[House Hearing, 109 Congress]
[From the U.S. Government Publishing Office]
PERSPECTIVES ON EARLY CHILDHOOD
HOME VISITATION PROGRAMS
=======================================================================
HEARING
before the
SUBCOMMITTEE ON EDUCATION REFORM
of the
COMMITTEE ON EDUCATION
AND THE WORKFORCE
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED NINTH CONGRESS
SECOND SESSION
__________
September 27, 2006
__________
Serial No. 109-59
__________
Printed for the use of the Committee on Education and the Workforce
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COMMITTEE ON EDUCATION AND THE WORKFORCE
HOWARD P. ``BUCK'' McKEON, California, Chairman
Thomas E. Petri, Wisconsin, Vice George Miller, California,
Chairman Ranking Minority Member
Michael N. Castle, Delaware Dale E. Kildee, Michigan
Sam Johnson, Texas Major R. Owens, New York
Mark E. Souder, Indiana Donald M. Payne, New Jersey
Charlie Norwood, Georgia Robert E. Andrews, New Jersey
Vernon J. Ehlers, Michigan Robert C. Scott, Virginia
Judy Biggert, Illinois Lynn C. Woolsey, California
Todd Russell Platts, Pennsylvania Ruben Hinojosa, Texas
Patrick J. Tiberi, Ohio Carolyn McCarthy, New York
Ric Keller, Florida John F. Tierney, Massachusetts
Tom Osborne, Nebraska Ron Kind, Wisconsin
Joe Wilson, South Carolina Dennis J. Kucinich, Ohio
Jon C. Porter, Nevada David Wu, Oregon
John Kline, Minnesota Rush D. Holt, New Jersey
Marilyn N. Musgrave, Colorado Susan A. Davis, California
Bob Inglis, South Carolina Betty McCollum, Minnesota
Cathy McMorris, Washington Danny K. Davis, Illinois
Kenny Marchant, Texas Raul M. Grijalva, Arizona
Tom Price, Georgia Chris Van Hollen, Maryland
Luis G. Fortuno, Puerto Rico Tim Ryan, Ohio
Bobby Jindal, Louisiana Timothy H. Bishop, New York
Charles W. Boustany, Jr., Louisiana [Vacancy]
Virginia Foxx, North Carolina
Thelma D. Drake, Virginia
John R. ``Randy'' Kuhl, Jr., New
York
[Vacancy]
Vic Klatt, Staff Director
Mark Zuckerman, Minority Staff Director, General Counsel
------
SUBCOMMITTEE ON EDUCATION REFORM
MICHAEL N. CASTLE, Delaware, Chairman
Tom Osborne, Nebraska, Vice Lynn C. Woolsey, California,
Chairman Ranking Minority Member
Mark E. Souder, Indiana Danny K. Davis, Illinois
Vernon J. Ehlers, Michigan Raul M. Grijalva, Arizona
Judy Biggert, Illinois Robert E. Andrews, New Jersey
Todd Russell Platts, Pennsylvania Robert C. ``Bobby'' Scott,
Ric Keller, Florida Virginia
Joe Wilson, South Carolina Ruben Hinojosa, Texas
Marilyn N. Musgrave, Colorado Ron Kind, Wisconsin
Bobby Jindal, Louisiana Dennis J. Kucinich, Ohio
John R. ``Randy'' Kuhl, Jr., New Susan A. Davis, California
York George Miller, California, ex
Howard P. ``Buck'' McKeon, officio
California,
ex officio
C O N T E N T S
----------
Page
Hearing held on September 27, 2006............................... 1
Statement of Members:
Osborne, Hon. Tom, Vice Chairman, Subcommittee on Education
Reform, Committee on Education and the Workforce........... 1
Woolsey, Hon. Lynn C., ranking minority member, Subcommittee
on Education Reform, Committee on Education and the
Workforce.................................................. 3
Statement of Witnesses:
Burack, James, Milliken, CO, chief of police................. 24
Prepared statement of.................................... 26
Daro, Deborah, Ph.D., Chapin Hall Center for Children,
University of Chicago...................................... 15
Prepared statement of.................................... 17
Response to written questions submitted by Congressman
Davis.................................................. 45
Ridge, Michele, national board of directors, Nurse-Family
Partnership................................................ 5
Prepared statement of.................................... 7
Supplemental testimony and responses to written questions
submitted by Congressman Davis......................... 47
Newspaper article: ``Nurse-family Partnerships Coming to
Columbus,'' Columbus Dispatch, September 3, 2006....... 50
Scovell, Anna M., Sussex County Parents as Teachers program
supervisor................................................. 9
Prepared statement of.................................... 11
Responses to written questions submitted by Congressman
Davis.................................................. 50
PERSPECTIVES ON EARLY CHILDHOOD
HOME VISITATION PROGRAMS
----------
Wednesday, September 27, 2006
U.S. House of Representatives
Subcommittee on Education Reform
Committee on Education and the Workforce
Washington, DC
----------
The subcommittee met, pursuant to call, at 10:30 a.m., in
room 2175, Rayburn House Office Building, Hon. Tom Osborne
[vice chairman of the subcommittee] presiding.
Present: Representatives Osborne, Biggert, Platts, Wilson,
Musgrave, Kuhl, McKeon, Woolsey, Davis of Illinois, Scott,
Kucinich, and Davis of California.
Staff present: Jessica Gross, Press Assistant; Cameron
Hays, Legislative Assistant; Richard Hoar, Professional Staff
Member; Kate Houston, Professional Staff Member; Lindsey Mask,
Press Secretary; Chad Miller, Coalitions Director for Education
Policy; Deborah L. Emerson Samantar, Committee Clerk/Intern
Coordinator; Rich Stombres, Deputy Director of Education and
Human Resources Policy; Toyin Alli, Staff Assistant; Ruth
Friedman, Legislative Associate/Education; Lloyd Horwich,
Legislative Associate/Education; and Joe Novotny, Legislative
Assistant/Education.
Mr. Osborne [presiding]. Good morning. A quorum being
present, the Subcommittee on Education Reform will come to
order.
We are meeting today to hear testimony and perspective on
early childhood home visitation programs.
Under Committee Rule 12(b), opening statements are limited
to the chairman and the ranking minority member of the
subcommittee. Therefore, if other members have statements, they
may be included in the hearing record.
With that, I ask unanimous consent for the hearing record
to remain open 14 days to allow members' statements and other
extraneous material referenced during the hearing to be
submitted.
Without objection, so ordered.
Good morning. I am pleased to convene this hearing to
examine early childhood home visitation programs. The purpose
of today's proceedings is not necessarily to demonstrate
support for any one program or any one piece of legislation.
Rather, we are here to listen and to learn and we have
assembled a strong panel of witnesses to guide us through this
examination.
I would like to thank the panel for assembling today.
Few would argue that parent-child relationships in the home
environment are not critical elements of child development and
early childhood home visitation programs aim to bolster those
relationships and improve the environment at home.
The home visitation programs that we will focus on today
seek to deliver parent education and family support services
directly to parents with young children and aim to offer
guidance to parents on how to support their children's
development from birth through their enrollment in
kindergarten.
Advocates of these home visitation programs argue that the
services they offer comprise an effective research-based and
cost-efficient strategy to bring families and resources
together to ensure that children grow up healthy and ready to
learn.
I look forward to hearing the perspectives of our witnesses
on these assertions.
And I might just add parenthetically that in the state of
Nebraska, we have a very high ratio of out-of-home placements
for foster care and we have found that home visitations early
on are very effective in preventing some of the tragedies that
happen, family split-ups, so on.
Some research into home visitation programs indicates that
combining these in-home programs with out-of-home center-based
programs may be more effective in producing positive outcomes
for the child, including cognitively, than programs using
either approach alone.
Again, I look forward to hearing perspectives from our
witnesses on this, as well.
Home visitation programs are not a new topic for Congress.
Legislation that has been referred to this subcommittee, H.R.
3628, The ``Education Begins at Home Act,'' would authorize
$400 million in state grants over 3 years to establish or
expand early childhood home visitation programs.
I would like to add that I am proud to be a cosponsor of
this legislation, which was introduced by my colleagues, Danny
Davis and Todd Platts.
Sometimes in Congress, we do things that aren't very cost-
effective and we spend huge amounts of money on substance
abuse, dropouts, incarceration, and not enough on the
prevention side. So I think this will be money very well spent.
The secretary of health and human services, in consultation
with the secretary of education, would award these funds
competitively and the grants may be used to support parent
education and family support services provided in home
settings, much like the programs we are here to discuss today.
Within this program, assistance would be targeted to
English language learners and military families, with more than
$50 million over 3 years directed toward programs serving these
populations specifically.
Once again, we are not here to vote on, endorse, or even
consider this legislation today. Rather, we are here simply to
listen and learn. I look forward to our discussion.
With that being said, we have a very impressive group of
witnesses this morning. I thank them for joining us today as we
learn more about home visitation programs. I look forward to
hearing from them, as well as my colleagues.
And with that, I yield to Ms. Woolsey for any opening
statements that she may have.
Ms. Woolsey. Thank you, Mr. Chairman. Thank you for holding
today's hearing.
Before I talk about today's topic, I want to express my
best wishes to our chairman, Mr. Castle. He and I have been
working together since we were both elected in 1992 and sworn
in in 1993, and we have been working together on education and
children's issues.
He is the chair of this subcommittee and my ranking member
position. We can't go on without him and we will have him back
and he will be whole and strong. But we just now want him to
take care of himself so that he will be back. So that is what I
wanted to say about Mr. Castle.
We know that every child needs the opportunity to reach his
or her full potential in this country in order for us to reach
our full potential as a nation. That is why today's hearing is
so very, very important.
I look forward to hearing from witnesses about the
successes of early childhood visitation programs and the
challenges that you face, that have been faced, and the
solutions that you see.
In particular, I look forward to hearing about the specific
services that these programs offer parents and children and the
outcomes they have achieved in improving school readiness.
We know the difference between a young child that is ready
to start school and a young child that is starting school
needing to get ready, what a disadvantage it is to that child.
And we need to know about the parents' ability to support
their children through their social, emotional, cognitive,
language, and physical development. I is a learning experience,
particularly with the first one.
What do they talk about, the first waffle? We call our
trial and experimenting is on the first waffle and look what we
do with that one.
But I look forward to discussing these programs to ensure
that families receive the training that they need.
One of our greatest challenges will be that the program
needs a dedicated source of funding. We have no certainty about
the level and quality of services unless we are able to promise
year to year funding.
So that is why I so honor Congressman Danny Davis and
Congressman Todd Platts and Congressman Osborne, who introduced
The ``Education Begins at Home Act,'' and I thank them for
doing this.
I thank you for being here and sharing with us.
But we have to remember the context that we are working in.
And I am not going to lash out. I am going to only say one
little short thought.
We have had 6 years of gross under-funding for early
childhood development programs under the Bush administration.
This has to turn around or wonderful, wonderful programs like
yours will not have any way of being funded. So know that we
all understand that and we are going to be working to that end.
So I look forward to hearing from you.
And could I yield to Danny? Do I have a little bit of time?
Do you have any opening statements? Then your time will
be--I guess you will be the first to speak.
Mr. Osborne. I think we are going to have Danny introduce
one of our guests, and anything he wants to say at that time he
certainly can. We never muzzle Danny.
I might just add to Ms. Woolsey's comments on Chairman
Castle. He seems to be doing well, expected to have a full
recovery, and I am sure he will return here after the election.
We have a very distinguished group of witnesses today, and
I will begin by introducing three of them, and Danny will
introduce one.
Mrs. Michele Ridge is a former first lady of Pennsylvania,
an advocate for children and families. She is chair of the
Children's Partnership and a member of the board of Nurse
Family Partnerships.
