people from all
    walks of life who have shared heart wrenching stories about how
    the opioid crisis is taking lives and inflicting pain on
    families. This crisis can be particularly devastating for
    mothers and newborn children.
        As our understanding of child abuse and neglect deepens, we
    must update our approach accordingly. We cannot continue to
    address this public health crisis by just reacting after child
    maltreatment cases arise. As this committee considers
    reauthorizing the Child Abuse Prevention and Treatment Act,
    last updated nearly a decade ago, we must shift our focus to
    preventing, preventing the maltreatment from occurring in the
    first place.
        We need a CAPTA reauthorization that strengthens federal
    investments in community-based prevention services so families
    across the country can receive help before children suffer. We
    need to build networks of wraparound services that lower the
    risk of child maltreatment by helping families navigate complex
    health, educational, and financial hardships, and we need to
    streamline communication between and among states so child
    protection agencies across the country can connect the dots and
    prevent cases of child maltreatment, no matter where they
    occur, from slipping through the cracks.
        All of us in this room recognize that Congress has a
    responsibility to protect children. We must work together to
    invest in services that prevent, not just treat, child abuse
    and neglect. Today's hearing is an important step toward making
    sure that all children grow up in a safe and healthy
    environment that allows them to reach their full potential.
        I want to thank all of our witnesses for being here today.
    I look forward to your testimony, and I now yield to the
    ranking member, Mr. Comer.
        [The statement of Chairwoman Bonamici follows:]

     Prepared Statement of Hon. Suzanne Bonamici, Chairwoman, Subcommittee
                       on Civil Rights and Human Services

        We are here today to discuss our responsibility to protect the
    health and safety of our Nation's children.
        Child abuse and neglect, collectively child maltreatment, are
    quiet, nationwide tragedies that unfold every day in communities across
    the country. In 2017, State child protection services agencies received
    a total of 4.1 million referrals of possible child abuse or neglect
    involving 7.5 million children. Altogether, child maltreatment affects
    as many as one in seven children.
        Victims of child maltreatment typically suffer both immediate and
    lasting harm. In the short-term, maltreatment can result in significant
    physical injuries, in addition to emotional and psychological
    disruption. And the effects can last over a lifetime. Emotional and
    psychological abuse can hinder not only social growth but also the
    physical growth of the brain, itself.
        As adults, victims of child maltreatment can suffer from inhibited
    memory processing and struggle to control their emotions and behaviors.
    As a result, they are 7 percent more likely to drop out of high school
    and nine times more likely to become involved with the juvenile justice
    system than their peers. The trauma suffered by these children and
    families will stay with them for a lifetime, and in Congress we should
    always look for ways to support trauma-informed care.
        In addition to the high personal costs, child maltreatment also
    carries devastating societal costs. Research shows that the long-term
    effects can have lifetime costs of more than $800,000 per child.
    Altogether, this public health crisis costs more than $400 billion each
    year.
        Since the passage of the Child Abuse Prevention and Treatment Act,
    or CAPTA, more than three decades ago, we have made progress toward
    reducing cases of child maltreatment. In fact, from 1990 to 2009, rates
    steadily declined, and then plateaued through 2012.
        Despite that, we face new challenges in our efforts to address
    child maltreatment. Since 2013, the rate at which children are abused
    and neglected has steadily increased. And with it, tragically, the rate
    of child deaths has also gone up. In the year 2017, child deaths from
    maltreatment reached an all-time high--1,720 children lost their lives.
        Evidence suggests that the opioid crisis is giving rise to new
    challenges in protecting vulnerable children.
        In my home State of Oregon, I have met with parents, health care
    professionals, community leaders, veterans, and people from all walks
    of life who have shared heart-wrenching stories about how the opioid
    crisis is taking lives and inflicting pain on families. This crisis can
    be particularly devastating for mothers and newborn children.
        As our understanding of child abuse and neglect deepens, we must
    update our approach accordingly.
        We cannot continue to address this public health crisis by just
    reacting after child maltreatment cases arise. As this Committee
    considers reauthorizing the Child Abuse Prevention and Treatment Act--
    last updated nearly a decade ago--we must shift our focus to preventing
    the maltreatment from occurring in the first place.
        We need a CAPTA reauthorization that strengthens Federal
    investments in community-based prevention services so families across
    the country can receive help before children suffer.
        We need to build networks of wrap-around services that lower the
    risk of child maltreatment by helping families navigate complex health,
    educational, and financial hardships.
        And we need to streamline communication between and among States so
    child protection agencies across the country can connect the dots and
    prevent cases of child maltreatment, no matter where they occur, from
    slipping through the cracks.
        All of us in this room recognize that Congress has a responsibility
    to protect children. We must work together to invest in services that
    prevent, not just treat, child abuse and neglect.
        Today's hearing is an important step toward making sure that all
    children grow up in a safe and healthy environment that allows them to
    reach their full potential.
        I want to thank all our witnesses for being with us today. I look
    forward to your testimony and I now yield to the Ranking Member, Mr.
    Comer.
                                     ______

        Mr. Comer. Thank you, Madam Chairman, for yielding. Thank
    you all for being here today. As the dad of three young
    children, today's topic is a very difficult one to discuss. No
    child should ever have to endure the pain of abuse or neglect
    by a parent or caregiver. That is why today's hearing is so
    important.
        The Child Abuse Prevention and Treatment Act or CAPTA is
    the key federal legislation that helps states combat child
    abuse and neglect. This legislation, which was enacted in 1974,
    provides states with grant funding to develop programs aimed at
    prevention, assessment, investigation, prosecution, and
    treatment.
        The scope of this law is significant, and the number of
    children that are affected by abuse and neglect each year is
    staggering and absolutely heartbreaking. In 2016, Child
    Protective Services received over 4 million referrals involving
    7.4 million children. Teachers, law enforcement, and social
    service professionals accounted for over half of all referrals.
    Of those 4 million reports, 2.2 million received a direct
    response from Child Protective Services. Of that number,
    approximately 676,000 children were determined to be victims of
    abuse or neglect.
        While neglect is notoriously more challenging to confirm,
    it still accounted for close to 75 percent of cases reported to
    CPS. And while we know that abuse can have serious lasting
    impacts on children well into the latter parts of their lives,
    research shows that the effects of neglect can be just as
    detrimental. In fact, some studies have shown that neglect can
    have an even greater impact on a child's healthy brain
    development.
        As this committee works to make CAPTA more effective in our
    fight against child abuse and neglect, our efforts should begin
    with prevention. Prevention takes a holistic approach to
    combating neglect and abuse by focusing on strengthening
    communities and educating parents and caregivers on how to keep
    children safe. CAPTA receives $158 million in annual
    appropriations with $39.8 million designated specifically for
    community-based child abuse prevention formula grants. We
    support community level organizations focused on preventing
    child abuse and neglect.
        In addition to bolstering our prevention efforts, this
    committee's work should streamline current assurances and
    requirements so states can focus on serving and providing
    treatment to children rather than spending more time filling
    out paperwork. state agencies benefit from increased
    flexibility that allows them to respond more swiftly and
    effectively to reports of abuse and neglect. We must equip
    states with the tools and resources needed to address
    maltreatment and keep kids safe.
        Children who have suffered abuse and neglect have unique
    needs, and it is our duty to ensure that they receive excellent
    care. I have no doubt that this subcommittee can lead this
    effort and champion bipartisan initiatives that strengthen
    CAPTA.
        I look forward to today's discussion about how we as a
    Nation can effectively and compassionately serve these
    children.
        I yield back.
        [The statement of Mr. Comer follows:]

    Prepared Statement of Hon. James Comer, Ranking Member, Subcommittee on
                        Civil Rights and Human Services

        Thank you for yielding.
        As a dad to three young kids, today's topic is a tough one to
    discuss. No child should ever have to endure the pain of abuse or
    neglect by a parent or caregiver, and that's why today's hearing is so
    important.
        The Child Abuse Prevention and Treatment Act (CAPTA) is the key
    Federal legislation that helps States combat child abuse and neglect.
    This legislation, which was enacted in 1974, provides States with grant
    funding to develop programs aimed at prevention, assessment,
    investigation, prosecution, and treatment.
        The scope of this law is significant, and the number of children
    that are affected by abuse and neglect each year is staggering and
    absolutely heartbreaking. In 2016, child protective services (CPS)
    received over 4 million referrals involving 7.4 million children.
    Teachers, law enforcement, and social services professionals accounted
    for over half of all referrals. Of those 4 million reports, 2.2 million
    received a direct response from child protective services. Of that
    number, approximately 676,000 children were determined to be victims of
    abuse or neglect.
        While neglect is notoriously more challenging to confirm, it still
    accounted for close to 75 percent of cases reported to CPS. And while
    we know that abuse can have serious lasting impacts on children well
    into the later parts of their lives, research shows that the effects of
    neglect can be just as detrimental.
        In fact, some studies have shown that neglect can have an even
    greater impact on a child's healthy brain development.
        As this committee works to make CAPTA more effective in our fight
    against child abuse and neglect, our efforts should begin with
    prevention. Prevention takes a holistic approach to combating neglect
    and abuse by focusing on strengthening communities and educating
    parents and caregivers on how to keep children safe. CAPTA receives
    $158 million in annual appropriations, with $39.8 million designated
    specifically for Community Based Child Abuse Prevention (CB-CAP)
    formula grants which support community-level organizations focused on
    preventing child abuse and neglect.
        In addition to bolstering our prevention efforts, this committee's
    work should streamline current assurances and requirements, so States
    can focus on serving and providing treatment to children, rather than
    spending more time filling out paperwork. State agencies benefit from
    increased flexibility that allows them to respond more swiftly and
    effectively to reports of abuse and neglect. We must equip States with
    the tools and resources needed to address maltreatment and keep kids
    safe.
        Children who have suffered abuse and neglect have unique needs, and
    it is our duty to ensure they receive exemplary care. I have no doubt
    that this subcommittee can lead this effort and champion bipartisan
    initiatives that strengthen CAPTA. I look forward to today's discussion
    about how we as a nation can effectively and compassionately serve
    these children.
                                     ______

