[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

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           Available via the World Wide Web: www.govinfo.gov
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                              __________
                               

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
36-587 PDF                  WASHINGTON : 2019                     
          
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                    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:]
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    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:]
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    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:]
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    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
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

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

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