And we are delighted to have you here this morning.
And I believe that Dr. Daro is a constituent or an
acquaintance of Mr. Davis. So he can introduce her at this
time.
Mr. Davis of Illinois. Thank you very much, Mr. Chairman.
And I, too, want to thank you, Chairman Castle and Ms. Woolsey
for holding this hearing.
And it is my distinct pleasure to introduce an expert in
this field of work, one who was born and grew up in my
congressional district in Oak Park, Illinois, but then lives in
Representative Judy Biggert's district, and then works in
Representative Bobby Rush's district.
Dr. Deborah Daro is a research fellow at the Chapin Hall
Center for Children at the University of Chicago. Her 20 years
of experience in evaluating prevention and child abuse
treatment programs clearly reflect her expertise in child well-
being.
Dr. Daro has a long history with home visiting. Growing on
her work in child abuse prevention, she developed and put in
motion Healthy Families America, one of the largest home
visiting programs in the nation.
She has been involved in comprehensive research efforts to
understand the contributions of home visiting, providing a
balanced perspective on its successes and areas for
improvement.
In addition, Dr. Daro has the unique ability among
researchers to understand how research can inform and aid
policy. I think her comments will do much to help us understand
how policymakers can best support child development to prepare
children for school, and we are indeed delighted that she is
with us this morning.
Thank you, Mr. Chairman.
Mr. Osborne. Thank you, Mr. Davis.
We are a little bit out of order here. Ms Scovell, I don't
want you to think we are going to leave you out.
Ms. Scovell is the state Parents as Teachers supervision
coordinator at the Lake Forest School District in Delaware
Early Childhood Center, and Ms. Scovell is a certified Parents
as Teachers parent educator and supervisor.
Glad to have you here this morning.
And the last panelist we have is Chief James Burack, serves
in Milliken, Colorado, and interim co-administrator. Chief
Burack also serves as a current member of the Weld County
Community Corrections Board.
And I would like to yield to Marilyn Musgrave at this time.
I believe that the chief is from your district, and she wanted
to make a comment on the chief, hopefully favorable.
So, Ms. Musgrave?
Mrs. Musgrave. Well, thank you, Mr. Chairman. And, indeed,
my comments are favorable.
Milliken is a wonderful, small community in the northern
part of my district. I would just like to tell the chief, as we
had visited on another occasion, that I have a son-in-law in
law enforcement and I have the highest regard for what you do.
And I want to tell you that your influence on the lives of
children and the redirection that you would have them take is
most admirable.
So I am just happy and proud to have you here before the
committee today and I just want to thank you for the good work
that you do.
Thank you, Mr. Chairman.
Mr. Osborne. Thank you, Ms. Musgrave.
I think you are all familiar with the lights. You have a
green light for 5 minutes, and then you see the red light come
on and that is when you are supposed to wrap up your remarks.
And so, we would like to adhere to that schedule as best we
can.
And so we will begin with the witnesses. Ms. Ridge, we will
start with you. And thank you for being here this morning.
STATEMENT OF MICHELE RIDGE, FORMER FIRST LADY OF THE
COMMONWEALTH OF PENNSYLVANIA, MEMBER OF BOARD OF DIRECTORS OF
NURSE FAMILY PARTNERSHIP
Mrs. Ridge. Thank you, Mr. Chairman, and thank you to all
the committee for the opportunity to testify on behalf of the
Nurse Family Partnership and the ``Education Begins at Home
Act.''
I am Michele Ridge, a member of the national board of
directors of the Nurse Family Partnership, a national nonprofit
organization dedicated to producing long-term improvements in
the health and well-being of low-income first-time mothers and
their children.
Research has proven that the Nurse Family Partnership
program can break the cycle of poverty, abuse, crime, poor
health, and government dependence. At the same time, this
program increases labor force participation, improves school
readiness, saves substantial resources, and changes the course
of life for mothers, children and future generations.
Nurse Family Partnership is an evidence-based nurse home
visitation program, with proven clinical multigenerational
outcomes. This voluntary intervention and prevention program
model is delivered by highly trained registered nurses and
beginning early in pregnancy and continuing until a child is 2.
The program's founder, Dr. David Olds, has conducted,
during the past 25 years, three randomized control trials
across three diverse populations. This research shows numerous
significant and positive outcomes, including a 48 percent
reduction in child abuse and neglect, improvements in
elementary school readiness, including a 50 percent reduction
in language delays for a child at age 21 months, and a 67
percent reduction in behavioral and intellectual problems for a
child at the age of 6.
Reduction in high risk pregnancies include 32 percent fewer
subsequent pregnancies, a 31 percent reduction in closely
spaced subsequent pregnancies, a 46 percent increase in father
presence in the household, and a 59 percent reduction in
arrests of juveniles, and a 61 percent reduction in the arrests
of mothers.
In Pennsylvania, Governor Ridge and I worked to implement
the Nurse Family Partnership model as a proven youth violence
prevention program. Several local Pennsylvania communities went
through a rigorous strategic planning process under an
initiative called Communities that Care, which has now been
adopted by the Substance and Mental Health Administration.
Communities voluntarily selected Nurse Family Partnership
because evidence showed this model could deliver hard to
achieve outcomes. NFC emerged as the most strongly endorsed
violence prevention model in Pennsylvania.
Today, the Nurse Family Partnership national service office
supports programs in 270 counties and 22 states, serving 20,000
families a year, including 2,280 families in 36 counties across
Pennsylvania.
In addition to Pennsylvania, NFC is statewide in
California, Colorado, Louisiana, Ohio and Oklahoma. Many other
states are seeking to expand local Nurse Family Partnership
program.
Its replication plan reflects a proactive, state-based
growth strategy that maximizes fidelity to the program model
and ensures consistent program outcomes. In other words, it
gets results.
As NFC's program model has moved from science to practice,
great emphasis has been placed on building the necessary
infrastructure to ensure quality during replication.
Nurse Family Partnership provides intensive and ongoing
education and training for nurses and we maintain a unique data
collection and program management system, called clinical
information system, which helps Nurse Family Partnership to
monitor program implementation and outcomes in a real time day-
to-day basis.
A more thorough description of this quality assurance tool
is provided in my written statement.
Nurse Family Partnership's success and cost-effectiveness
and been proven through four independent evaluations, each of
which are cited in my written statement.
A Department of Justice evaluation identified Nurse Family
Partnership as one of 11 prevention and intervention programs
nationwide out of a pool of 650 programs that met the highest
standard of program effectiveness in reducing adolescent
violent crime, aggression, delinquency and substance abuse.
RAND Corporation and the Washington State report weighted
the costs and benefits of Nurse Family Partnership and
concluded that the program returns approximately $3 for every
$1 invested. These reports identify Nurse Family Partnership as
having the highest cost-benefit ratio of any home visit program
studied.
The Nurse Family Partnership supports the ``Education
Begins at Home Act,'' as introduced in the House of
Representatives. This bill provides consolidated funding to
support the important work of home visitation programs,
including Nurse Family Partnership.
Nurse Family Partnership urges Congress to direct funds
toward home visit models that maintain the highest level of
evidentiary standards in order to ensure the largest possible
return on the Federal investment.
On behalf of the Nurse Family Partnership staff and
volunteer leadership, I would like to thank Congressman Davis,
Congressman Platts, and Congressman Osborne for their
leadership on behalf of this legislation.
I would share with you that I have visited a nurse home
visitation program in Congressman Platts' district in York
several years ago and enjoyed that visit and the results of
that home visitation program are outstanding.
I would like to particularly thank Congressman Davis for
his willingness to include in the legislation language
encouraging high standards of quality assurance and evaluation.
In this era of limited Federal funding, we must invest Federal
resources in programs that have proven outcomes and that really
work on behalf of our nation's mothers and children.
So thank you again for the opportunity to appear before you
and testify on behalf of Nurse Family Partnership.
[The prepared statement of Mrs. Ridge follows:]
Prepared Statement of Michele Ridge, National Board of Directors,
Nurse-Family Partnership
Good morning Mr. Chairman and thank you for the opportunity to
testify on behalf of the Nurse-Family Partnership and in support of the
Education Begins at Home Act.
I am Michele Ridge, a Member of the National Board of Directors of
the Nurse Family Partnership, a national non-profit organization
dedicated to producing long-term improvements in the health and well-
being of low-income, first-time parents and their children. One reason
I chose to join this National Board is because Governor Ridge and I
established this program throughout the state of Pennsylvania in 2000.
The Pennsylvania NFP program remains strong and active today, serving
approximately 2280 families in 36 counties in Pennsylvania, and nearly
8,000 Pennsylvania families since the program began. After describing
the NFP program model, I will discuss the process by which Governor
Ridge and I chose this program to serve first-time, low-income mothers
and their families.
Nurse Family Partnership (NFP) is an evidence-based, nurse home
visitation program with multi-generational, enduring outcomes that have
been demonstrated in three randomized clinical trials, each conducted
with a different population living in different social settings. A
randomized trial is the most rigorous research method for measuring the
effectiveness of an intervention.
NFP is a voluntary program that provides nurse home visitation
services to low-income, first-time mothers by highly trained,
registered nurses beginning early in pregnancy and continuing through
the child's second year of life. NFP nurses and their clients make a 2
and 1/2 year commitment to one another, with 64 planned visits focusing
on the mother's personal health, quality care giving, and life course
development. NFP nurses undergo more than 60 hours of training prior to
receiving their caseload of no more than 25 families.
The NFP model is designed to help families achieve three major
goals: improve pregnancy outcomes; improve child health and
development; and improve parents' economic self-sufficiency. By
achieving these program objectives, many of the major risks for poor
health and social outcomes can be significantly reduced.
Each day in America, 2,482 children are abused or neglected, 4
children are killed by abuse or neglect, 2,447 babies are born into
poverty, 888 babies are born at low birthweight, 77 babies die before
their first birthdays, and 4,356 children are arrested. Every second, a
public school student is suspended, every 9 seconds a high school
student drops out, every minute a baby is born to a teen mother, every
8 minutes a child is arrested for violent crimes, every 41 minutes a
child or teen dies in an accident, and every day a mother dies in
childbirth. Today, more than 20% of U.S. workers are functionally
illiterate and innumerate. The high school dropout rate is increasing.
The U.S. has the highest child poverty rate of the 20 developed
countries belonging to the Organization for Economic Cooperation and
Development.
The Nurse-Family Partnership is successfully addressing these poor
social and health outcomes. We know that investing in children during
the earliest years of their lives holds promise for both improving
long-term human functioning and improving the economic productivity of
our society. Economists tell us that economic growth depends on human
capital, the label they use to describe the resource represented by
people and their productivity. The Nurse-Family Partnership is an
opportunity to invest in human capital.
NFP is the only evidence-based prevention program of its kind to be
subjected to over 30 years of rigorous research, development, and
evaluation conducted by Dr. David L. Olds, program founder and Director
of the Prevention Research Center for Family and Child Health (PRC) at
the University of Colorado in Denver. Dr. Olds has conducted three
randomized, controlled trials with three diverse populations in Elmira,
NY (1977), Memphis, TN (1987), and Denver, CO (1993). Evidence from the
trials document powerful outcomes, including the following:
48% reduction in child abuse and neglect (Elmira, 15 year follow-
up)
59% reduction in child arrests (Elmira, 15 year follow-up)
61% fewer arrests for the mother (Elmira, 15 year follow-up)
72% fewer convictions for the mother (Elmira, 15 year follow-up)
46% increase in father presence in the household (Memphis, year 5)
Reduction in high-risk pregnancies:
32% (Elmira, 15 year follow-up) and 23% (Memphis, year 2) fewer
subsequent pregnancies
31% fewer closely spaced (<6 months) subsequent pregnancies
(Memphis, year 5)
Improvement in elementary school readiness:
50% reduction in language delays at child age 21 months (Denver)
67% reduction in behavioral/intellectual problems at child age 6
(Memphis)
Improvements in cognitive development at child age 6 (Memphis)
Improvements in language development at child age 4 and 6 (Memphis)
Improvements in child executive functioning at age 4 (Denver)
Each study has been reevaluated to find out if the program effects
seen while families were receiving home visits faded out once the
program ended, or were sustained over time. The results of each study
have been positive, and provide the evidence necessary to justify
offering the program for public investment.