        Chairwoman Bonamici. Thank you very much, Mr. Comer, for
    your statement.
        Without objection, all other members who wish to insert
    written statements into the record may do so by submitting them
    to the committee clerk electronically in Microsoft Word format
    by 5 p.m. on April 8, and I will now introduce the witnesses.
        Dr. Yo Jackson is a board-certified clinical child
    psychologist who studies the mechanisms of resilience for youth
    exposed to trauma. She is a professor at the University of
    Kansas and at Penn State University where she also serves as
    the Associate Director of the Child Maltreatment Solutions.
    Over the last 20 years, Dr. Jackson has developed an extensive
    body of research focused on the mechanisms that foster
    resilience for youth exposed to trauma. Throughout her career,
    she has served and continues to serve as the principal
    investigator on several grants from the National Institutes of
    Health.
        And I am going to skip over Ms. King temporarily because we
    are hoping that Dr. Schrier arrives to introduce Ms. King.
        Mr. Bradley Thomas has been the CEO of Triple P America
    since 2011. Triple P, Positive Parenting Program, is a system
    of evidence-based education and support for parents and
    caregivers of children and adolescents with a prevention focus.
    Prior to being appointed as CEO, he was involved in various
    capacities in working with public research organizations
    interested in transferring their research into the community.
    Following his work with research organizations, he accepted the
    position as CEO to focus on Triple P which to date has been
    provided in over 25 countries. In that capacity, he has
    overseen the expansion of the program's utilization in the U.S.
    from 11 to 38 states. He has a law degree and a Bachelor of
    Information Technology from Queensland University of Technology
    in Australia.
        Mrs. LaCrisha Rose is a resident of Cabin Creek, West
    Virginia where she is a loving wife and a mother of three
    children. Her own personal experiences with parenting have
    inspired her to be an advocate for all children and families.
    Mrs. Rose is here today to talk about her experience as a
    parent. Mrs. Rose is currently the facilitator of the West
    Virginia Circle of Parents Network which comprises parent-led
    self-help groups that allow parents and caregivers to share
    ideas, celebrate successes, and address the challenges
    surrounding parenting. She is a former home visitor through the
    Parents as Teachers program and currently serves as a board
    member to her local program. Ms. Rose is also active in her
    local community through volunteering with her local elementary
    school and youth sports.
        And I know Dr. Schrier wanted to introduce Ms. King, but I
    am going to go ahead and do that. Ms. Judy King serves as the
    Director of Family Support Programs at the Washington State
    Department of Children, Youth, and Families. She has 30 years
    of experience in human services and family support and has
    worked at the community, state, and national levels. In her
    current role, she oversees work related to home visiting system
    development, child abuse prevention strategy, early
    intervention, therapeutic and trauma informed childcare, health
    and early childhood and infant mental health. Ms. King also
    serves as the Executive Director of the Prevent Child Abuse
    America Washington State chapter and serves on the board of the
    National Alliance for Children's Trust and Prevention Fund.
        Oh. I just finished, Dr. Schrier. Welcome.
        Welcome to all of our witnesses. We appreciate all of you
    for being here today, and we look forward to your testimony.
        Let me remind the witnesses that we have read your written
    statements, and they will appear in full in the hearing record.
    Pursuant to committee rule 7(d) and committee practice, each of
    you is asked to limit your oral presentation to a 5-minute
    summary of your written statement.
        Let me remind the witnesses that pursuant to Title 18 of
    the U.S. Code, Section 1001, it is illegal to knowingly and
    willfully falsify any statement, representation, writing,
    document, or material fact presented to Congress or otherwise
    conceal or cover up a material fact.
        Before you begin your testimony, please remember to press
    the button on the microphone in front of you so it will turn
    on, and the members can hear you. As you speak, the light in
    front of you will turn green. After 4 minutes, the light will
    turn yellow to signal that you have 1 minute remaining. When
    the light turns red, your 5 minutes have expired, and we ask
    that you please wrap up.
        We will let the entire panel make their presentations
    before we move to member questions. When answering a question,
    again, please remember to turn your microphone on.
        I first recognize Dr. Jackson.

      STATEMENT OF YO JACKSON, PH.D, ABPP, PROFESSOR, PSYCHOLOGY
    DEPARTMENT AND ASSOCIATE DIRECTOR, CHILD MALTREATMENT SOLUTIONS
      NETWORK, THE PENNSYLVANIA STATE UNIVERSITY, PENNSYLVANIA &
     RESEARCH PROFESSOR, UNIVERSITY OF KANSAS STATE COLLEGE, KANSAS

        Ms. Jackson. Good afternoon, Madam Chair Bonamici, Ranking
    Member Comer, and members of the committee. My name is Dr. Yo
    Jackson, and I am a Professor of Psychology as well as the
    Associate Director of the Child Maltreatment Solutions Network
    at Penn State University. I am also a research professor at the
    University of Kansas. And I have worked for over 20 years as a
    board-certified clinical child psychologist and a researcher on
    the development of resilience for kids exposed to trauma and
    child maltreatment. Thank you for inviting me to speak with you
    today.
        Child maltreatment is a significant public health problem.
    In 2017, 7.5 million children were referred to protective
    services with 3.5 million children meeting at least the minimum
    criteria to warrant an investigation. Of those, 674,000
    children were determined to be victims of child maltreatment.
    That translates to a child being significantly harmed about
    every 45 seconds.
        Child maltreatment includes experiences like neglect,
    physical abuse, sexual abuse, with neglect being the most
    common. Sadly, 1,720 children died as a result of child
    maltreatment in 2017, placing the United States second only to
    Mexico for the most intentional child fatalities in the
    developed world.
        Child maltreatment is second in terms of the most prevalent
    childhood public health problems in the U.S. just after obesity
    and ahead of things like attention deficit disorder, asthma,
    cancer, and autism. In 2015, the average lifetime public cost
    associated with child maltreatment is estimated to be over
    $830,000 per victim, coming to a total of roughly $428 billion
    in costs for the number of victims over the course of just 1
    year, money that could have been saved if abuse and neglect
    were prevented.
        Maltreatment is associated with a plethora of negative and
    often devastating outcomes. It is important to note that most
    victims are under the age of 7, a time of great plasticity in
    the developing brain and social interaction systems. Early
    childhood is a sensitive period for the development of social
    relationships and forming secure attachments, something that is
    not possible in abusive and threatening caregiver-child
    relationships.
        Child maltreatment has serious negative consequences for
    brain development, impacting areas critical for learning,
    memory, emotion regulation, cognitive abilities,
    decisionmaking, and social skills. Beyond the grave
    neurological and biological effects, child maltreatment results
    in a lifetime of negative health behaviors such as risky sexual
    behaviors, obesity, substance use disorders, chronic pain, and
    cardiovascular disease.
        Maltreatment is consistently associated with higher rates
    of all forms of mental health diagnoses including risk for self
    harm. Youth exposed to maltreatment are five times more likely
    than their peers to fail in school, to leave high school
    without a degree, to become a teen parent, to be consistently
    unemployed, to experience chronic physical and mental health
    problems in adulthood, and are three times more likely to be
    incarcerated, homeless, or live below the poverty line as
    adults.
        The range of emotional, behavioral, cognitive, and social
    delays as a result of child maltreatment are limitations that
    some may be able to adapt to but most will never overcome. If
    adequate prevention programs were in place, these negative
    outcomes would not occur. Moreover, the negative effects of
    maltreatment are significantly increased with each
    revictimization making what was a hard to treat problem much
    worse and increasing the odds of long-term maladjustment.
        Given that on average, a child referred for protective
    services will be referred for abuse concerns three more times
    before they reach the age of 18, child maltreatment is likely
    underestimated in terms of its impact in the research presented
    here.
        The bulk of primary prevention efforts currently fall under
    the definition of home visiting where professionals visit
    parents in their homes and focus on the well being of children
    ages 0 to 5. Several of these primary prevention programs have
    been shown to reduce reports of child maltreatment. A paper in
    2018 reported the cost benefit return of $4 for every dollar
    spent on universal primary prevention programs.
        In contrast, targeted prevention includes a host of
    programs implemented within protective services to improve home
    environments and protect children from another instance of
    child maltreatment. A cost benefit analysis found that two of
    the most widely lauded targeted programs, Safe Care, returned
    over $21, and parent child interaction therapy returned over
    $15 in benefit for every dollar spent on implementation.
        Although child maltreatment is pervasive, it is also
    preventable. Because most victims of maltreatment are young
    children, prevention programs are critical to avoid the
    biological and social development impacts, impairments, and
    downstream effects. Child maltreatment requires a comprehensive
    prevention strategy. The reauthorization of CAPTA is an
    exceptional opportunity to better support the systems that
    protect children from maltreatment. Through CAPTA, we seek to
    better coordinate our efforts across the patchwork systems of
    federal, state, and local agencies and services, to seek out
    efficiencies and best practices that are supported by an
    evidence base. Data driven approaches are necessary to increase
    the research base and to advance knowledge on what works for
    whom.
        We also need to seek to find and develop innovative
    coordinated solutions that facilitate the feasible and
    sustainable involvement of schools, parents, adults, government
    agencies, and service providers.
        Coordination, data focus, innovation. These frames are
    vitally important for prevention because what we know is that
    our current efforts have shown little to modest impacts. What
    we are doing now is not enough to stem the tide of child
    maltreatment.
        [The statement of Dr. Jackson follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Chairwoman Bonamici. Thank you for your testimony,
    Professor Jackson.
        I now recognize Ms. King for your testimony.

    STATEMENT OF JUDY KING, MSW, DIRECTOR, FAMILY SUPPORT PROGRAMS,
     WASHINGTON STATE DEPARTMENT OF CHILDREN, YOUTH, AND FAMILIES,
                          OLYMPIA, WASHINGTON

        Ms. King. Good afternoon, Chair Bonamici, Ranking Member
    Comer, and members of the subcommittee. I appreciate the
    opportunity to speak to you today about community-based child
    abuse prevention or CBCAP. I serve as the Director of Family
    Support Programs at Washington State's new Department of
    Children, Youth, and Families, and I am the CBCAP State lead in
    Washington.
        Thanks to CBCAP, Washington State served 1,698 parents and
    2,153 children with family support services in 12 out of 39
    counties last year. We still have a long way to go in reaching
    all of the children and families who could benefit from CBCAP
    services and systems building efforts, but that task would be
    difficult and less effective without CBCAP funding.
        Brain science tells us that laying a strong foundation
    early in life critically impacts healthy development. Science
    also tells us that addressing trauma at the individual, family,
    and community levels allows us to prevent bad things from
    happening, promotes strength in children and families, and
    intervene early. In our everyday work, this means we notice the
    important things. We identify the tremendous stress, pressure,
    and uncertainty that leaves parents feeling alone, unconnected,
    and ashamed.
        CBCAP is designed to create environments where families get
    the support they need before harm occurs. This supports
    children on a positive trajectory to reach their full potential
    in school and life. This work includes parental skills
    building, voluntary home visiting programs, self-help programs,
    coordination and connection with mental health, and substance
    use services and other family supports.
        Prevention requires a highly integrated, multi-systemic
    public health approach. Just as we don't wait for someone to
    show signs of the flu before we encourage them to get a flu
    shot, we shouldn't wait for warning signs that a family needs
    support before making sure they have that support.
        In 2018, Washington's newest state agency formed combining
    the strengths of an early learning department and child welfare
    services into one unified agency. A two-generation approach
    informed by brain science leverages CBCAP funding for families
    receiving TANF benefits to offer home visiting services and
    parenting education. Experiencing success in education,
    employment, and parenting can break the intergenerational cycle
    of poverty. We offer specific programs shown to be effective
    with tribal populations and are working extensively to build
    pathways for new moms to get the support that they need while
    experiencing perinatal mental health challenges like postpartum
    depression.
        These are a few examples of how my state uses its CBCAP
    funding. As a chapter of Prevent Child Abuse America and member
    of a National Alliance of Children's Trust Funds, I have a
    front row seat to witness the extraordinary work being done by
    my colleagues around the country and in each of your own
    states.
        The flexibility in CBCAP provides options for communities
    to implement evidence-based, evidence-informed, and promising
    practices. CBCAP awardees can tailor their programs to serve
    the needs of their communities while evaluating programs,
    measuring outcomes, meeting fidelity, and adhering to
    implementation science principles to achieve the positive child
    and family outcomes. states have said they need flexibility to
    use federal funds to help families sooner, before serious
    danger arises or harm occurs.
        As far as resources, CBCAP represents the main federal
    investment in primary prevention for the entire country with an
    investment of $39 million over all 50 states in 2018. This
    funds prevention at $0.53 per child per year resulting in a
    great deal of unmet need. The current funding in Washington
    State allows 10 to 12 local organizations to offer small-scale
    programs with more than 90 percent of qualified applicants
    turned away. DCYF, my agency, recently identified 23 small
    locales with highest rates of abuse or neglect that we are not
    able to serve due to funding constraints. With more funding for
    prevention, we would work within each community to build
    community-driven interventions using a targeted universalism
    approach to increase services available in communities at known
    risk. This is prevention at its best and it requires resources.
    The pursuit of the goal of strengthening families is through
    primary prevention, strong and responsive communities, and
    collaborative efforts among public health, early learning, and
    child welfare.
        Every parent wants to be a good parent. They just need the
    tools and supports to get them there. Families describe this
    work as raising their children with opportunities to achieve
    their hopes and dreams. I say it helps families live their best
    lives.
        I appreciate your time and attention this afternoon, and I
    would be happy to answer any questions you may have. Thank you.
        [The statement of Ms. King follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Chairwoman Bonamici. Thank you for your testimony.
        I now recognize Mr. Thomas for 5 minutes for your
    testimony.

    STATEMENT OF BRADLEY THOMAS, CEO, TRIPLE P, POSITIVE PARENTING
                   PROGRAM, COLUMBIA, SOUTH CAROLINA

        Mr. Thomas. Chairwoman Bonamici, Ranking Member Comer, and
    members of the subcommittee, my name is Brad Thomas, and for 8
    years I have served as the CEO of Triple P America. I thank the
    committee for the opportunity to share my experience with the
    Positive Parenting Program which takes a primary prevention
    approach to child abuse and neglect.
        In the four decades since CAPTA was first authorized, the
    U.S. has built a foundation of child welfare and safety based
    upon best practices, evidence, and lessons learned. Systems can
    always strive to improve, and we are now in a position to build
    upon that foundation. We believe that the current system is
    under significant stress because it is designed primarily to
    provide intervention rather than focus on the prevention of
    abuse and neglect before it occurs.
        Costly systems have been built to deal with the conveyor
    belt of maltreatment, and therefore, avoidable abuse and
    neglect of children occurs. The child welfare system is
    overwhelmed, and the taxpayer is faced with the resultant cost.
    There is a better way, primary prevention that targets the
    broader population.
        Notwithstanding the immediate and tragic impact of child
    maltreatment, it can also have long-term effects on health and
    well-being if not addressed. The treatment of child abuse and
    neglect after it occurs is significantly more expensive than
    the prevention of it. A study conducted by the Perryman Group
    estimated the lifetime impact of first time child maltreatment
    occurring in 2014 as costing the U.S. 5.9 trillion.
        Conversely, evidenced-based models for primary prevention
    catch parents well ahead of adverse experiences for children.
    They normalize parents asking questions and ensure quick,
    reliable, and actionable information. Oftentimes, this can be
    the difference between equipping parents with the confidence to
    problem solve daily stresses or allowing stressful and
    challenging behaviors, left unchecked, to escalate for both
    parent and child.
        The challenge, however, is building systems that can scale
    and achieve reductions in child maltreatment at a county or
    state level. There is some essential elements that make
    programs like Triple P work to achieve population level change.
    One, program design. Two, evidence based. Three, use of an
    existing work force. And four, cost effectiveness. Let me
    explain.
        The most impactful programs to achieve population level
    effects are designed to make services available for delivery in
    an array of settings that suit the parent's preferences and
    allow parents to receive help according to their needs, not
    taking a one-size-fits-all approach.
        Next, it is essential that programs and services are
    evidence-based. As an example, Triple P is the most researched
    parenting program in the world with over 300 evaluation papers
    involving more than 400 academic institutions worldwide. One
    such evaluation was a landmark randomized control trial funded
    by the CDC in 18 counties in South Carolina in 2005. During the
    period studied, child maltreatment rates increased by 7.9
    percent in the nine controlled counties and decreased by 23.5
    percent in the nine counties where Triple P was implemented.
    Similar patterns were found for out-of-home placements and
    hospital-treated child maltreatment injuries.
        Training a community's existing work force to deliver
    parenting supports dramatically increases the speed at which a
    program is able to scale and leverages existing trusted
    relationships between parents and providers. In turn, systems
    that only provide supports to the extent needed and utilize a
    work force that is already in place saves money and resources.
    Independent research undertaken by the Washington State
    Institute for Public Policy on a range of program supports
    these savings. By way of example, the research demonstrates
    that for every dollar invested in the Triple P system upstream,
    there is a resultant $10.05 in benefits downstream. In spite of
    proven outcomes, evidence-based models that align with primary
    prevention have been limited in their ability to scale due to a
    lack of available funding for prevention programs.
        CAPTA is the main federal legislation providing population
    level primary prevention capacity building, so appropriate
    funding is absolutely critical. We applaud Congress for
    examining CAPTA and the prevention of child abuse and neglect
    generally. As Congress looks to reauthorize CAPTA, we encourage
    you to consider the following:
        First, a focus on primary prevention designed to reach the
    broad population or provide both monetary savings and reduce
    the human toll taken on children and families exposed to abuse
    and maltreatment.
        Second, the designation of appropriate lead agencies for
    CBCAP that have a demonstrated commitment to broad community
    prevention work such as children trust chapters, prevent child
    abuse chapters, and health departments may help to unfurl the
    streams of funding and have a more significant impact on
    communities.
        Finally, ensuring funding is allocated to evidence-based
    holistic primary prevention will thereby invert and shrink the
    funding pyramid over time and reduce the incidence of and costs
    associated with child maltreatment.
        I appreciate and welcome your committee's dedication to
    this important endeavor and stand ready to be of assistance in
    any and all ways possible.
        [The statement of Mr. Thomas follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Chairwoman Bonamici. Thank you for your testimony.
        And finally, Mrs. Rose, thank you so much for being here. I
    recognize you for 5 minutes for your testimony.

     STATEMENT OF LACRISHA ROSE, FACILITATOR OF THE WEST VIRGINIA
      CIRCLE OF PARENTS NETWORK, TEAM FOR WEST VIRGINIA CHILDREN,
                          MIAMI WEST VIRGINIA