As NFP's program model has moved from science to practice, great
emphasis has been placed on building the necessary infrastructure to
ensure quality and fidelity to the research model during the
replication process nationwide. In addition to intensive education for
nurses, NFP has a unique data collection and program management system,
called the Clinical Information System (CIS), which helps NFP monitor
program implementation. CIS was designed specifically to record family
characteristics, need, services provided, and progress towards
accomplishing NFP program goals. Program quality and outcomes can be
measured and/or monitored in real time as every home visit is reported
by the respective NFP nurse.
In Pennsylvania, the Nurse-Family Partnership model was identified
as an evidence-based program for youth violence prevention and
reduction. As a result, Governor Ridge directed juvenile justice funds
to establish and support NFP in Pennsylvania. Juvenile justice and TANF
funds have been used to maintain the program in 36 counties across
Pennsylvania. Other states have used a variety of funding sources to
establish and sustain NFP program sites, including Medicaid, TANF,
Tobacco settlement, Title V Maternal & Child Health Block grant,
Healthy Start, and private funds.
Today, the Nurse-Family Partnership National Service Office
supports programs in 270 counties and 22 states serving 20,000 families
a year. In addition to Pennsylvania, NFP has statewide implementations
in states including California, Colorado, Louisiana, Ohio, and
Oklahoma, and many other states are seeking to expand local NFP
programs into statewide initiatives. NFP's replication plan reflects a
proactive, state-based growth strategy that maximizes fidelity to the
program model and ensures consistent program outcomes. NFP urges
Congress to direct funds toward home visit models that maintain the
highest level of evidentiary standards in order to ensure the largest
possible return on the federal investment.
NFP's success and cost-effectiveness has been proven through four
independent evaluations (Washington State Institute for Public Policy,
2004; 2 RAND Corporation studies 1998 and 2005; Blueprints for Violence
Prevention, Office of Juvenile Justice and Delinquency Prevention).
Blueprints identified NFP as 1 of 11 prevention and intervention
programs nationwide that met the highest standard of program
effectiveness in reducing adolescent violent crime, aggression,
delinquency, and substance abuse, out of a total of 650 programs
reviewed to date.. The RAND and Washington State reports weighed the
costs and benefits of NFP and concluded that the program produces
significant benefits for children and their parents, and over time will
return a minimum of $2.88 for every dollar invested, with a return of
$5.70 for higher risk populations. Savings accrue to government in
lower costs for health care, child protection, education, criminal
justice, mental health, and government assistance, and higher taxes
paid by employed parents. The Washington State Report found a net
return to government of $17,180 per family served by NFP, far higher
than the return from all other social service programs measured in
these studies. Although the costs for NFP in this study were higher
than the costs for some other home visit programs, NFP had a higher
cost-benefit ratio. More recent analyses indicate that the costs of NFP
compared to other home visitation programs fluctuates by region, and
even though the NFP model is more intensive than other programs, it is
not always more expensive.
Among home visitation programs, NFP is unique in that the model
focuses on a specific population of low-income, first-time mothers and
the use of highly trained registered nurses. In the Denver clinical
trial, NFP evaluated the impact of using registered nurses versus
paraprofessionals when providing home visitation services to this
select population of first-time low income mothers. Nurses were found
to provide stronger outcomes for this population. During the program,
paraprofessionals produced effects that were approximately half the
size of those produced by nurses. Two years after the program ended, at
the child's age four, paraprofessional-visited mothers began to
experience some benefits, but their children did not. Nurse-visited
mothers and children continued to benefit from the program two years
after it ended, with the greatest impact on children born to mothers
with low psychological resources. I'd like to note, however, that this
evaluation has only been applied to the Nurse-Family Partnership and
may or may not translate to other home visitation programs.
The Nurse-Family Partnership supports the Education Begins at Home
Act as introduced by the House of Representatives. This Act proposes
intelligent solutions to core problems facing new families nationwide.
This bill provides consolidated funding to support the important work
of home visitation programs including NFP. I'd like to thank
Congressmen Davis, Platts, and Osborne for their leadership on behalf
of this legislation and particularly Congressman Davis for his
attention to quality assurance and evaluation criteria. In this era of
limited federal funding, we must invest federal resources in programs
that have proven outcomes.
Thank you again, Chairman Castle and Members of the Subcommittee,
for the opportunity to testify before you today.
______
Mr. Osborne. Thank you, Ms. Ridge.
Ms. Scovell?
STATEMENT OF ANNA SCOVELL, PARENTS AS TEACHERS SUPERVISOR,
SUSSEX COUNTY, DE, PARENTS AS TEACHERS
Ms. Scovell. Good morning, Mr. Chairman, distinguished
members of the committee, fellow witnesses, and honored guests.
My name is Anna Scovell, and I am here today to provide
personal testimony on my experiences with home visitation
services for families with young children.
I would like to take a moment to recognize my colleagues
from Delaware.
Would you please take a moment and rise? Thank you.
I have had the privilege of being the Sussex County Parents
as Teachers program supervisor for the last 4 years, and I am
currently celebrating my 10th year as a certified Parents as
Teachers parent educator.
In my testimony today, I will describe Parents as Teachers
services in the state of Delaware, specific techniques used in
delivering services to families, and the benefits of Parents as
Teachers for parents and children.
Parents as Teachers is a proven parent education and family
support program that provides home visiting services to
families throughout pregnancy up until the child enters
kindergarten.
In the state of Delaware, Parents as Teachers serves
approximately 1,750 families per year. In Sussex County, we
served 450 families during the last school year, including teen
parents, rural families, military families, English language
learners, parents who did not finish high school, as well as
those with advanced degrees.
The one thing that all of these parents have in common is
that they want to be the very best parents that they can
possibly be. Home visitation services, such as Parents as
Teachers, helps parents realize this goal.
I want to share with you a story about one of my families,
because I think it is really special.
I worked with a married couple some years ago who had a
young son. Mom was a high-strung, excitable person, and dad was
just the opposite. He was pretty laid back and calm.
Living in low-income housing at the time, they were doing
their very best, trying to juggle their jobs, child care,
transportation, and mounting bills. Through our routine
screening process, I realized that their son had a possible
language delay.
After referring the family for further evaluation, the
little boy was able to receive speech therapy services. And
before this little boy turned 3, the parents found out they
were expecting twins.
After the twins were born, the parents discovered that one
of the babies had Down's syndrome. Mom wasn't very sure that
she could handle these three children under the age of 3, much
less cope with two children who had special needs. She was
overwhelmed and in need of additional support.
The family and I searched for community resources for their
special needs children, which proved to be particularly
difficult in this rural community. While the family faced many
struggles in their day-to-day life, they were committed to
Parents as Teachers and rarely missed our scheduled visits.
Dad participated in as many of the home visits as he could
and the entire family attended evening parent-child special
events.
I worked with this family for almost 6 years, sharing their
joys and working through their concerns and fears. They still
stay in touch with me and send me pictures and family updates
at Christmas.
Sussex Parents as Teachers is funded by the Delaware
Department of Education and sponsored by the Lake Forest school
district and is free to participating families. Enrollment is
on a voluntary basis.
While we give priority to parents with identified risk
factors, we strive to serve all families.
There are four major components of the Parents as Teachers
program: personal visits, parent group meetings, developmental
screenings, and resource networking.
Personal visits in the home or child care facility are
typically scheduled on a monthly basis. Using a strength-based
model, parent educators share child development observations
and discuss upcoming milestones.
We reinforce positive parenting skills, address their
questions and concerns, explain the importance of brain
development during the first 3 years of life, and share parent-
child activities.
Our parents participate in group meetings, which we offer 3
days a week. During these meetings, parents learn from and
support each other. They observe their child with other
children and practice parenting skills.
We conduct annual developmental screenings to identify
strengths and delays and make follow-up referrals, when
appropriate. In addition, we connect parents to community
resources for financial, medical and educational assistance.
Families who participate in Parents as Teachers have an
increased knowledge of child development, improved parenting
practices, early detection of developmental delays and health
issues, prevention of child abuse and neglect, and increased
school readiness, which leads to school success.
Because our program is affiliated with the school district,
there is a continuum of services for families with children,
prenatally through school age. Evaluation results show that
Parents as Teachers children are more likely to be on tract
developmentally and to have developmental delays identified
early and remediated, when possible.
Parents as Teachers children, at age 3, are significantly
more advanced in language, social development, and problem-
solving and other cognitive abilities than comparison children.
The ``Education Begins at Home Act'' would provide critical
Federal funding to support home visitation services, such as
Parents as Teachers, not only in Sussex County, Delaware, but
across the country.
All parents deserve parenting information and family
support so they can help their child reach their full potential
and the ``Education Begins at Home Act'' will help this become
a reality.
Thank you, Mr. Chairman and distinguished members of the
committee, for allowing me this opportunity to share with you
today.
[The prepared statement of Ms. Scovell follows:]
Prepared Statement of Anna M. Scovell, Sussex County Parents as
Teachers Program Supervisor
Good morning Mr. Chairman, distinguished members of the committee,
fellow witnesses, and honored guests. I am here today to provide
personal testimony on my experiences with home visitation services in
Delaware and to emphasize the need for federal governmental support for
such services for families with young children. I have had the
privilege of being the Sussex County Parents as Teachers program
supervisor for the last four years and I am currently celebrating my
tenth year as a certified Parents as Teachers parent educator providing
direct services to families and childcare providers. In this testimony,
I will describe my experience with home visitation activities, specific
techniques used in delivering services to families, how our program
collaborates with existing community supports and resources, and the
benefits of the Parents as Teachers program for families.
In the state of Delaware, Parents as Teachers serves approximately
1,750 families and 1,850 children per year through 4 programs based in
the following Delaware cities: Georgetown, Bear, Newark, and Woodside.
In Sussex County, we served 451 families during the last school year.
Of those enrolled families, over three quarters of the families were of
low income; nearly three quarters were single parent households; one
third of the families had parents having less than a high school
diploma or GED; over one third were teen parents; one third were
speakers of other languages, mostly Spanish; one quarter of the
children did not have health insurance; and almost one quarter of the
children were identified with disabilities. As you can tell from the
percentages, many of our families have multiple risk factors. Other
families enrolled were involved in chemical dependency, mental health,
the corrections systems, homeless shelters, relative care, and foster
care. I personally have served families ranging from teen mothers, to
rural families, to dual income middle class families, to single parent
families receiving public assistance. The one thing that all these
parents have in common is that they want to be the very best parents
they can possibly be. Home visitation services such as the Sussex
Parents as Teachers program helps parents realize this goal.
Sussex Parents as Teachers is funded by the Delaware Department of
Education and is sponsored by the Lake Forest School District. The
program is free to families who enroll. Enrollment is on a voluntary
basis and families may exit the program at any time. While we give
priority to parents with identified risk factors, we strive to serve
all families regardless of the age of the parents or the number of
children in their family because we believe that all families can
benefit from our services. Parents may be enrolled during the prenatal
period or after their child is born. Our program makes long term
parenting education and family support available to families during
those critical first three years of their child's life. Providing this
parenting education and family support in the home is critically
important because it strengthens the individual relationship with the
family, increases the parent's ability to utilize the services, and
encourages parents to incorporate the parenting information and
strategies in their day-to-day home life.
Each year there are more than 50 identified families on a waiting
list to be served. There is a great need for home visitation that spans
across all socio-economic and educational levels. In Delaware, we have
an initiative called ``Ready Families, Ready Children, Ready Schools,
and Ready Communities''. This campaign is a solid first step in
providing parenting education and family support for the education of
our youngest children. The federal legislation that you are considering
takes this concept and propels it into the national spotlight. ALL
parents deserve parenting information and family support and the
Education Begins at Home Act will provide a reliable funding source for
home visitation programs that will meet this tremendous need not only
in Sussex County, Delaware, but across the country.
There are four components of the Parents as Teachers home
visitation activities in Sussex County. Personal visits in the home or
child care facility are scheduled on a regular basis. Parent educators
visit prenatal childbirth classes and share prenatal developmental
information to new parents. We visit high schools and facilitate teen
parenting groups. Weekly parent group meetings with parent-child
activities are conducted in local libraries, churches, community
centers, or with other partnering agencies. Developmental screenings
and health questionnaires for children are conducted on an annual
basis. Referrals are made to Child Development Watch for further
evaluations if needed. Parents and children are connected with local
resources for financial, medical and educational assistance. Families
are connected to resources for children and family enrichment such as
infant massage, gymnastics, music for tots, family fun events at the
zoo and local museums.
In each of the components, fathers are encouraged to become
involved in the activities, including our weekly play groups. During a
recent group meeting, I was able to videotape a father and son sitting
on the floor playing blocks. The father was helping his son build an
airplane hanger and dramatically provided the sound affects of the
airplane landing. This parent-child interaction was facilitated by the
parent educator and may not have occurred without this intervention.
The Sussex Parents as Teachers home visitation services uses a
strength based model for parenting education and family support. A
strength based model builds upon parenting assets so parents can help
their children learn, grow and develop to reach their fullest
potential. Educators are encouraged to build rapport with parents,
share child developmental observations and discuss what is coming next
in a child's development. During personal visits, the parent educator
reinforces positive parenting skills, shares parent-child activities,
provides resources for parents, administers developmental screenings
and connects parents to resources. The Parents as Teachers Born to
Learn curriculum that we use provides research-based information about
early childhood development in all domains: language development,
cognitive development, social-emotional development, and motor
development. We emphasize the critical role that parents play in their
children's growth and development and the importance of the first three
years for brain development.
Parent educators in the Sussex Parents as Teachers home visitation
program use specific techniques such as goal setting, active listening,
affirming parental knowledge, skills and behaviors. They help parents
through developmentally appropriate and/or challenging parent-child
experiences. Routines and activities important to the parents are
discussed with parent educators to help parents address specific
issues. Parent educators share written material that is available on
two different readability levels in both English and Spanish which
covers an array of child development and parenting topics. Community
resources are also included in the material and discussed with the
parents. Videos or DVDs are utilized during home visits. Parent
educators receive feedback on a routine basis by supervisors trained in
reflective supervision. Parent educators meet on a monthly basis to
discuss individual case management, identify professional development
needs and share resources.
Benefits to families enrolled in the Sussex Parents as Teachers
program include increased parent knowledge of childhood development,
improved parenting practices, early detection of developmental delays
and health issues, prevention of child abuse and neglect, and increased
school readiness and school success. Because our program is affiliated
with a school district, there is a continuum of services for families
with children, beginning with pregnancy and extending through school-
age. Evaluation results show that Parents as Teachers prepares children
to enter kindergarten ready to succeed. Parents as Teachers children
are more likely to be on-track developmentally and to have
developmental delays identified early and remediated. Parents as
Teachers children at age three are significantly more advanced in
language, social development, and problem solving and other cognitive
abilities than comparison children. The positive impact on Parents as
Teachers children carries over into the elementary school years.
Parents as Teachers children score higher on kindergarten readiness
tests and on standardized measures of reading, math and language in
first through fourth grades.
Community supports and collaborations include parents themselves,
family members, friends, neighbors, parent educators, faith based
organizations, or local agencies. Sussex Parents as Teachers has
developed collaborative relationships with local hospitals, public
health clinics, Nemours Health and Prevention Services, the Pregnancy
Care Center, Division of Family Services, Delaware First Home Visiting
Program, Delaware Adolescent Pregnancy Program (DAPI), Children and
Families First; public school wellness centers; Early Head Start; Head
Start; Even Start; Parent Information Center; childcare centers; and
the United Way. During the 2005-2006 school year, more than 200
families were referred to our program by these and other agencies.
Sussex Parents as Teachers employs sixteen part-time parent
educators and one full-time family consultant. Our parent educators
have backgrounds in early childhood education, special education,
elementary education, social work, counseling, and nursing. Educators
are available to make home visits during the day, evenings and
Saturdays, depending on individual family's schedules. Each visit is
usually 45-60 minutes in length and visits typically are offered once a
month. However, individual family needs are assessed during regularly
scheduled supervision meetings and families may be visited more than
once each month if there is an identified need. A variety of Parents as
Teachers curricula are used during home visits. They include: Born to
Learn--Prenatal to Three; three Years to Kindergarten Entry; Working
with Teen Parents; and Supporting Families of Children with Special
Needs. Our Early Intervention, Part C program educators who work with
families who have children under the age of three with an identified
developmental delay or special need visit families once each week to
work on Individualized Family Service Plans. These plans have specific
goals and objectives for the child and family to work on. A variety of
supports are offered between visits such as weekly parent-child
activities at our Stay and Play centers and parent groups meetings on
specific topics. Families often email or phone their parent educators
with questions or concerns that arise between visits.
Some families referred to our program have many issues and over the
course of time things change in their lives, sometimes dramatically.
This was the case with a married couple I worked with a several years
ago. Mom was a high strung, excitable person and dad was just the
opposite. He was laid back and calm. Living in low-income housing at
the time, they were already doing their best trying to manage time,
living expenses, jobs, childcare, and transportation. A possible
language delay was detected during a home visit when I administered a
Denver II screening to their son and a referral was made for further
evaluation. Subsequently, their son qualified for and received speech
therapy. Before the child was three, the parents found out they were
expecting twins. After the twins were born the parents discovered one
of them had Down Syndrome. Mom was not sure she could handle three
children under the age three or cope with two children having special
needs. She was overwhelmed and in need of more support. I was able to
enroll the twins in Parents as Teachers and continue visiting the
family. The family and I searched for community resources for their
special needs children. It was difficult at times because resources in
a rural community are limited and we did not know whether or not the
family qualified for different services. Through it all, the parents
always made time for my visits and calls. Dad participated in some of
the home visits and the entire family attended some evening parent-
child special events. I worked with this family for almost 6 years
sharing their joys and working through their concerns and fears. They
still stay in contact with me and send pictures and family updates
every Christmas.
I was first introduced to Sussex Parents as Teachers home
visitation program in 1992. I had just left my job as a public school
special education pre-kindergarten and kindergarten teacher to stay at
home to raise my two sons, ages 2 and 4. My extended family lived far
away, my husband worked full-time and was involved in local activities
in the evenings and on weekends, and my close friends were working
parents or parents of adult children. I had a master's degree in
education and thought I knew how to be a great parent. It was not long
before I started to experience feelings of isolation, depression, lack
of patience, and total exhaustion on some days. We tend to parent the
way we were parented and although my parents did their best, I did not
necessarily want to use the same parenting style and techniques my
parents used with my siblings and me. It was by working part-time with
Sussex Parents as Teachers that I learned to be the best parent I could
be.
The Parents as Teachers Born to Learn training to become a
certified parent educator was unlike anything that I had experienced in
college. The Born to Learn Prenatal to Three Years training is intense
and comprehensive. The training provides the educator with information
and learning opportunities to share with parents, family members and
providers on how to promote healthy child development and how to be the
best possible teacher in a young child's life. This was such a
wonderful new program that allowed me to stay with families for three
years and meet with them on a monthly basis. As I grew more confident
as a parenting educator, I become more competent and confident as a
parent. Thanks to the new knowledge gained from Parents as Teachers, I
felt equipped to give my boys the best possible early education and I
knew that I was truly contributing to the well being of other families.
A year after my initial Parents as Teachers training, I was
facilitating a parent-child play group in my community, making regular
home visits with a diverse group of parents, recruiting new families,
administering developmental screenings, and linking families to
community resources. I loved my job, however there were a few
drawbacks. A lack of supervision, a sense of professional isolation in
the field and a change in my family's financial situation prompted me
to return to full-time work.
In 1995 I helped open a new state of the art child care facility
and was able to continue with Parents as Teachers at the center by
initiating the newly developed Parents as Teachers Supporting Care
Providers through Personal Visits program. I coordinated the program
for several years before I left to teach child development at a local
university. Those personal visits with child care providers, parents
and children were magical. Trusting and respectful relationships
developed between parents and providers. Parental and provider
resilience was built. Concrete support during times of need was
provided. Knowledge of parenting and child development was increased.
I taught at the university for several years when my friend Cris,
one the three women who pioneered Sussex Parents as Teachers,
encouraged me to apply for the newly formed full-time coordinator
position. I accepted the position with the hope that I could give to my
staff of parent educators what they give to parents and children--new
knowledge and skills, recognition, validation and affirmation. I
believe I do this on a regular basis. I have completed my doctoral
coursework, successfully passed my comprehensive exams and drafted my
dissertation proposal. Friends and family ask what I want to do when I
finish my Ph.D. in organizational leadership and I tell them that I
want to continue in the home visitation field because we have much more
work to do with families in this 21st century. Parents as Teachers has
afforded me the knowledge, skills and confidence to be a better parent,
skilled teacher and successful administrator. All families with young
children, and their providers, deserve to have access to the best
parent educators, current child development information, and family
supports so that children will learn, grow and develop to reach their
fullest potential.
Thank you, Mr. Chairman and distinguished members of the committee,
for allowing me the opportunity to share this testimony with you today.
______
Mr. Osborne. Thank you very much.
And, Dr. Daro?
STATEMENT OF DEBORAH DARO, RESEARCH FELLOW, RESEARCH ASSOCIATE
(ASSOCIATE PROFESSOR), CHAPIN HALL CENTER FOR CHILDREN,
UNIVERSITY OF CHICAGO
Ms. Daro. Thank you very much.
I want to begin with thanking Congressman Davis for that
wonderful, kind introduction, and to thank him and Mr. Osborne
and Mr. Platts for your support of this legislation that most
certainly is designed to improve outcomes from children.
There is uniform agreement, I think, around the country
about the importance of early learning. Learning begins at
birth, not when a child enrolls in kindergarten.
Within this early learning context, voluntary home
visitation programs have surfaced as a promising vehicle for
providing support to new parents in how to nurture and promote
their child's healthy development.
The ``Education Begins at Home Act'' is an important
milestone in fostering more comprehensive systems of early
learning. It has two key characteristics. First, it vests
decisionmaking authority in the states in terms of selecting a
given intervention. This is in keeping with the historical
preference for state and local interest in public education.
At present, about 37 states are involved in trying to
develop early learning systems for their communities and their
constituents and our review find that state leaders do
understand the importance of quality, careful documentation and
implementation and impacts, and sustaining their programs
through a system of public and private partnerships.
Federal legislation that can promote this good behavior on
the part of states is certainly something to be applauded.
Second, I think the bill requires the collection and use of
information to improve practice. As such, the legislation goes
a long way toward creating the type of learning environment we
know are needed to improve social service delivery quality and
outcomes.
We often in our lives move forward without perfect
knowledge, but we should never move forward without having a
community of learning to guide our decisionmaking.