        Mrs. Rose. Thank you. Good afternoon, Madam Chair Bonamici,
    Ranking Member Comer, and members of the committee. Thank you
    for the invitation to be here today.
        My name is LaCrisha Rose, and I live in Cabin Creek with my
    husband and three children. I am employed by TEAM for West
    Virginia Children where I facilitate a program with mutual
    self-help groups on the state level using the Circle of Parents
    model. And today I would like to talk to you about why the
    reauthorization of the Child Abuse Prevention Treatment Act is
    important for families like mine.
        Have you ever found yourself wondering or wishing that
    someone would sit down with you and help you be a better
    parent? That is exactly how I felt when my husband and I found
    ourselves facing the same challenges that our parents had
    before us. And just like most first-time parents, you use the
    methods that were used on you as a child. But that didn't work
    for us. So the more I spanked my child, the worse his behavior
    became.
        One day I joined a local play group at the Sharon Dawes
    Elementary School through the Starting Points Family Resource
    Center, right by our home. Talking with other parents made me
    feel like I wasn't alone, and I really enjoyed learning about
    my child's brain development. Eventually I signed up for other
    programs at the Starting Point Center such as the home
    visitation program with Parents as Teachers, and it was through
    building a trusting relationship with my home visitor that
    allowed me to reach out for help with my concerns surrounding
    discipline.
        My home visitor was wonderful. She provided me with tons of
    positive parenting solutions such as time in versus time out,
    getting down to my son's level and looking him in the eye. She
    encouraged me to look at these tools like tools in a toolbox.
    And some of the concepts were so simple, but yet, they never
    crossed my mind. Maybe that is because the only tool I ever had
    in my toolbox was a hammer, so everything looked like a nail.
        A couple months later I was at a group exercise for the
    Circle of Parents, and I had to play the role of a parent who
    lost her child due to harsh physical punishment. And this hit
    me like a ton of bricks because the only difference between
    that parent's outcome and my own was prevention.
        This sparked a fire inside of me and made me realize that I
    needed to pay it forward, and so I started to climb the parent
    leadership ladder. I became a home visitor for the Parents as
    Teachers program in my local community, and then I started to
    facilitate the Circle of Parents groups at a state level. Then
    I was invited to become the co-chair of the Alliance National
    Parent Partnership Council.
        But my favorite achievement on my journey was becoming
    certified to deliver the same program that saved my life, the
    Strengthening Families Protective Factor Framework of bringing
    the framework to life and your work. Sorry. This snowball
    effect has led me here today.
        Growing up, my parents worked very hard but yet struggled
    to provide my brother and I with the best life that they could.
    And today families continue to struggle, but local prevention
    programs help families like mine succeed. Prevention matters,
    and it can be used in all families, so here are my hopes.
        I hope that something I have said here today helps you
    recognize the importance of increasing the resources that are
    available to families. Currently Congress invests about $0.53
    per child annually across the Nation. We can do so much better.
    It would be great if we could increase that to $0.53 per child
    per month versus annually.
        I hope that you hear more testimoneys in the future with
    happy endings like mine due to the efforts of prevention that
    you have created and supported. And I hope that 1 day my
    children will be able to stand here in front of you and thank
    you for listening to their mother's story and tell you about
    the lives of their children and how much richer they are
    because of the decisions you make in the next coming days.
        Thank you for your time here today and letting me tell you
    what I believe helps build strong families; yours, mine, and
    all the families across the Nation.
        [The statement of Ms. Rose follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Chairwoman Bonamici. Thank you very much for your
    testimony. What a wonderful example of how you can break the
    cycle, and we really appreciate your being here and sharing
    your own personal story.
        Under committee rule 8(a), we will now question witnesses
    under the 5-minute rule. As chair, I will start and be followed
    by the ranking member, and then we will alternate between the
    parties.
        Ms. King, thank you for discussing the importance of the
    federal community-based child abuse prevention grants and your
    agency's prevention work in Washington State, my neighbor to
    the north. We know that child abuse and neglect is preventable,
    and yet, as you mentioned in your testimony, the grants are
    currently funded at half of the federal authorization cap.
        In my home state of Oregon, the CBCAP grants are critical
    to supporting key prevention activities. In the Fiscal Year
    2018, we got $280,000. That is it. That is not nearly enough to
    meet the needs. So can you talk about how increased federal
    investment in the CBCAP grants would benefit your state's work
    and the work of other states on prevention?
        Ms. King. Sure. Thank you. It is an interesting experience
    for us because we provide very small grants for small scale
    programs with our CBCAP funding, approximately $30,000 to
    $40,000 per program that is involved for a 3-year cycle. We end
    up only funding three to four new programs per year with
    usually asks coming in from communities for between $800,000
    and a million dollars. So just the nature of communities that
    are ready to be implementing services needs in their
    communities have models are going to work, we see a tremendous
    need.
        I also discussed briefly that we have identified 23
    locales. Think about neighbor--a little larger than a
    neighborhood but not as large as a subcounty that really have
    some of the highest risk, and what we would like to do in the
    future is figure out how to embed more programs and services,
    not just prevention but early learning and other types of
    support services in those communities driven by the community,
    and that something to do that deeper work we can't do with
    current funding as well.
        So I would say we have a lot of unmet needs and a lot of
    communities ready to take action.
        Chairwoman Bonamici. Indeed, thank you so much. I mentioned
    in my opening statement, the opioid crisis, and I am very
    concerned about the increase in the rate of child abuse and
    neglect, and some of it, you know, we have in conjunction with
    conversations about the opioid crisis.
        I remember in Oregon, listening to the story of a woman who
    became addicted to opioids--well, they were prescribed to her
    following a C-section, and then when she ran out of her
    prescription, went to the streets, lost her kids for a while.
    And it was hard work to get them back. And I have seen--so we
    hear tragic stories like that across the country, but I have
    seen promising programs to support these families, for example,
    Health Share of Oregon, a coordinated care organization in
    Portland, provides integrated care for mothers with addiction
    and their children, some of whom are born with withdrawal
    symptoms.
        And another project--program called Project Nurture that
    supports families during their pregnancy for a year, and then
    after the child is born, they receive substance abuse
    treatment, mental health services, and parenting resources. And
    the majority of mothers who have participated in the program
    are now parenting successfully.
        So what more can be done at the federal level to address
    this increase in child abuse and neglect that is exacerbated by
    the opioid crisis and support those families? I think I will
    start with Professor Jackson, if you have thoughts on that?
        Ms. Jackson. I think it is really important to remember
    that this an issue that has multi sides to it, that child abuse
    and neglect is not caused by one thing. There is not one
    situation that we can point to, that will tell us every time
    what is going to happen next, and so we have to be vigilant
    about what the data tells us.
        So I think what I would encourage you to think about is
    really the multifaceted nature of the factors that contribute
    ultimately to this happening and then--and part of why we have
    to think about prevention in a multipronged way as well.
        Chairwoman Bonamici. Thank you.
        Does anybody else have thoughts on the--especially the
    mothers keeping them with their kids, what is the best way to
    address that?
        Ms. King?
        Ms. King. I would agree with Professor Jackson. I think it
    is a very complex problem, and it requires a complex set of
    solutions across those many partners. Your suggestion of the
    work in Oregon with really embedded-in, coordinated care on the
    health side, also being really supported through where dollars
    flow for substance use and mental health treatment. And child
    welfare and early learning, all having a response to this. What
    we know is that some of our youngest children, infants in our
    state--and I know many other states--are the highest percentage
    of children coming into the child-welfare system with a high
    degree of those children coming in due to substance use. And we
    have to look at how we can work together across the system to
    provide more opportunities for families.
        I have had a story shared relatively recently about a
    family who was receiving home visiting services, had been
    using--hadn't screened in the questionnaire for using
    substances, and got to the point in her comfort level with a
    home visitor to say, I am afraid that my baby will be affected
    when it is born, and that home visitor then was able to work
    with that mom to do some planning, let go of some of the shame
    and guilt and try to help her be successful.
        Chairwoman Bonamici. Thank you. I don't mean to cut you
    off, but I want to set a good example because I am over time. I
    yield back. Thank you.
        I right now recognize Representative Stefanik from New York
    for her questions.
        Ms. Stefanik. Thank you, Chairwoman Bonamici. I also want
    to thank all of the witnesses for your very important and
    compelling testimony today.
        I wanted to particularly highlight your testimony, Mrs.
    Rose. Thank you so much for being here. Your statement was
    incredibly powerful to hear from you as a mom, and you are an
    example for so many parents across this country. So thanks for
    your courage today and for telling your story.
        I wanted to ask the panel as a whole--and anyone can
    answer--the data shows that neglect is the most prominent form
    of abuse cases. Can you talk about the different ways children
    are neglected that may not be obvious to viewers today or
    people at this hearing. And then specifically how we can
    structure programs to help prevent these cases of neglect.
        So first the indicators of neglect, descriptions of
    examples of neglect, and then broadly, how we prevent neglect.
        Professor Jackson, I will start with you.
        Ms. Jackson. Sure. So there is a couple different ways we
    think about neglect. That actually covers several different
    things. So it includes things like personal hygiene, physical
    hygiene. It includes health, so taking your child to the doctor
    when they need to go to the doctor. It also includes things
    like educational neglect, which is making sure your child goes
    to school. So there is a variety of different things.
        Some of them are very clear from the outside. So kids who
    show up to school who haven't changed clothes, for example. But
    sometimes things are harder to see, right, so in terms of the
    neglect in the home environment, right, sometimes those are
    basic needs, kinds of things, is there enough food, right,
    things that a caseworker maybe could easily spot.
        But there is other types of neglect that are, I think to
    your point, more challenging to see because they are not so
    obvious and physical, right? So that might be more things like
    emotional neglect, right, where you are not providing support--
    emotional support, praises, and encouragements to your child
    for the things that they do. Children need that. That is not
    extra. Children need your support. They need your praise.
        And so what prevention efforts do in terms of addressing
    some of those harder-to-see, everyday things, is, they provide
    parents with education. They provide them with support of their
    own, so that they have the capacity to be able to support their
    children emotionally and socially as they move forward.
        Ms. Stefanik. Thank you.
        Mr. Thomas, did you want to comment on how your program
    invests in preventative measures when it comes to preventing
    neglect?
        Mr. Thomas. Sure. And I think Professor Jackson handled
    that really nicely in terms of the answer. I think the
    emotional neglect is certainly one that is not as obvious. And
    a large part of what Triple P does is simply to get a parent to