So what constitutes best practice in home visitation? There
is a difference, in my mind, between looking at empirically
based programs and empirically based practice. Most of the
research that I do and spend time examining really looks at the
characteristics of service delivery that makes for strong
outcome.
This body of knowledge suggests that there are certain
characteristics of home visitation that increase the odds of
them achieving positive outcomes. By positive outcomes, I think
one of the most important is building a strong parent-child
relationship, building a strong sense of attachment between
that child and their primary caretaker.
If we know nothing else about education in this country, we
know that children that show up at school socially and
emotionally healthy are ready to learn.
And what does that mean? These are children that can
establish relationships and keep them, these are children that
can manage their emotions, and these are children that, most
importantly, can see a goal for themselves and then motivate
themselves to get there.
That is the kind of outcome quality home visitation can
produce.
But it is not just any home visitation program. What are
some of the characteristics that make a difference? Certainly,
solid internal consistency. A program says what it is going to
do and then sets up a method to get there.
Forming an established relationship with the family, so
that it extends for a sufficient period of time to accomplish
the goals of the program, to increase knowledge, to build
skills, to help that parent form and sustain a relationship
with their child.
It requires competent, well trained staff, staff that not
only have the book knowledge of how to do this work, but the
relationship knowledge on how to do this work.
It requires high quality supervision, so that workers are
constantly supported in the work they need to do.
It requires solid organizational capacity. To deliver these
programs, organizations themselves need to be robust and able
to weather the comings and goings of various funding streams.
And then, finally, this program needs to be able to link to
other community resources and services. No one program can do
it all. The only strength that we have is when we collectively
work together for the well-being of children.
Even when home visitation programs embrace these
characteristics, I would love to tell you they are a 100
percent successful, but they are not. They are not for a host
of reasons, partly because families are difficult, families are
challenging, and partly because we just don't know all the
answers we need to know.
We know more today than we knew 10 or 15 years ago. We have
a greater understanding of what it takes to enroll and engage
these families in the service delivery process. We have
stronger service protocols. We have better staff training and
methods of supervision, a greater understanding of how to link
families with services.
We don't, however, have all the answers, and that brings me
to my last point.
I think the importance of this legislation is it does not
require a single model. It doesn't tell people, ``Here is the
program that will work.'' It requires more of states.
First, it requires that they go through a planning process,
a discernment process to discover what strengths they have,
what limitations they have, and how can they build best on
their existing services in order to launch an effective system
of early intervention.
For some states, that will be their healthcare system. For
other states, it may be their education system.
In Illinois, we have a strong early learning coalition,
where advocates have come together and are really building a
collective response to the problem.
Second, no one program works for all families. A program
that enrolls families prenatally can't service families if they
are not getting prenatal services.
For some families, the link and attraction will be an
education program. For other families, it is going to be
healthcare program.
For home visitation to be successful, it needs to have the
ability to meet parents where they are and engage them
appropriately.
And, finally, this field is in desperate need of new
learning. By allowing states the opportunity to select and then
test the utility of different models, both in terms of outcomes
and implementation and the scale-up potential they may have for
advancing learning.
Such learning is essential if we are to identify and
resolve the adaptive challenges we face in ensuring that
children born today are ready for school tomorrow.
Thank you.
[The prepared statement of Ms. Daro follows:]
Prepared Statement of Deborah Daro, Ph.D., Chapin Hall Center for
Children, University of Chicago
Background
Early intervention efforts to promote healthy child development
have long been a central feature of social service and public health
reforms. Today, prenatal care, well-baby visits, and assessments to
detect possible developmental delays are commonplace in most
communities. The concept that learning begins at birth, not when a
child enrolls in kindergarten, has permeated efforts to improve school
readiness and academic achievement (Kauffman Foundation, 2002). More
recently, child abuse prevention advocates have applied a developmental
perspective to the structure of prevention systems, placing particular
emphasis on efforts to support parents at the time a woman becomes
pregnant or when she gives birth (Daro & Cohn-Donnelly, 2002).
Although a plethora of options exist for providing assistance to
parents around the time their child is born, home visitation is the
flagship program through which many states and local communities are
reaching out to new parents. Based on data from the large, national
home visitation models (e.g., Parents as Teachers, Healthy Families
America, Early Head Start, Parent Child Home Program, HIPPY, and the
Nurse Family Partnership), it is estimated that somewhere between
400,000 and 500,000 young children and their families receive home
visitation services each year (Gomby, 2005). In addition, 37 states
have early intervention service systems that include home visitation
services, which may include one or more of these national models or may
be based on a locally developed model (Johnson, 2001). Although the
majority of these programs target newborns, it is not uncommon for
families to begin receiving home visitation services during pregnancy,
to remain enrolled until their child is 3 to 5 years of age, or to
begin home visits when their child is a toddler. Given that there are
about 23 million children aged 0-5 in the U.S. (and about 4 million
births every year), the proportion of children with access to these
services is modest but growing.
The Education Begins at Home Act represents an important milestone
in establishing an effective and more easily accessible system of
support for all new borns and their parents. Among the bill's most
important features are identifying the critical elements that
constitute a quality home visitation program; allowing states to select
a specific service model that reflects these quality elements and best
complements its other early intervention efforts; and requiring the
collection and use of information to enhance practice. Although no
legislation comes with absolute guarantees, the Education Begins at
Home Act builds on an impressive array of knowledge regarding the
efficacy of home visitation programs and creates an implementation
culture which emphasizes quality and continuous program improvement.
In my time this morning I want to briefly summarize the evidence
supporting the expansion of home visitation programs for new borns,
identify those program elements associated with more positive outcomes,
and discuss the array of efforts underway by several of the national
home visitation models both individually and collectively to sustain
ongoing quality improvements.
The Broader Context of Early Learning
Before considering the specific outcomes of home visitation
programs, it is important to reflect on the full body of research that
initially supported the current policy emphasis on newborns and their
parents. The rapid expansion of home visitation over the past 20 years
has been fueled by a broad body of research that highlights the first 3
years of life as an important intervention period for influencing a
child's trajectory and the nature of the parent-child relationship
(Shonkoff & Phillips 2000). The empirical base for this conclusion grew
out of the early brain research, translated for popular consumption by
the Carnegie Foundation's ``Starting Points'' report (1994) and a
special issue of ``Time'' (Spring/Summer, 1997).
In addition, longitudinal studies on early intervention efforts
implemented in the 1960s and 1970s found marked improvements in
educational outcomes and adult earnings among children exposed to high-
quality early intervention programs (Campbell, et al., 2002; McCormick,
et al., 2006; Reynolds, et al., 2001; Schweinhar, 2004; Seitz, et al.,
1985). These data also confirmed what child abuse prevention advocates
had long believed--getting parents off to a good start in their
relationship with their infant is important for both the infant's
development and for her relationship with parents and caretakers (Cohn,
1983; Elmer, 1977; Kempe, 1976).
The key policy message from this body of research is that learning
begins at birth and that to maximize a child's developmental potential
requires more comprehensive methods to reach new borns and their
parents. Individuals may debate how best to reach young children; few
dispute the fact that such outreach is essential for insuring children
arrive at school ready to learn.
Why Home Visitation?
A particular focus on home visitation within the context of
developing a system to support new parents and their young children
emerged, in part, from the work of the U. S. Advisory Board on Child
Abuse and Neglect in the early 1990s (U.S. Advisory Board 1990,1991).
Drawing on the experiences of many western democracies and the State of
Hawaii in taking home visitation ``to scale'' as well as the initial
promising results of David Olds's nurse home visitation program in
Elmira, New York (Olds, et al., 1986), the U.S. Advisory Board
concluded that ``no other single intervention has the promise that home
visitation has'' (U.S. Advisory Board, 1991: 145). Although the Olds
data showing initial reductions in reported rates of child abuse among
first-time, low-income teenage mothers was often cited as evidence the
method worked, the fact that at least a dozen assessments of other home
visitation efforts had demonstrated gains in such diverse outcomes as
parent-child attachment, improved access to preventive medical care,
parental capacity and functioning, and early identification of
developmental delays was equally influential (Daro, 1993). This pattern
of findings, coupled with the strong empirical support for initiating
services at the time a child is born and Hawaii's success in
establishing its statewide system, provided a compelling empirical and
political base for the initial promotion of more extensive and
coordinated home visitation services.
The Evidence of Success
Over the past 15 years, numerous researchers have examined the
effects of home visitation programs on parent-child relationships,
maternal functioning and child development. These evaluations also have
address such important issues as costs, program intensity, staff
requirements, training and supervision, and the variation in design
necessary to meet the differential needs of the nation's very diverse
new-parent population. Some of these studies have confirmed the initial
faith placed in the strategy by the U. S. Advisory Board; others find
that many questions remain unanswered, even as states continue to
expand services in this area.
Attempts to summarize this research have drawn different
conclusions. In some cases, the authors conclude that the strategy,
when well implemented, does produce significant and meaningful
reduction in child-abuse risk and improves child and family functioning
(AAP Council on Child and Adolescent Health, 1998; Geeraert, et al.,
2004; Guterman, 2001; Hahn, et al., 2003). Other reviews draw a more
sobering conclusion (Chaffin,2004; Gomby, 2005). In some instances,
these disparate conclusions reflect different expectations regarding
what constitutes ``meaningful'' change; in other cases, the difference
stems from the fact the reviews include different studies or place
greater emphasis on certain methodological approaches (e.g., randomized
controlled studies).
It should not be surprising to find more promising outcomes over
time. The database used to assess program effects is continually
expanding, with a greater proportion of these evaluations capturing
post-termination assessments of models that are better specified and
better implemented. In their examination of 60 home visiting programs,
Sweet and Appelbaum (2004) documented a significant reduction in
potential abuse and neglect as measured by emergency room visits and
treated injuries, ingestions or accidents (ES = .239, p < .001). The
effect of home visitation on reported or suspected maltreatment was
moderate but insignificant (ES = .318, ns), though failure to find
significance may be due to the limited number of effects sizes
available for analysis of this outcome (k = 7).
Geeraert, et al. (2004) focused their meta-analysis on 43 programs
with an explicit focus on preventing child abuse and neglect for
families with children under 3 years of age. Though programs varied in
service delivery strategy, 88 percent (n = 38) utilized home visitation
as a component of the intervention. This meta-analysis, which included
18 post-2000 evaluations not included in the Sweet and Appelbaum
summary, notes a significant, positive overall treatment effect on CPS
reports of abuse and neglect, and on injury data (ES = .26, p < .001),
somewhat larger than the effect sizes documented by Sweet and
Appelbaum.
Stronger impacts over time also are noted in the effects of home
visitation on other child and family functioning. Sweet and Appelbaum
(2004) note that home visitation produced significant but relatively
small effects on the mother's behavior, attitudes, and educational
attainment (ES .18). In contrast, Geeraert et al. (2004) find
stronger effects on indicators of child and parent functioning, ranging
from .23 to .38.
Similar patterns are emerging from recent evaluations conducted on
the types of home visitation models frequently included within state
service systems for children aged 0 to 5. Such evaluations are not only
more plentiful, but also are increasingly sophisticated, utilizing
larger samples, more rigorous designs, and stronger measures. Many of
these evaluations, however, are not published in peer review journals,
and therefore not captured in the types of meta-analyses outlined
above. Although positive outcomes continue to be far from universal,
parents enrolled in these home visitation programs report fewer acts of
abuse or neglect toward their children over time (Fergusson, et al.,
2005; LeCroy & Milligan, 2005; Mitchel-Herzfeld, et al., 2005; Old, et.
al., 1995; William, Stern & Associates, 2005); more positive health
outcomes for the infant and mother (Fergusson, et al., 2005; Kitzman,
et al., 1997); more positive and satisfying interactions with their
infants (Klagholz, 2005); and a greater number of life choices that
create more stable and nurturing environments for their children than
either participants in a formal control group or than various
comparison groups identified on the basis of similar demographic
characteristics and service levels (Anisfeld, et al., 2004; LeCroy &
Milligan, 2005; Wagner, et al., 2001). One home visitation model that
initiates services during pregnancy has found that its teenage
participants reported significantly fewer negative outcomes by age 15
(e.g., running away, juvenile offences and substance abuse) (Olds, et
al., 1998).
Home visits offered later in a child's development also have
produced positive outcomes. Toddlers who have participated in home
visitation programs specifically designed to prepare them for school
are entering kindergarten demonstrating at least three factors
correlated with later academic success--social competency, parental
involvement, and early literacy skills (Levenstein, et al., 2002; Allen
& Sethi, 2003; Pfannenstiel, et al., 2002). Longitudinal studies of
home visitation services initiating services at this developmental
stage have found positive effects on school performance and behaviors
through sixth grade (Bradley & Gilkey, 2002) as well as lower high
school dropout and higher graduation rates (Levenstein, et al., 1998).
In addition to documenting the positive impacts of home visitation
services, these studies are contributing to a broader understanding of
how to do this work better. When mothers are enrolled during pregnancy,
not only are birth outcomes more positive but mothers enrolled during
this period have stronger parenting outcomes than women enrolled post-
natally (Mitchel-Herzfeld, et al., 2005). Although positive impacts
have been observed by programs employing home visitors with various
educational backgrounds and skills, one study, which examined the
relative merits of different types of home visitors within the context
of a program designed to be provided by nurses, found nurses more
effective in achieving program goals than a group of paraprofessionals
(Olds, et al., 2002). Others have found that outcomes are more robust
when home visitation is partnered with other early intervention
services or specialized support (Anisfeld, et al., 2004; Daro &
McCurdy, in press; Klagholz, 2005; Love, et al., 2002).
Despite continued variation in program objectives and approach,
agreement is growing around a number of key factors that represent the
types of programs most likely to accomplish expectations. This list
includes:
Solid internal consistency that links specific program elements to
specific outcomes;
Forming an established relationship with a family that extents for
a sufficient period of time to accomplish meaningful change in a
parent's knowledge levels, skills and ability to form a strong positive
attachment to her infant;
Well-trained and competent staff;
High-quality supervision that includes observation of the provider
and participant;
Solid organizational capacity; and
Linkages to other community resources and supports.
As the number and breadth of interventions targeting the 0-5
population grow, the need to carefully allocate resources becomes more
acute. Each model, be it home visitation, Pre-K programs, or child
health insurance programs, needs to demonstrate both its effectiveness
and its added value to a system of early intervention. Current
empirical evidence suggests that home visitation does offer this type
of added value. Early Head Start and various meta-analyses find more
robust outcomes when families are offered both home-based and center-
or group-based options (Daro & McCurdy, in press; Love, et al., 2002).
When the primary objective of the intervention is enhancing school
readiness or improving developmental outcomes, it is clear that
children who are offered the opportunity for several hours a day of
structured, high-quality, early education, in addition to home
visitation services do better in school, seem more socially poised and
have more positive life outcomes. This added value appears not only to
improve parent-child interactions but also to reduce the type of
negative behavioral patterns that others have identified among children
spending long hours in child-care settings. And, not surprisingly, when
a child's behavior improves, relationships with parents are more
positive and abuse rates might potentially be lowered.
Assuring Continuous Program Improvement
Greater positive impacts among a broad range of home visitation
models reflect, in part, two trends--improved program quality and
improved conceptual clarity. With respect to quality, most of the major
national home visitation models are engaged in a series of self-
evaluation efforts designed to better articulate those factors
associated with stronger impacts and to better monitor their
replication efforts. For example the Nurse Family Partnerships (NFP)
maintain rigorous standards with respect to program site selection.
Data collected by nurse home visitors at local sites is reported
through the NFP's web-based Clinical Information System (CIS), and the
NFP national office manages the CIS and provides technical support for
data entry and report delivery. These data provide information to sites
about program management, details on how closely a site is following
the program model, and compare individual sites with other NFP sites to
help nurse home visitors refine their practice.
Since 1997, Healthy Families America's (HFA) credentialing system
has monitored program adherence to a set of research-based critical
elements covering various service delivery aspects, program content,
and staffing. In an effort to promote ongoing quality improvement, the
standards have been revised periodically to meet the changing needs of
families and programs. At present, over 80 sites use a common data
collection system developed by the national staff to monitor
implementation and ensure compliance with these standards. In addition,
an implementation study conducted in 2004 brought researchers and
practitioners together to examine key challenges within the service
delivery process, including issues of participant and staff retention,
service intensity, staff supervision, and service content.
And, after 3 years of extensive pilot testing and review, Parents
as Teachers (PAT) released its Standards and Self-Assessment Guide in
2004. Every 3 years, PAT programs are expected to complete a self-
assessment process that covers service delivery and program management
indicators, which emphasize continuous quality improvement.
In addition to model-specific efforts, representatives from six
national models (NFP, HFA, PAT, Parent Child Home Program, HIPPY, and
Early Head Start) have worked collaboratively as part of a Home Visit
Forum since December 1999 to explore possible areas of mutual need and
interest and to establish a vehicle for cross-program cooperation. At
the time it was established, the Forum committed to achieving three
major goals, considered central to advancing research and service
provision in the field of home visiting:
Strengthening the empirical and clinical capacity to assess and
improve home visit services and outcomes;
Developing strategic multi-model research inquiries and reinforcing
the reciprocal links back to practice, training, and model development;
and
Creating and supporting efforts to share and explore the
implications of lessons learned with the broader home visitation field.
Over time, this process has resulted in the refinement of each
model's theory of change, in the development of shared standards with
respect to staff training and supervision, and in the commitment to
advocate for program expansion within a framework of best practice
standards supported by empirical evidence.
Achieving Broader Outcomes
Home visitation is not the singular solution for preventing child
abuse, improving a child's developmental trajectory or establishing a
strong and nurturing parent child relationship. However, the empirical
evidence generated so far does support the efficacy of the model and
its growing capacity to achieve its stated objectives with an
increasing proportion of new parents. Maintaining this upward trend
will require continued vigilance to the issues of quality, including
staff training, supervision, and content development. It also requires
that home visitation be augmented by other interventions that provide
deeper, more focused support for young children and foster the type of
contextual change necessary to provide parents adequate support. These
additions are particularly important in assisting families facing the
significant challenges as a result of extreme poverty, domestic
violence, substance abuse or mental health concerns.
Preventing negative outcomes such as academic failure and poor
social emotional development will not be achieved through tunnel vision
or the adoption of a single intervention. The roots of these and
similar problems are buried in both the individual and in the social
context. For any intervention to realize a notable and sustained
reduction in a participant's risk factors or improvements in key
protective factors, the planning process must consider the
complementary changes that need to occur in the major institutions and
norms that influence a parent's actions and shape a child's social
environment. High expectations for home visitation services must be
accompanied by a commitment by state and federal legislators to the
types of systemic change that will create a context in which early
learning interventions can thrive. Although programs such as early home
visitation can change a parent's willingness to access health services,
health services need to alter their structure and funding procedures to
become more accessible. Home visitation programs can better prepare a
child to learn, but public education systems need to be better prepared
to accept children who will continue to face educational challenges.
Those planning and implementing home visitation programs for new
borns and their parents can not limit their vision or interests to a
narrow scope of work. They must look beyond the confines of their own
efforts and create explicit connections to the work of others. At the
most basic level, home visitation programs must include a set of
necessary ``wraparound'' services that are offered to program
participants that will build an effective bridge to their child's
preschool education. Equally important but rarely tackled is the effort
to define the conditions for change in relevant institutions or
mainstream efforts. Blending funding streams, reducing central control
and bureaucratic requirements, and providing greater local autonomy
require more than a minor adjustment in existing operations. The task
is not simply instituting a new model program, but rather discerning
and resolving the adaptive challenges that would face the nation's
social, educational, and health institutions were we to make a serious
commitment to supporting young children and their families.
All journeys begin with a single step. The Education Begins at Home
Act provides states an important vehicle for identifying the best way
to introduce home visitation into its existing system of early
intervention services. Chapin Hall's review of this process suggests
states are already responding to this challenge by requiring that any
model being replicated reflect best practice standards, embrace the
empirical process and be sustainable overtime through strong public-
private partnerships (Wasserman, 2006). The ultimate success of this
legislation will hinge on the willingness of state leaders to continue
to support data collection and careful planning and on the willingness
of program advocates to carefully monitor their implementation process
and to modify their efforts in light of emerging findings with respect
to impacts.
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______
Mr. Osborne. Thank you very much, Doctor.
And, Chief Burack?
STATEMENT OF JAMES BURACK, CHIEF, MILLIKEN, CO, POLICE
DEPARTMENT
Chief Burack. Thank you, sir. Mr. Chairman and members of
the Subcommittee on Education Reform, thank you for the
opportunity to present this testimony.
My name is Jim Burack. I am the chief of police in
Milliken, Colorado. I have been there for 5 years. Milliken is
a community about 45 miles north of Denver. We have a
population of about 5,000 folks.
My public safety career has included services as a patrol
officer, as a Marine Corps prosecutor, as a special assistant
U.S. attorney, as counsel with the police executive research
forum here in Washington, and, most recently, as the Marine
civil affairs officer in charge of judicial engagement and
reform for Anbar Province, Iraq, last year.
I am also a member of Fight Crime, Invest in Kids, an
organization of more than 3,000 police chiefs, sheriffs and
prosecutors who have come together to analyze the research on
what keeps kids from becoming criminals.
As police chief, I know there is no substitute for tough
law enforcement. Yet, cops know better than anyone that we
cannot arrest and imprison our way out of the crime problem.
The great challenge of policing is to identify that mix of
proven prevention and enforcement strategies that work to make
our communities safer. And as the agency that is usually the
first responder to social service emergencies 24/7, police know
the need to target at-risk youth and the environment that
produces them if they are to forge an effective crime control
strategy.
My police department, like thousands across the country,
has embraced community problem-solving as its service delivery
model. That does not mean we are not aggressive enforcers, only
that we try to deal with recurring problems proactively and in
partnership with the community.
We work closely with the boys' and girls' club. We have a
full-time school resource officer at a middle school. We are
facilitating a school dropout prevention and intervention
program.
These are all worthy programs that largely focus on our at-
risk youth. But we sometimes ask if our contact with at-risk
kids for a few hours during school or at boys' and girls' club
after school can really overcome the abuse and neglect or
negative influences that these kids endured in their early
years.
At the point we arrest a juvenile or young adult, it is
sometimes too late. Even though the majority of children who
are abused or neglected are able to overcome their maltreatment
and become productive adults, many victims of abuse and neglect
cannot.
Not only are they more likely to abuse and neglect their
own children, they are also more likely to become violent
criminals.
Fortunately, in-home parent coaching programs, also known
as home visiting programs, can help stop this cycle. They offer
frequent voluntary home visits by trained individuals to help
new parents get the information, skills and support they need
to promote healthy childhood development and raise their
children in a safe home.
There are several models of home visiting that help young
children get off to a good start life, and I want to focus on
the Nurse Family Partnership, or NFP, a proven crime fighting
strategy that improves child and family outcomes in a wide
range of area, including health, academic achievement,
employment, and criminality.
For example, NFP can prevent nearly half of abuse and
neglect cases among at-risk children. That is not catching
child abuse and neglect and responding to it. That is
preventing it from ever happening in the first place.