    enjoy parenting again, and to build a stronger relationship
    with their child.
        And there are strategies such as praise that Professor
    Jackson mentioned, and getting involved in activities with the
    child, to have that relationship and build that relationship
    with the child.
        Ms. Stefanik. One followup, and this may fall under the
    educational focus that you talked about, Professor Jackson. One
    of the challenges we have in the 21st century is screen time.
    Can you talk about whether we have invested in parenting
    classes or information on how technology specifically regarding
    the regular use of screen time to keep kids occupied can
    potentially lead to harm down the road?
        Professor Jackson?
        Ms. Jackson. So the short answer is yes. There is a whole
    area of burgeoning research on what screen time is doing and
    how that operates in the growing, developing brain of children,
    what ages children should have screens, when they shouldn't
    have screens, appreciating, too, that they have screens in
    schools, right? So that is actually--there is a good side of
    this, right? You see kindergartners learning faster. You see
    kids who demonstrate symptoms of autism able to communicate
    better, right? So there are--we talk about screen time, we are
    not always talking about video games, I think which is what a
    lot of times that means, when children are sort of babysat by
    the screen, right?
        But suffice it to say, there is a growing area of research
    clearly pointing out what the negative effects can be in terms
    of the reduced capacity to pay attention, reduced capacity to
    be frustrated, challenges with listening and being able to
    follow complex commands. But this is a growing area, because
    clearly screens are everywhere. They are not, you know,
    something that we see in just the home or maybe just as a toy
    or an activity.
        Ms. Stefanik. And just in my remaining 30 seconds, I think
    it is important, when we talk about educational tools for
    parents, that we provide information about screen time and
    potential long-term negative impacts of too much screen time at
    an early age. So thank you very much again for the testimony
    and for answering my questions.
        Chairwoman Bonamici. Thank you. I now recognize
    Representative Trone from Maryland for 5 minutes for your
    questions.
        Mr. Trone. All right, good afternoon and thank you again
    for your testimony, Mrs. Rose. That was really important, and--
    so the numbers are very sobering, there is no question about
    it. The enactment of the Protect Our Kids Act, in January 2013,
    established the commission to eliminate child abuse and neglect
    fatalities and called on the commission to produce a national
    strategy and recommendations for eliminating fatalities across
    the country.
        Chairwoman Bonamici, I would like to submit the final
    report, Within Our Reach, A National Strategy to Eliminate
    Child Abuse and Neglect Fatalities--
        Chairwoman Bonamici. Without objection.
        [The information referred to follows:]LINK#2 (TRONE)
         Within Our Reach: https://www.govinfo.gov/content/pkg/
    CPRT-116HPRT37765/pdf/CPRT-116HPRT37765.pdf
        Mr. Trone [continuing]. for your approval into the record.
    Thank you.
        Dr. Jackson, the commission recommended the Federal
    Government create national, uniform definitions for counting
    child abuse and neglect fatalities and life-threatening
    injuries. In my state of Maryland, we recognize the value of
    comprehensive data and have integrated steps into our system,
    such as working with child fatality review teams, office of
    chief medical examiners, et cetera. Can you talk and speak a
    little bit about the importance of standardized data
    nationally?
        Ms. Jackson. So as a researcher, that is something that is
    really important to me. So I think the simplest way to explain
    it is that you can't further knowledge if we don't all agree on
    what the definition of ``it'' is, right? And so we all have to
    agree on what it is, and then we can move forward with studying
    it, right, and whatever that might be.
        In this case, a very, very serious topic, a critical topic,
    to better understand the rates, prevalence incidence rates of
    child fatalities in the country, especially those related to
    child maltreatment.
        So that seems almost without question to be a critically
    important next step for folks, to have a universal definition.
    If you don't have a universal definition, if we don't all agree
    on what that is, then we can't further our knowledge. Moreover,
    we can't understand why these things happen, we don't know what
    leads up to them, because there is a myriad of things included
    in the pool.
        So it is important for us, if we actually want to create
    interventions, right, or prevention interventions, that speak
    to reducing those numbers, that everyone be operating out of
    the same definition.
        Mr. Trone. Thank you.
        Last year, Congress dedicated an entire section in the
    SUPPORT For Patients and Communities Act to trauma-informed
    care. This section affirmed the importance of preventing opioid
    addiction. In my district the other day, over 25 percent of the
    babies born had opioids or alcohol in their bloodstream. Four
    percent were born addicted. It is mind-boggling.
        So this importance of preventing this--this report will
    address a key element that often underlies substance abuse and
    the harm caused by childhood trauma. This week, we are sending
    a letter to the bipartisan coalition of members to the
    Appropriations Committee to support funding for these
    provisions. I hope we can continue to invest in tools to
    identify, understand, address, and mitigate the effects of
    trauma on children and families.
        Ms. King, in your written testimony, you mentioned, to
    prevent childhood maltreatment, you must put science into
    action. Research tells us by the age of 3, 80 percent of the
    brain is done developing. So laying a strong foundation early
    in life is important. Could you address the importance of
    addressing trauma in individual family and community levels and
    how we have to have family serving systems be trauma-informed?
        Ms. King. Yes, I can. I think for us, especially on the
    early learning side of the spectrum, again during that critical
    time of brain development--and the critical time where children
    learn that their needs can be met by a caregiver--that we look
    at all of the places that those children and family interact
    with and make sure we have standards for what that looks like,
    to both be trauma-informed and also healing-focused. We like to
    look at what our settings and environments are doing to promote
    healing among parents and children.
        One of the key strategies that has been used and is being
    implemented in a lot of states is building trauma-informed care
    in childcare and early learning settings. So we have childcare
    providers that understand when a child comes in and is
    struggling and having a hard day, that it is not aimed at the
    teacher, it is not aimed at the childcare provider. It is the
    child working on trying to regulate their emotions and deal
    with some things that are happening with them.
        It helps us with thinking about how we can build that
    capacity in our full system so that the places that those
    children are during the day, they get that positive experience,
    and build relationships with trusting adults.
        Mr. Trone. Thank you.
        Chairwoman Bonamici. Thank you.
        I now recognize the ranking member of the full committee,
    Dr. Foxx from North Carolina, for 5 minutes for your questions.
        Ms. Foxx. Thank you, Chairwoman Bonamici. And I want to
    thank our panelists for being here today.
        Mr. Thomas, when you talk about saving $10 on the back end
    for every $1 spent on the front end, are those real dollars?
    And is it the federal, local, or state Government that is
    reaping the benefit?
        Mr. Thomas. Because the--the issue of child maltreatment
    cuts across so many different agencies, the benefits that flow
    from the investment of evidence-based programs cut across
    local, state, and federal funding streams.
        You also see in those benefits, some of those benefits also
    go to the participants as well, and also the taxpayer. But it
    is spread across all of those different systems, such as child
    welfare, justice, and education, as some examples.
        Ms. Foxx. Thank you. Mr. Thomas, why is it important for
    state and local governments to think about where these kinds of
    programs are housed within their systems?
        Mr. Thomas. In the case of programs like Triple P, that are
    focused on primary prevention, it is critical to have a fit
    within an agency that has, as its mandate, a focus on the
    broader population, and so it is important when assessing the
    best fit for these programs as to what is the best agency to
    actually deliver--or at least oversee the delivery of these
    programs into the community, to make sure that they can scale
    up effectively, and reach the broad population.
        Ms. Foxx. Thank you. Pardon me. I have another question.
    Mr. Thomas, I believe collaboration across stakeholders is
    critical if any program is going to be successful in addressing
    the issue attempting to be solved. What kind of collaboration
    do you do in your program to know you understand the key
    triggers of abuse?
        Mr. Thomas. You are absolutely right, collaboration amongst
    the various stakeholders within a state's system is--or a
    county system, is critical. That if you were going to scale up
    a program at a population level, you need to have all of the--
    the entities involved with parents involved in that process.
    And so we actually spend a lot of time, when we go into a
    community, identifying what systems are in place, and making
    sure that we bring those people along, to participate in the
    process of bringing the program to all those various systems
    and to the general population.
        Ms. Foxx. Thank you. I want to say to the panelists that
    some of us were going in and out, and I apologize for that, but
    we had another committee down the hall that was having votes,
    and, unfortunately, we had to run down and vote and then come
    back.
        So I apologize for having been out of the hearing for some
    time, but that was the problem. Thank you again for being here.
        Chairwoman Bonamici. Thank you.
        I now recognize Representative Hayes from Connecticut for 5
    minutes for your questions.
        Mrs. Hayes. Thank you, Madam Chair, and also thank you,
    Representative Foxx, for just the explanation that the
    committee--I apologize for coming in late. And I also want to
    thank the witnesses for being here and for your tireless work
    on this very issue of child abuse and neglect.
        I spent the majority of my adult life as a teacher. In
    fact, before coming to Congress, I was a classroom teacher, a
    mandated reporter, so I know exactly what you are talking
    about. And as some of my colleagues have expressed, I also
    recognize that abuse is not always blatant, you know, for me it
    was, neglect was more of a factor, you know, and understanding
    and recognizing what that meant and what that looked like.
        In my community, in the city of Waterbury, where I taught,
    generally, that was associated with addiction, and trauma from
    addiction that really reverberated out into the entire family.
    In Waterbury, Connecticut, where I was a teacher, last year, we
    had 85 opioid-related deaths, and in most of those families
    there are children who are coming to school, and they don't
    have a label that says, you know, my mom is an addict, or no
    one at home is feeding me, or my dad is in prison. And so a lot
    of this--it was up to the educator to have an appreciation and
    understanding of what they were seeing and, you know, what
    their responsibility was in that.
        This is something that was very important to me because I
    was one of those kids. I grew up in a home like that. And I
    guess what I want to make sure--and, Ms. Jackson, my question
    is for you--being that we know that poverty is a risk for many
    of these young people, addiction is a risk, when we are
    responding to referrals for child maltreatment, how can we
    assure that we are addressing the underlying issues and not
    simply separating parents from children because they are poor
    or they don't have the--the background or the information they
    need?
        Ms. Jackson. Right. So I think that is a really important
    question, because a lot of research that has been done through
    the years, especially in the early years of identifying child
    maltreatment, looked for correlates, right, things that seem to
    be associated with abuse. What do these abused children and
    these abusive families have in common? Science has evolved
    tremendously since those early days, but some of the early
    findings are still with us, right, in terms of trying to
    clarify really what the active factors are.
        So to be clear, we are much better now in our place and our
    science of knowing what are the causal factors for child
    maltreatment. We are very clear about those things. What we
    notice about those families is that they have several things in
    common with each other. They are not always identical, but they
    have several things in common. There usually is a significant