By the time those home visited kids reach their teens, they
have about 60 percent fewer arrests than the kids left out of
the program. Home visited kids are more prepared for school.
They have fewer hospitalizations for injuries, and they are
less likely to have behavior problems.
Home visited moms also benefit. They are more likely to be
employed and are less likely to be arrested.
NFP also generates, as we heard earlier from a fellow
witness, also generates over $3 of savings for every $1
invested, with two-thirds of that savings derived from reduced
crime. On average, that amounts to more than $17,000 in net
savings for every family in the program.
Now, unfortunately, there is a great deal of unmet need
among at-risk families nationally. But an approach with proven
results, like in-home parent coaching, should be more widely
replicated across the Nation and it frequently takes Federal
leadership to encourage communities to experience the value of
certain programs, and we believe this is one of those
opportunities that will pay dividends for generations to come.
I and my colleagues with Fight Crime, Invest in Kids, who
are leaders of American law enforcement, are grateful that this
subcommittee is holding today's hearing and we encourage the
subcommittee to continue to move forward and schedule the
markup early next year on the ``Education Begins at Home Act,''
introduced by Representatives Davis, Platts and Osborne.
I am reminded of a comment a friend and fellow member of
Fight Crime, Invest in Kids told a reporter recently.
Dean Esserman, who is the chief of police in Providence,
Rhode Island, said that ``This nation has rightly focused on
homeland security for the last 5 years, but we cannot afford to
simultaneously neglect hometown security, and this is a measure
that could significantly improve the outlook on crime in
hometown America.''
So we encourage Representative Castle, when he is back,
Representative McKeon, my own representative, Congresswoman
Musgrave, and all of their colleagues on the Education and
Workforce Committee to move forward the ``Education Begins at
Home Act'' early next year.
Thank you so much, and I would be happy to try to answer
any questions you may have.
Thank you, sir.
[The prepared statement of Chief Burack follows:]
Prepared Statement of James Burack, Milliken, CO, Chief of Police
Mr. Chairman and Members of the Subcommittee on Education Reform:
Thank you for the opportunity to present this testimony. My name is Jim
Burack and I have been the Chief of Police in Milliken, Colorado for
the last five years. Milliken is a community of just over 5,000 about
45 miles north of Denver. My public safety career has included service
as a patrol officer, as a Marine Corps prosecutor, as a Special
Assistant U.S. Attorney in Southern California, as Counsel with the
Police Executive Research Forum here in Washington, and as a Marine
civil affairs officer in charge of judicial engagement and reform for
Anbar Province, Iraq last year. I am also a member of FIGHT CRIME:
INVEST IN KIDS, an organization of more than 3,000 police chiefs,
sheriffs, prosecutors, and victims of violence, who have come together
to analyze the research on what keeps kids from becoming criminals.
As a police chief, I know there is no substitute for tough law
enforcement. Yet cops know better than anyone that we cannot arrest and
imprison our way out of the crime problem. The great challenge of
policing is to identify that mix of proven prevention and enforcement
strategies and tactics that work to make our communities safer. As the
agency that is the first responder to social service emergencies 24/7,
police know that they need to target at-risk youth and the environment
that produces them if they are to forge an effective crime control
strategy.
My police department, like thousands across the country, has
embraced community problem-solving as it service delivery model. That
does not mean we're not aggressive enforcers, only that we try to deal
with recurring problems proactively and in partnership with the
community. We work closely with the Boys & Girls Club, we have a full-
time School Resource Officer in our Middle School, we're facilitating a
school drop-out prevention and intervention program--all worthy
programs that largely focus on our at-risk youth. But we sometimes ask
if our contact with at-risk kids for a few hours during school or at
the Boys & Girls Club after school can really overcome the abuse or
neglect, or negative influences that child endured in his early years.
At the point we arrest a juvenile or young adult, it is sometimes
too late. Even though the majority of children who are abused or
neglected are able to overcome their maltreatment and become productive
adults, many victims of abuse and neglect can not. Not only are they
more likely to abuse or neglect their own children, they are also more
likely to become violent criminals. Research shows that, based on
confirmed cases of abuse and neglect in just one year, an additional
35,000 violent criminals and more than 250 murderers will emerge as
adults who would never have become violent criminals if not for the
abuse or neglect they endured as kids.
Fortunately, in-home parent coaching programs, also known as home
visiting programs, can help stop this cycle. They offer frequent,
voluntary home visits by trained individuals to help new parents get
the information, skills and support they need to promote healthy child
development and raise their children in a safe home.
There are several models of home visiting that help young children
get off to a good start in life. They each serve a slightly different
population and have different, but complementary goals: the Nurse
Family Partnership, Healthy Families America, Parents as Teachers,
Early Head Start, Home Instruction for Parents of Preschool Youngsters
and the Parent Child Home Program. I want to focus on the Nurse Family
Partnership, or NFP, a proven crime-fighting strategy that improves
child and family outcomes in a wide range of areas including health,
academic achievement, employment and criminality.
The NFP provides at-risk new moms with two and a half years of
visits from trained nurses, beginning during pregnancy. Random control
trial scientific research shows in-home parent coaching can be one of
our strongest weapons in the fight against crime. Research, originally
published in the Journal of the American Medical Association, shows
that the NFP can prevent nearly half of abuse and neglect cases among
at-risk children. That's not catching child abuse and neglect and
responding to it--that's preventing it from ever happening in the first
place.
By the time those home-visited kids reach their teens, they have
about 60% fewer arrests than the kids left out of the program. Home-
visited kids are more prepared for school, have fewer hospitalizations
for injuries and are less likely to have behavior problems, setting
them up for success. Home-visited moms also benefit. They are more
likely to be employed, have fewer subsequent pregnancies and are less
likely to be arrested.
Analysis by the Rand Corporation and the Washington State Institute
for Public Policy determined that NFP also generates over three dollars
of savings for every dollar invested, with two-thirds of the savings
derived from reduced crime. On average that amounts to more than
$17,000 in net savings for every family in the program.
Unfortunately, there is a great deal of unmet need among at-risk
families nationally. Every year, over 600,000 low-income women in the
U.S. become mothers for the first time, resulting in 1.5 million
mothers (who are pregnant or have a child under the age of two) who are
eligible for the NFP. However, the program is only able to serve about
20,000 mothers annually, while other models serve an additional 400,000
at-risk and other families. That leaves hundreds of thousands of at-
risk mothers across the country without the benefit of one of these
programs.
An approach with proven results like in-home parent coaching should
be more widely replicated across the nation. It frequently takes
federal leadership to encourage communities to experience the value of
certain programs. We believe this is one of those opportunities that
will pay dividends for generations to come.
I and my colleagues with Fight Crime: Invest in Kids who are
leaders of American law enforcement, are grateful that this
Subcommittee is holding today's hearing and I encourage the
Subcommittee to continue to move forward and schedule a markup early
next year on the Education Begins at Home Act, introduced by
Representatives Davis, Platts and Osborne. We look forward to similar
movement next year on a companion bill in the Senate, sponsored by
Senators Bond, DeWine, and Talent.
The law enforcement leaders of Fight Crime: Invest in Kids join the
many, bi-partisan co-sponsors of the Education Begins at Home Act in
support of this important legislation. We know that a small investment
now will help stop abuse and neglect, improve children's school
readiness and reap dividends down the road by saving lives and money.
I'm reminded of a comment a friend and fellow member of Fight
Crime: Invest in Kids told a reporter recently. Dean Esserman, the
Chief of Police in Providence, RI, said recently that this nation has
rightly focused on homeland security for the last five years, but we
cannot afford to simultaneously neglect hometown security. This is a
measure that could significantly improve the outlook on crime in
hometown America.
We urge Representative Castle, Representative McKeon, my own
Representative, Congresswoman Musgrave, and all of their colleagues on
the Education and the Workforce Committee to move forward the Education
Begins at Home Act early next year. Thank you, and I would be happy to
answer any questions that you may have.
______
Mr. Osborne. Well, thank you very much. Sorry I
mispronounced your name. I tried to put a Czech connotation on
there, coming from that type of area. So, anyway, Chief Burack,
thank you for being here. Appreciate it very much.
I will begin the questioning. I will try to be fairly
brief, because we may have a vote in 45 minutes or less, 25
minutes. So I think if every panelist will try to keep their
answers short and concise, we might be able to get this done
before then.
And, Ms. Ridge, you talked a lot about being cost-
effective, your program, and others, as well. Do you have an
estimate as to about what this costs per family and what it
would take to reach most of the families who are in need of
this type of program in the country? Because, obviously, we are
just doing bits and pieces here and there.
But any thoughts you or any panelist would have on that
question I would appreciate.
Mrs. Ridge. As far as the number of families that are in
need, I would not be expert enough to give you that
information. I would be happy to submit, in written testimony,
a response to that, the numbers. The numbers are great.
Nurse Family Partnership targets first-time pregnancies for
low-income mothers. And I think what our typical site is, our
minimum is a 100 families. We have four nurses and a nurse
supervisor and we estimate that it is $.5 million for each
year.
So we prefer a larger site, 200 families, but the minimum
site is a 100 families.
Mr. Osborne. So you would be talking roughly $5,000 per
family, if you did a 100 families at $500,000, something like
that.
Mrs. Ridge. Well, it depends on the number of families. It
is $.5 million to do a site and so if you have 200 families, it
is $.5 million divided by 200 families.
But I think the important thing to note is that cost that
you save, the cost savings that you save are so far out and a
part of any kind of formula looking at this, but that is the
precise cost.
Mr. Osborne. I certainly agree with you, it is cost-
effective. I think two or three different witnesses mentioned a
three-to-one ratio. So if you spend $500,000, that means you
are saving a $150,000 in social costs and other negatives.
So I certainly agree with that.
Do any of the other panelists have any observations on cost
or number of families nationwide that would need a program like
this? Because, obviously, the Federal Government can't do
everything, but maybe in partnership with the states, we could
reach more.
And so you see the need out there. I was in the coaching
profession for 36 years and when I first started coaching in
1962, the number of people we saw from one-parent families was
minimal, and usually it was because one parent or the other was
deceased.
By the time I finished that career 36 years later, roughly
one-half of children were growing up without both biological
parents.
That is one reason I was so interested in your comment that
it increased father presence by 46 percent, because if you get
back to a lot of the base problems that we are looking at,
fatherlessness is huge. It is not the only problem, but it is
huge.
Any other observations any of you have in terms of cost per
family in programs that you have observed?
Ms. Scovell. The costs vary from program to program. And
the Nurse Family Partnership is certainly at the high end, but
it is a very high quality program.
The programs that are delivered with an equal attention to
detail probably can be delivered for $2,000, $2,100 a family,
$1,500 a family. But it also depends on what kind of
environment the program is being implemented in.
There is a lot of other ancillary services around that the
home visitation program can then partner with and use. So it is
really moving the system forward as opposed to thinking about
what would it take for the single intervention to do the job.
You are really trying to change the culture in which that
program is located.
Mr. Osborne. I appreciate your comments on the fact that
you have to have multiple partnerships throughout the community
and best practices are critical, because we can spend a lot of
money doing something that doesn't work very well.
I think that is one thing that sometimes the Federal
Government is really good at is spending money on things that
maybe aren't real effective. And so we need measurable,
quantifiable goals, and I think that is one of the purposes of
the legislation proposed is to make sure that we do target it
effectively.
Well, my time is about it and, in the interest of brevity,
I will turn it over to Ms. Woolsey at this point.
Ms. Woolsey. And I would yield to Danny Davis.
Mr. Osborne. And I understand she will yield to Danny
Davis.
Mr. Davis of Illinois. Well, thank you very much, Mr.