    difficulty in support in those families, maybe some challenges
    with mental illness in the parents, maybe a tremendous amount
    of stress in the family, maybe there is a tremendous amount of
    conflict in the family, lots of different things that we could
    point to that are active, causal factors for child
    maltreatment.
        Poverty is not one of them. Okay? So I get that that is
    where in the beginning the thing that seemed to tie a lot of
    people together. Right? But that actually isn't a factor that
    is an active ingredient in risk for child maltreatment. It is
    really the host of many other things that we know very well
    that contribute.
        So what prevention does, is, it speaks to those things, it
    speaks to the things that the science tells us actually make a
    difference, right? Those things that are actually important in
    effecting change. The anecdotes we see a lot of still, to this
    very day. But as a scientist, what I am most interested in are
    the efforts that the prevention makes to tie to what we know
    actually makes a difference. So prevention will tie to things
    like education and conflict resolution and giving support and
    resources to those families, regardless of economic background.
        Mrs. Hayes. Thank you. I so appreciate you saying that.
        Ms. King, my next question is for you. Based on what we are
    talking about, how can we better prepare teachers and mandated
    reporters to ensure that bias is not a contributing factor when
    they are looking for signs and symptoms of abuse or neglect? I
    have seen many young people who come from families who didn't--
    not have a lot of money, you know, who lived in poverty, but
    there was an abundance of love, and parents were doing the best
    they could. And someone from the outside looking in at that
    might not see the same thing that I saw or be able to identify
    that this was a caring and supportive family.
        So how do we ensure that our teachers, our mandated
    reporters, the people on the receiving end of this information,
    don't let their own biases get in the way?
        Ms. King. Well, I think you nailed it very carefully about
    the disproportionality that we see in our system, and I think
    that is an ongoing struggle. It is an ongoing struggle in
    education for teachers. It is an ongoing struggle in early
    learning, and in reality it is an ongoing struggle in child
    welfare, as well. I picked up on your comment at the beginning,
    thank goodness children aren't wearing a label about what they
    have going on at home, because we want our educators, the
    trusted adults that work with children, to see the strength,
    see their resiliency, and we want our network of the
    multidisciplinary approach to child well-being to respond
    looking at strengths.
        That is the important piece, and I think that is where I
    see a paradigm shift happening in prevention, is, we are
    looking at strengths to build strong families. We have to focus
    on harm when it has occurred, but if we are looking upstream,
    we are looking at building strengths in families.
        Mrs. Hayes. Thank you so much.
        Chairwoman Bonamici. Thank you. I now recognize the Ranking
    Member, Mr. Comer, from Kentucky for 5 minutes for your
    questions.
        Mr. Comer. Thank you.
        Mr. Thomas, I appreciated your testimony about the insight,
    about the principles that guide your organization. What are
    some key aspects of your program that could be used by other
    entities to attain the success that you have seen?
        Mr. Thomas. I think the--some of the discussion previous to
    this focuses on that. And it is this--you don't know where
    child abuse is necessarily and you can't make assumptions. And
    so one of the elements that makes Triple P successful is that
    it reaches the broad population, and that way you know that you
    are covering families that need the services. But also using an
    existing work force enables us to scale up very quickly, and
    also it leverages off that trusted relationship that is already
    there, say, with a primary-care provider or a schoolteacher,
    and enables that advice to be given in a trusted relationship.
        Mr. Comer. This next question will be for all four members
    of the panel. What is working now with CAPTA and what is not,
    briefly?
        Mr. Thomas, you want to start?
        Mr. Thomas. Yes. I think there is--it is sometimes
    difficult for agencies that have a mandate to provide services
    to a specific population, to also then juggle primary
    prevention which takes it outside of the narrow population that
    they are serving and requires a focus on the general
    population. So where we have seen it work very well is where
    CBCAP moneys have flowed to children's trust, for example, in
    South Carolina, where they have used CBCAP money there to
    expand on some Triple P work and other things as well. And
    because they have that broader population-level focus, that is
    where we have seen it work exceptionally well.
        Mr. Comer. Ms. King, would you like to add anything?
        Ms. King. Yes, I will add. I think, I appreciate Mr.
    Thomas' comments on that because I think what we have to do,
    is, get out of the space where we are only thinking about
    direct services to that more coordinated system, and the
    systemic efforts that we really need to have to build
    relationships with existing providers, existing partners that
    work with families, to have that message carried out in all
    kinds of ways.
        We know that one message alone typically isn't enough.
    Things like safe-sleep practices, that we are working really
    hard on across states because we want to prevent fatalities
    related to unsafe sleep. We know that message needs to be
    embedded by lots of folks, many times, different ways, to be
    able to ensure that we--we have children sleeping in a safe
    way. So we will use that with primary care. We use it with
    child-welfare staff. We use it with social network messaging
    among families, sharing that information. Because those are the
    ways that we--we embed it in more of a system. So moving from
    individual programs to more of a system would be one of my
    recommendations.
        Mr. Comer. Thank you.
        Professor Jackson?
        Ms. Jackson. I would agree with that as well. What we
    really need is this integration. I think that it is the
    patchwork that we struggle with so much day to day, from one
    state to the other or one agency to the other, within the same
    sort of community. There is not a great deal of communication
    about these things. So that is another part of the frustration
    is that when there are things that work well, it is actually
    very difficult to let a large proportion of folks who would be
    interested know about that in a way that they can receive it.
    So that is one of my recommendations as well, as we think about
    integration coordination and making sure we have a vehicle, a
    mechanism, that is an easy vehicle, a mechanism for
    communication.
        Mr. Comer. Thank you.
        Ms. Rose?
        Ms. Rose. So like they have said, as well as relationships,
    and not only building relationship with the family, but
    treating the entire family, because children grow up in
    families and families grow up in communities. And so to treat
    the whole family, and I mean from one generation to the next,
    you know, treating that as a whole and providing that
    consistent messaging that children are exposed to.
        For example, my in-laws and my parents being able to sit in
    on our home visits and learn the same language and the same
    methods, ensures that no matter what environment my children
    are in, they have the same language, they have the same
    methods. And the same with our local schools and, you know, you
    can just go, build, build, build, build, but--so I think the
    consistent messaging and relationships as a whole, treat the
    whole family.
        Mr. Comer. Thank you all very much. And I yield back.
        Chairwoman Bonamici. Thank you.
        I now recognize Dr. Schrier from Washington for 5 minutes
    with your questions.
        Ms. Schrier. Thank you, Madam Chairwoman.
        First, Mrs. Rose, I just want to thank you so much for
    sharing your story, because you have personalized your story
    for all of us. I think--I am a pediatrician, and I still found
    parenting to be a challenge, and so I think we all understand
    how important the job is, and how little training we get for
    it. And it is the most important job of our lives, so thank
    you.
        Ms. King, I am sorry I was not here to introduce you. My
    question is for you. As the lead CBCAP entity in Washington,
    you are the primary funder of child abuse and neglect
    prevention programs in our state. And in your testimony, you
    talked about a coaching program for parents. You also mentioned
    a two-generation approach, and I was wondering if you could
    talk about this coaching program for positive discipline and
    what the interaction looks like between the coach and the
    parent, between the parents and the children. Then we will see
    if I have time for another question.
        Ms. King. Thank you. Yes, we like to use the word parent
    coaching because sometimes if we use the word parent visitor or
    parent educator, people view it as a top-down messaging, and
    really coaching the parent has to do with the interaction
    between the parent and child that someone is helping to
    support. So, yes, there is pieces that have to do with
    knowledge, but it is actually a lot about attitudes, skills,
    and behavior.
        So if you were working with a program that focuses on
    infants, you would expect that coach to work a lot on
    attachment issues. That serve and return, tennis term about,
    you know, a child making--making some communication and a
    parent being able to respond, starting that very early brain
    development.
        For toddlers, I would say one of the most typical things we
    see with parent coaches is trying to understand what is
    expected of a toddler, where they are developmentally. You
    know, they just can't share right away. And working with
    toddlers on, again, regulating emotions, being able to have
    words for feelings, and for parents not to get triggered. So
    developing that capacity in parents just to be calm and be able
    to address what is going on with their child.
        So the coaching really is about side-by-side work, noticing
    the strengths and building on those.
        Ms. Schrier. Does the coach in these interactions--I am
    imagining them at a family's home, watching the interaction
    between the parents--do they model it at the same time? Do they
    check in afterwards and say, here is what I observed, try this
    next time? All of the above?
        Ms. King. Yes, I think they can. I think a lot of our
    programs are really trying to focus on seeing what the parent
    is already doing and helps the parent notice that. Again, with
    that notion that looking at strengths, but there is lots of
    side-by-side coaching because a parent, you know, wants a do-
    over. They got worked up and it was hard for them to deal with
    something with the child and to be able to say, that is okay,
    you know, let's think about how you could try that the next
    time.
        So I think we get some of both, but again sort of
    scaffolding, sometimes it is about how a parent's experiencing
    their child, and sometimes it is actually about skills and
    behaviors that a parent needs to practice, to work with a
    particular age.
        Ms. Schrier. Have you seen even maybe within a family, a
    difference in outcomes, kindergarten readiness, later success
    in life, between say the first or second child where the parent
    didn't have this kind of coaching and then subsequent children
    where they did have this kind of coaching and what that meant
    for a family long-term?
        Ms. King. I probably can't speak to research on that. I do
    know what we hear from families where they say, wow, if I only
    had known this with the first child--because they may not have
    found that trusted partner or that appropriate service when
    they had their first child, and the second child comes around,
    and there is this notion of, wow, it would have been a lot
    easier if only I had known.
        I don't actually know if we have any research or data that
    is showing different outcomes by--
        Ms. Schrier. I have another question that you might have an
    easier answer to. You said you have only been able to serve 12
    out of 39 counties. And I was wondering if you had more
    resources, can you tell me where--where you would put them,
    either which counties or which sorts of programs expanding to
    different areas?
        Ms. King. Well, it is interesting. We are sort of in a
    unique place. I think there is a commitment to evidence-based
    models, and there is also really a commitment to working in
    communities with changing demographics, and building evidence
    for things that have been shown to be effective in a community.
    So we have 23 we have identified in this analysis, and we would
    really like to begin that work, planning with those communities
    with the solutions that they want to best meet the needs of
    their families. Not us choosing the model or approach, but
    really having the community look at what is available to match
    for their needs.
        Ms. Schrier. Thank you very much.
        Chairwoman Bonamici. Thank you. I now recognize
    Representative Johnson from South Dakota for 5 minutes for your
    questions.
        Mr. Johnson. Thank you very much, Madam Chair.
        Mr. Thomas, for almost a decade I was on the board of
    directors at Abbott House, which is a home for abused and
    neglected girls in my hometown of Mitchell. And I have seen the
    cost in human terms, as well as dollars and cents, in dealing--
    in providing a therapeutic-based approach. And so I was
    connected very deeply with your conversation about the
    importance of prevention as opposed to just treatment.
        And I thought the outcomes, the data from your program, was
    really impressive, some of the things you mentioned. You
    mentioned that it was widespread deployment. I mean, give me
    some sense of how widespread?
        Mr. Thomas. You mean in terms of--throughout the U.S.?
        Mr. Johnson. Yes.
        Mr. Thomas. Yes. So we have trained in over 38 states in
    the U.S., and one of the states that I like to highlight in
    terms of really scaling up within the state is North Carolina,
    where there is, at the moment, services being delivered in--
    between 40 and 50 counties with plans to scale up to the full
    100 counties within the next year or two. And so programs like
    Triple P are built and designed to scale.
        Mr. Johnson. You mentioned in your testimony having some--
    you know, a flexible and tailored approach. I would think that
    would make it more difficult to scale up. That's Not the case?
        Mr. Thomas. No. It is--the planning of it is the critical
    part. And so when you go into a community, you need to work out
    where the--because there are a variety of approaches from
    light-touch intervention through to more intensive services.
    You need to identify where the parents are that are likely to
    need to receive those services, and then you engage with those
    groups and train those people.
        So we have invested heavily in implementation science to
    understand how best to roll out an evidence-based program. The
    trial data always shows that a program works. The next
    challenge you have got then, is, how do you then take that and
    make that work within a community. And that is where the field
    of implementation science has taught valuable lessons in terms
    of how to scale up.
        Mr. Johnson. And you talked about using existing labor,
    existing professionals, which I agree, seems like it would make
    it much easier to scale up. When I talk to these people out in
    the real world, they all, without an exception, describe how
    full their jobs already are, how complete the demands of their
    profession are. I mean, how do you clear space for those people
    to deploy yet another intervention?
        Mr. Thomas. Often it is a case of--it is not adding on to
    what they do. It is a case of--particularly, I will use the
    example of a pediatrician. They will quite often get asked
    questions that are not health-related. They will get asked
    questions that are behavioral-related or developmental-related.
    And so a lot of the time they struggle to know how to actually
    answer that question in an evidence-based manner. And so it is
    not adding to the job, but it is giving them the tools to do
    their job in a better way.
        Mr. Johnson. And I don't know a lot about your curriculum
    or your approach, although what you described in your written
    testimony and verbally made a ton of sense to me. I mean,
    having parents engaged and, you know, playing with and
    experiencing things with their children, when I do that as a
    father, I feel far more connected with my children. I think I
    would assume that is a message that needs to be reinforced on a
    regular basis with parents so that is really sticks. You know,
    is that demanding too much of someone like a pediatrician?
        Mr. Thomas. No. Because when you roll out a program like
    Triple P, the idea is to have multiple touch points within a
    community--I think that was mentioned before--that the more the
    message is heard, the more the messages are reinforced. So if
    you embed a program like Triple P within a community, you will
    be getting similar messaging from a teacher, from a
    pediatrician, or a place of worship. And so when the parent is
    consistently exposed to that--part of what we also do is a
    communications strategy, and that is a large part of the
    program where there are messages either on the internet or
    radio, TV, posters, flyers, that really destigmatize the need
    for parenting supports, and normalize that process for asking
    for assistance, and also is another touch point for providing
    assistance.
        Mr. Johnson. So the data suggests that what you are
    describing works well. Is there anything within CAPTA or other
    federal regulations or programs that makes it more difficult
    for your program to scale up and help more people?
        Mr. Thomas. No. I think the evidence we have seen is that--
    that the CBCAP moneys that are flowing to the agencies that
    have rolled out Triple P, it has worked well in that regard.
        Mr. Johnson. Thank you very much.
        Thank you, Madam Chair.
        Chairwoman Bonamici. Thank you. And I now recognize the
    chairman of the full committee, Representative Scott from
    Virginia, for 5 minutes for your questions.
        Mr. Scott. Thank you, Madam Chair.
        Mr. Thomas, you were asked about real numbers on
    prevention, and one of the problems with prevention generally
    is that the person funding the prevention program isn't going
    to be the one reaping the benefits. If the city could fund a
    nice summer program, intensive enrichment program in a
    community, the benefits are going to be reduced incarceration
    and social services, to some other agencies down the way. That
    is just the way it is.
        But if a case goes bad and it costs a million dollars, it
    seems to me that somewhere along the lines, we should have
    figured out how to prevent it if we could.
        You talked about the community--primary community
    prevention generally as opposed to trying to target the
    prevention to a small group. Can you--you just said a little
    bit about it. Can you say why it is important to be community-
    wide and not try to target it?
        Mr. Thomas. Sure. First, it is thought that there is more--
    it is likely there is 40 times more abuse occurring than is
    actually reported. And so even if you tried a targeted
    approach, you don't know where that abuse is occurring. And so
    a broader approach is critical for that reason. But also, even
    what you would consider typically well-resourced parents are
    also susceptible to abuse. And there can be triggers within any
    household that can lead to that abuse and neglect.
        And so the other issue with targeting specific populations,
    you start to stigmatize those families and the program as well,
    when you target families in that fashion, when you are having a
    primary prevention focus. And so the idea is to make it widely
    available in order to really address child maltreatment rates.
        Mr. Scott. Thank you.
        And, Dr. Jackson, I guess one question people would have
    is, does prevention actually work? Are you familiar with the
    Nurse-Family Partnership program?
        Ms. Jackson. Yes, I am.
        Mr. Scott. Has that been studied, and can you say a word
    about the results of those studies?
        Ms. Jackson. Sure. The Nurse-Family program is probably one
    of the oldest programs, one of the first ideas, was to have a
    pair of professionals or have nurses or have other types of
    professionals come in the house, come meet with the family and
    help you in the house, really starting prenatally in lots of
    cases, right, so with pregnant, what might be considered high-
    risk families, and to prepare that family for the arrival of
    the child and then to work with them after they left.
        It has the most evidence perhaps because it has been around
    the longest. It has also been evaluated tremendously, but we
    find that that is considered to be an evidence-based program at
    the highest level of rigor that we have a metric for evidence.
        Mr. Scott. And what is it? Does it reduce child abuse?
        Ms. Jackson. Well, it reduces child abuse reports. The
    evidence also speaks to fewer hospitalizations. Bearing in
    mind, too, that child abuse is several different kinds of
    things. Primarily what we find--
        Mr. Scott. Does it reduce prison? Long-term, does it reduce
    prisons?
        Ms. Jackson. Well, I think that--that is a hard connection
    to make, for anything, long-term, at reducing time in prison.
    What we find more immediately is fewer juvenile-justice
    problems, right, fewer conflicts in the homes.
        Mr. Scott. Currently each state uses its own child abuse
    and neglect registry to collect information, which means that
    if somebody has a problem in Oregon and moves to Virginia,
    Virginia may not know. Would creating a mechanism that allows
    states to share data of their child abuse and neglect
    registries help other states avoid problems? Ms. Jackson?
        Ms. Jackson. So--so this is a vital next step, that states
    be able to speak to each other. It may surprise some members of
    the committee to understand that actually every state has its
    own system and that they don't necessarily speak to each other.
    And they don't--not only do they not speak to each other, they
    often are adversarial, in terms of sharing information.
        Where we see positive indication of this, there are some,
    if you will, rather informal agreements, between states. They
    are almost always states, though, that are close to each other,
    on the map. And around cities that sit around a state line,
    right, where it makes sense to share in Kansas City between
    Kansas and Missouri, and more informally, right, because you
    have a very fluid place like that.
        But it is absolutely critical, perhaps most importantly,
    because what we know is that being victimized, especially
    having a substantiated case of child maltreatment puts you at
    tremendous, exponential risk for another incidence of child
    maltreatment, right? So it doesn't go away because you move,
    right? The change of scenery doesn't do anything for your risk
    factors. In fact, it probably increases them because you are
    now in a place with fewer resources, fewer people you know,
    fewer programs that you are involved with. And it doesn't allow
    that new state to know what worked for you before, what
    services did you get before, what made a difference, what
    didn't work, right? So without sharing that information we set
    ourselves backward in terms of helping children in the country.
        Mr. Scott. And a quick followup on the Nurse-Family
    Partnerships, do you have a cost-benefit ratio?
        Ms. Jackson. I believe I provided one in my written
    testimony.
        Mr. Scott. Okay. Thank you.
        Chairwoman Bonamici. Thank you.
        I now Representative Thompson from Pennsylvania for 5
    minutes for your questions.
        Mr. Thompson. Chairwoman, thank you so much. Thanks for
    this hearing, and thank you to all members of the panel here
    for your testimony, your experiences you bring.
        Dr. Jackson, as on behalf of all my Penn State alumni,
    welcome to Happy Valley. We are sure glad to have you there.
    Welcome to the Penn State family. In your written testimony,
    you state that despite public health approaches--and certainly
    the emphasis that we have all had to child maltreatment
    prevention--that national rates have not fluctuated
    substantially over the past 15 years.
        You also mentioned that the most recent report shows that
    the number of children investigated for child maltreatment has
    actually increased by 10 percent over the past 5 years, and
    that the number of proven child-maltreatment cases has
    increased by almost 3 percent.
        Just--I wanted to drill down a little bit and get your
    impressions of why that is. Are we just more aware of these
    issues than we were in years past, or we really didn't have a
    good benchmark in the past--an accurate benchmark in the past?
    Or is it reflected with some of your most immediate
    conversations of, you know, we are not all reporting the same
    way? What are your thoughts on that, why that is occurring?
        Ms. Jackson. Right. So why do rates stay the same, or why
    do they change? It is a really great question, because it
    speaks to, I think, ultimately a question we want to ask about,
    is what we are doing making a difference, and can that be
    reflected in the prevalence and incidence rates that we see
    reported.
        So we do know a couple of things. One, the public is much
    more informed about child maltreatment than it ever was before,
    to be sure. There is many, many ways we are getting more
    information. Public service information within our school
    systems, right, so we get more information about the types of
    child abuse, the types of child maltreatment, so we are aware
    of those things.
        To my knowledge, though, the number of things like the
    mandated reporters haven't increased, like, so we don't have
    more people reporting, but we do have more people who are
    aware, and I know particularly in the state of Pennsylvania,
    where lights--when lights get shone on a situation, where they
    are concerned about a particular incidence of child abuse--Penn
    State, of course, experienced this several years ago--it tends
    to increase the knowledge base in that particular state. So we
    see rates of reporting in child maltreatment in the state of
    Pennsylvania skyrocket, particularly. So there is some sense
    that that is based on education, based on information that you
    have given them some encouragement to share that.
        But also to be clear, the risk factors for abusing your
    children, whether those are neglect, physical abuse, or sexual
    abuse, have also increased. The amount of stress that families
    are feeling, the amount of conflict that is present in the
    home, the amount of mental illness that parents are reporting,
    the amount of addiction that is present in this country are
    also contributing to those rates. And so as a clinical child
    psychologist those are usually the things that I am paying
    attention to, are those sort of active factors that speak to
    risk in the family, even if reports are also increasing.
        Mr. Thompson. Thank you.
        Mrs. Rose, thank you for your testimony. Excellent
    testimony. You know, and obviously life can be challenging.
    There is no doubt about it. Adversity is kind of a part of life
    from time to time. It comes in different degrees and shapes.
    Have you ever--That said, with the experiences that you have
    had, how can families and parents build resilience to be able
    to deal with that? What are some of the--I love your lessons
    learned--they were excellent--that you shared in your oral
    testimony, written testimony, you know--you know, but what else
    can we do, what can parents do or a family do to build that
    resiliency?
        Ms. Rose. Thank you for your question. So, I think back--in
    my written testimony, it is there--to a time when I lost a
    daughter, and it was a really hard time for us. And so
    everything I had essentially been equipped with, with the tools
    in my toolbox, were just kind of out the window. And really the
    connection and all the work that had been laid up to that
    point, with my children and spending time and building
    relationships with the family, gave me that reason to move
    forward.
        And so when you ask about building resilience and how we
    can make families do that, is just through simple, everyday
    actions. Pointing out family's strengths. So instead of
    pointing out, we are so sorry this happened to you, that is
    being empathetic and that is helpful, but this may have
    happened to you, but here is, you know, not a silver lining,
    but here is what you are strong at as a parent. Here is the
    reason why you need to move forward. Here are some things you
    can build upon. So not dismissing the fact of things that they
    may need to work on, but really building on the strengths of
    things that they are good at and highlighting that.
        Mr. Thompson. All right very good. Thank you.
        Thank you, Madam Chair.
        Chairwoman Bonamici. Thank you.
        And I now recognize the Representative Langevin from Rhode
    Island for 5 minutes for your questions.
        Mr. Langevin. Thank you, Madam Chair and Ranking Member
    Comer. I want to thank you for holding this important hearing
    and for allowing me to sit in and question today.
        And I want to thank our panel of witnesses and thank you
    all for the work that you are doing to promote child welfare.
        Clearly, we all have a lot that we can do, and we rely on
    experts, of course, like yourselves, who are on the front lines
    doing everything you can to make sure that we are protecting
    our children.
        I am proud to co-chair the Foster Youth Caucus with
    Congresswoman Karen Bass from--and several other co-chairs. And
    I came to these issues years ago. When I was growing up, my
    parents had welcomed many foster children into our home, and
    today it is a priority of mine. It has really helped me to be a
    better policymaker on these issues, to ensure that every child
    has a safe and loving home.
        So I would like to touch on a specific issue that I became
    aware of several years ago, sadly, as a result of a Reuters
    report. It is a frightening phenomenon known as unregulated,
    child-custody transfers, or UCT, also known colloquially as
    rehoming. And it is a practice of basically transferring
    custody of a child, usually an adopted child, to a stranger
    outside the safeguards of the child welfare system, resulting
    basically from a failed adoption.
        And I first learned about this about 5 years ago from a
    Reuters published report on parents who were advertising, if
    you can believe that, the children on online forums, often
    because they couldn't handle their child's behavioral issues
    resulting from past trauma.
        Without a system of support, these parents turned to
    strangers, people who hadn't been--who hadn't undergone
    background checks, home studies, or supervision. Some children
    from the report ended up in homes where they were subjected to
    physical, sexual, or emotional abuse, not to mention the
    additional trauma, instability of a new placement.
        Addressing UCT, of course, requires a multi-pronged
    approach, including increasing support services for families so
    that they never reach the crisis point where they feel they
    need to give up their child. Again, the result of a failed
    adoption.
        Just as important, however, is the need for uniform
    national standards to identify and--for identifying and
    responding to reports of UCT. So instinctively, we know that
    UCT is a form of abuse and neglect, and yet on the federal
    level, in the vast majority of states, the law doesn't clearly
    treat it as such, creating confusion for child protective
    services when they try to investigate cases, and sometimes
    leaving them uninvestigated entirely.
        So I would like to start, if I could, Dr. Jackson, with
    you. Based on your experience, can multiple home placements
    cause trauma for the children, and do you agree that
    unregulated custody transfers, which often place children in
    unsafe environments are a form of child maltreatment?
        Ms. Jackson. Thank you for the question. So the first part
    of your question is about multiple placements causing harm. So
    my answer to that question is, it depends on the placement. So
    if you are moving someone from a dangerous placement or a risky
    placement or unsupportive placement to some other place that is
    supportive, then it is a good idea. And if that environment no
    longer meets the needs of the child, finding a place that does
    is a good idea.
        Now, that said, children need stability in their lives.
    They need that kind of basic foundation to be able to
    understand routine. So we wouldn't encourage it by any means,
    but I wouldn't give a blanket statement to suggest that
    multiple placements are necessarily problematic. It is all
    about the quality. You know, this is true when it comes to
    alternative care in general. The idea of it is not bad. It is
    the implementation that can be problematic. It is the kind of
    home you get placed in, it is the supported environment that
    you are in now that makes a difference. And if that new place
    is not a better place, it doesn't meet your needs, then you
    will continue to have difficulty.
        To answer your second question, unfortunately, I am not
    familiar with this phenomena that you are describing, this--if
    I understand it correctly, this having adopted kids and saying
    this is not working out, and then on your own as a family,
    finding another place and bypassing child protective services.
    Unfortunately, I am not familiar with that.
        Mr. Langevin. Okay. Probably my time is about to expire,
    and I will put this one for the record. But in your testimony
    you mentioned the importance of coordinating efforts across the
    patchwork system of federal, state, and local agencies to
    prevent child maltreatment. How important is it to have clarity
    about what constitutes child abuse and neglect to this
    coordination, to preventing and responding to child
    maltreatment?
        So I know my time is expired, so I will yield back, and if
    you would answer that question for the record--
        Chairwoman Bonamici. Thank you, Mr. Langevin. I see no
    other Members to ask questions, so I want to remind my
    colleagues that pursuant to committee practice, materials for
    submission for the hearing record must be submitted to the
    committee clerk within 14 days following the last day of the
    hearing, preferably in Microsoft Word format.
        The materials submitted must address the subject matter of
    the hearing. Only a Member of the committee or an invited
    witness may submit materials for inclusion in the hearing
    record. Documents are limited to 50 pages each. Documents
    longer than 50 pages will be incorporated into the record via
    an internet link that you must provide to the committee clerk
    within the required timeframe, but please recognize that years
    from now the link may no longer work.
        And now without objection I would like to enter into the
    record a report from the U.S. Government Accountability Office
    which recommended that the Secretary of Health and Human
    Services strengthen the data quality of child abuse and neglect
    fatalities and current practices leading to incomplete counts.
        And a scholarly article written by researchers at the
    Centers for Disease Control, showing that the total lifetime
    cost of substantiated cases of child abuse and neglect is
    $830,928 per child, which bears a total annual cost of $428
    billion to our country.
        [The information referred to follows:]
        Strengthening National Data on Child Fatalities Could Aid
    In Prevention: https://www.govinfo.gov/content/pkg/CPRT-
    116HPRT37764/pdf/CPRT-116HPRT37764.pdf
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        Chairwoman Bonamici. Again, I want to thank the witnesses
    for their participation today. What we have heard is very
    valuable. Members of the committee may have some additional
    questions for you, and we ask that you please respond to those
    questions in writing. The hearing record will be held open for
    14 days, in order to receive those responses.
        And I remind my colleagues that pursuant to committee
    practice, witness questions for the hearing record must be
    submitted to the majority committee's staff or committee clerk
    within 7 days, and the questions submitted must address the
    subject matter of the hearing.
        And I now recognize the distinguished ranking member for
    his closing statement.
        Mr. Comer. Thank you, Madam Chair, and our witnesses gave
    excellent testimony today on the importance of CAPTA. We know
    this is a critical law that helps states, local governments,
    and organizations save lives. We also heard that there are some
    improvements that can be made to improve the system and help
    the grantees better help families and children, changes like
    looking at prevention programs, focusing on ensuring local
    programs can serve people in a way that works for them, and
    collaborating with stakeholders to improve services.
        I look forward to working with my colleagues on these
    improvements, and thank you all very much for your time.
        Madam Chair, I yield back.
        Chairwoman Bonamici. Thank you, and I now recognize myself
    for the purpose of making a closing statement.
        Thank you again to all of the witnesses for being with us.
    We appreciate your expertise and experiences.
        Today's hearing was an important step toward strengthening
    our approach to child abuse and neglect. Although we have made
    progress in reducing some rates of child maltreatment, we
    cannot allow ourselves to become complacent, and we cannot
    allow the disturbing rise in child abuse and neglect cases to
    go unaddressed. This is not only a public health crisis but a
    threat to the future of our country.
        Accordingly, Congress has the moral obligation to expand
    and improve the Child Abuse Prevention and Treatment Act for
    the new challenges facing our children, families, and
    communities. And we can all agree, regardless of party
    affiliation, that our current system needs improvement, to make
    sure that children are protected from immediate and long-term
    consequences of abuse and neglect.
        And as our witnesses also reminded us today, any proposal
    to reauthorize CAPTA, the Child Abuse Prevention and Treatment
    Act, must recognize the importance of holistic solutions that
    prevent families and children from suffering, instead of
    waiting to treat children after they have been hurt.
        We need to make sure that state agencies can work quickly
    and collaboratively with a broad range of protection and
    support services for all children, no matter where they are.
        Everyone here knows what is on the line. We are committed
    to taking bipartisan steps toward a Child Abuse Prevention and
    Treatment Act that our children desperately need and deserve.
    And I look forward to working with my colleagues on both sides
    of the aisle to make sure that all children have a safe and
    healthy environment that allows them to reach their full
    potential. The lives and future of so many of our children and
    families are at stake.
        With there being no further business, without objection,
    the committee stands adjourned.
        [Additional submission by Ms. Schrier follows:]
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        [Questions submitted for the record and their responses
    follow:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        [Whereupon, at 4:23 p.m., the subcommittee was adjourned.]

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