Chairman. I want to thank the ranking member for yielding,
also.
Let me thank all of the witnesses.
And, Ms. Ridge, let me just appreciate your outstanding
public service work. I think it is, indeed, commendable in the
way that you have made use of yourself.
In your experiences with the home visiting program, do you
find a level of receptivity? I notice the individuals are first
time pregnancies for low-income families.
What is the receptivity that you often experience?
Mrs. Ridge. First of all, thank you, Congressman Davis, for
your kind remarks. We have a lot of partners in Pennsylvania
working on behalf of children and families.
I think in a voluntary program, which is what Nurse Family
Partnership is, we found great receptivity and I think, in
part, some of that can be attributed to the use of registered
nurses.
What we have found with this particular home visitation
program, the Nurse Family Partnership, is that registered
nurses are highly trusted and bring great credibility and
perceived authority in addressing the needs and concerns of a
young mother and young parents.
So I think that has a lot to do with the receptivity.
Mr. Davis of Illinois. Thank you very much.
Chief Burack, I must say that I am fascinated by your
community's conceptualization of policing and crime prevention.
How did the community arrive at such a comprehensive
definition of what a police department is engaged in as a way
to reduce crime?
Chief Burack. Congressman, I guess that might be a--that is
a difficult question probably to answer in a few minutes.
But I think there has been a change of culture, of
expectations about what American law enforcement is capable of
doing in this era and I think that is happened over the last
two decades, with the leadership from Congress, and I think
there is a renewed expectation of community about what they
expect from our police.
And I think we have been incredibly successful and I think
you see law enforcement leaders across the country, including
in your district, who have done the very same things that we
have done, sir.
Mr. Davis of Illinois. Well, I must tell you that I think
it needs to be packaged and just simply sent around the country
as the way for law enforcement to really look at our long-range
objectives and what we attempt to do. So I certainly commend
you.
Dr. Daro, we have had lots of comments about cost-
effectiveness and during this day and age, practically
everything that we do, given the state of the economy, given
the usefulness of money and where does it come from and how can
we get it.
What do we know about the cost-effectiveness of programs
that are currently being used and being worked with pretty much
across the board?
Ms. Daro. Economists like Jim Hickman, at the University of
Chicago, will say if you look at the numbers, investing in
early childhood is the best bet any country could do, because
the returns on your investment are tenfold over the years.
So waiting until a child is harmed, waiting until a parent-
child relationship has gone south doesn't see to get you as
grand a savings as you can if you invest early.
The data that Ms. Ridge talked about is certainly strong,
because the Nurse Family Partnership has been around for 30
years and it is 30 years of follow-up data.
Increasingly, the home visitation programs that were
implemented maybe 10 years ago are just now getting a cohort of
children, where we can begin to show the same savings in terms
of better school outcome, less need for remedial education,
identifying children earlier that have learning disabilities,
so we don't spend a lot more money trying to remediate the
problems later on.
So all of those are potential for savings.
I have to say, though, when people go down the cost-benefit
road, costs are in real time. Benefits are in future time. And
most legislative decisions are made in real time.
So when we are looking for the adaptive challenges we face
in investing in early childhood, one of them is beginning to
look at how we consider legislation and how so we want a return
on our investment. We need to be able to have a long-term focus
and know that children will benefit from this, but it is going
to be a while, and those savings may not come back to the same
agency that invested in the program to start with.
Mr. Davis of Illinois. Thank you all very much. And, Mr.
Chairman, I would just ask unanimous consent to put into the
record two statements.
One is an issue brief from Chapin Hall, ``Implementation of
Home Visitation Programs,'' and the other one is a written
statement from the American Psychological Association, called
``Perspectives on Early Childhood Home Visitation Programs.''
Thank you. And I yield back the balance of my time.
Mr. Osborne. Thank you, Mr. Davis. And so ordered, on your
statements.
I would like to turn to one of the co-authors of the
legislation, Mr. Platts.
Mr. Platts. Thank you, Mr. Chairman. I appreciate Chairman
Castle and his staff in scheduling this hearing and your
standing in for the chairman. We certainly have Mike in our
prayers with his recovery.
Also, I am honored to join with our colleague,
Representative Davis, in sponsoring this legislation.
When I look at early education, I look at it from the
perspective of, one, as a former child myself and the education
I got at home from my mom and my dad, but especially mom, and
then as a parent of 7-and 10-year-olds and the blessings that
my children have had with my wife being able to be at home and
coming home, after our first child was born, from the not-for-
profit sector, executive, and being home.
But know that that is more the exception today, having that
opportunity.
But what I think this hearing is about is the importance of
early education, whether it be parent education, parent
visitation, home visitation, or other programs, because we
rarely have a debate about higher education funding and when we
do, it is about we are not spending enough.
But we seem to have more trouble when we come to early
education initiatives and it is a more heated debate of whether
it is a good investment. And the evidence, as our four
panelists, and I thank each of you for your testimony, so well
captured that if we invest early, the return is so significant
and the benefits to the child are so impressive, and, in
reality, the benefits to the taxpayer.
And when you see the studies that 85 percent of brain
development, neuron development is zero to 3 years of age, so
from an opportunity to learn down the road, what we do in these
early years is so critical.
I am delighted that we are having this hearing and kind of
laying the foundation for what I hope will be a very successful
effort in the coming months and session to move this
legislation.
I am certainly delighted with all of you participating and
your efforts in your respective positions. As a very proud
Pennsylvanian, Ms. Ridge, it was an honor to serve in
Harrisburg in the state house with you and Governor Ridge and
your family's leadership and service to our commonwealth is
going to be long, long remembered because of how blessed we
were by you and the Governor in so many ways, including here in
the area of the Nurse Family Partnership effort.
I do have a couple of quick questions I will get in before
I use up all my time.
One is, in just your respective dealings with the Nurse
Family Partnership, Parents as Teachers, and the various
programs, the selection process.
While we are going to push for our bill and more funds,
there are probably still going to be areas where you are going
to have to pick and choose.
What do you think is the best approach and how do you, the
respective programs, look at your clients, the parents that are
involved? How are they selected, screened, as far as being able
to participate?
And once they are in, is there a requirement--I will use
the term contract for their participation, to get the benefits
of the program, because we are going to invest the taxpayer
funds, the expectation that they are going to make an
investment back in giving their time.
Is there any kind of formal contract that the programs
enter into or is it more of a good faith that they are going to
participate, make the meetings, participate in any of the
events?
And, Ms. Ridge, maybe we will start with you and go across.
Mrs. Ridge. Well, as far as the Nurse Family Partnership
program guidelines, I would rather submit that as written
testimony to the actual process for selection and retention.
I think that is an important point for any home visitation
program, not just Nurse Family Partnership.
I think because of the comprehensiveness of Nurse Family
Partnership, I think you see a tremendous participation through
up to the child's second birthday and there are varying degrees
of retention for most of the home visitation programs.
So I think those specific statistics I would be happy to
submit with written testimony.
Ms. Scovell. As a program director with Parents as Teachers
at a local level, I know that we really give priority to
parents who were referred directly from the hospital.
We have a really close relationship with our local
hospitals and the nurses there will make direct referrals to
us. So we do give those referrals the highest priority.
We have lots of partnerships with various community
organizations and we work closely with social service and DFS
and they tend to have high priority, as well, when they come
into our program.
But we try to balance out all the parent educators'
caseloads so that they have a mix of parents who are considered
risk and non-risk, because at the program level and the service
delivery level, the parent educator really needs to have a
balance.
Otherwise, there is high turnover and burnout rate and we
really, really look forward to working with a variety of
families and giving all families that opportunity for parenting
education.
I agree that there are varying degrees of retention. We do
have a high percentage of our children in Sussex County
graduate at age 3 through the program.
It is a good faith effort. We don't have a formal contract,
but we do have parents who really, as in the testimony, who
really are committed to being the best they can be and they
feel that continuation of services until graduation for them
and their children really is a viable option.
Ms. Daro. Prevention is, by definition, in my mind, a
voluntary engagement process. And so there is nothing that is
keeping families there.
But what we find in our research and what does keep
families there is families go through a little benefit-cost
analysis in their mind every day and they are constantly
saying, ``Am I getting something out of this program that is
worth my investment in it?''
So to the extent that the program stays the course, to the
extent the staff relationships are strong, programs can,
indeed, retain families on what would be considered a voluntary
basis.
Chief Burack. Since we are going down the line, I will add
a couple comments. I think the really exciting part of this for
law enforcement is the potential, the potential to really
enhance that partnership between the deliverers here, whether
it is the Nurse Family Partnership or the other programs, and I
think the real benefits, as law enforcement becomes more
receptive and understanding of what these programs can do and
the benefits that they can--the costs we can save in the near
term and the benefits that we are going to receive in the long
term.
Mr. Platts. Thank you, Mr. Chairman. We are going to have
additional rounds, if time permits?
Mr. Osborne. We can do that if you want. We have votes in
about 15 minutes and I have noted that sometimes when you want
people back from votes, it is a little tough to get them back
here. So we will do the best we can.
Mr. Scott?
Mr. Scott. Thank you, Mr. Chairman.
Chief Burack, I have been intrigued by your testimony,
because you have suggested that we could reduce crime 60
percent and save money while we are doing it.
Does that include gang involvement?
Chief Burack. I think that is a fair speculation, sir. I
don't have the numbers. We could certainly see if the research
has referred to that particularly, but I think there would be
every expectation, especially in my community.
And Congresswoman Musgrave can attest to these, we have
some gang issues in my small town and I have every hope that
this would have some impact there. r. Scott. Well, you cite the
RAND Corporation as a study. We like mandatory minimums. My
other committee is the Crime Subcommittee in Judiciary. So, you
know, that committee loves mandatory minimums, which the RAND
Corporation has studied and concluded that it does nothing to
reduce crime and wastes the taxpayers' money.
You, on the other hand, have come up with a RAND study that
shows something that not only reduces crime, but saves money.
Which do you think is the more intelligent approach?
Chief Burack. That is a hard question. I think I like the
one that I was talking about, Congressman.
Mr. Scott. We also love to define more juveniles as adults.
Now, that is been studied, too. That actually increases the
crime rate, because in juvenile court, you can get services,
not only services for the juvenile, but also family services
and anything else, education and anything else the juvenile
needs.
The adult court judge can only let the juvenile walk out on
probation or lock him up with adult criminals, rapists, robbers
and drug dealers.
Does it make more sense to follow the strategy that reduces
crime 60 percent and saves money in the process or codify a
slogan that actually increases the crime rate?
Mr. Osborne. Are you leading the witness, sir?
Mr. Scott. Doing the best I can.
Chief Burack. How can I say no to that? I think law
enforcement is pretty sensitive to the special needs of
juveniles.
I don't want to go out of my lane here, but we feel very
strongly that early childhood interventions like this are a
cost-effective way to reduce those adverse impacts later on.
Mr. Scott. We have a bill, called ``Gangbusters,'' which
essentially tries more juvenile as adults, which increases
crime, has mandatory minimums, which waste taxpayers' money,
death penalty, which, for juveniles has been shown to do
nothing to reduce crime.
That was pretty much the sum and substance of the
legislation. It didn't have anything in there for the NFP
program or something that actually reduces crime, certainly
nothing that saved the taxpayers money.
Should we revisit the issue and try to do something a
little more intelligently on this issue?
Chief Burack. You know, with all due respect, Congressman,
I would love to have a longer conversation, but I am not sure I
am qualified right now or prepared to respond to that, other
than to say that I think the programs we are talking about
today are really the focus and we in law enforcement support
them.
Mr. Scott. They have been studied and they work and they
reduce crime.
For children that are abused, did somebody suggest there is
an intergenerational problem, that children who are abused tend
to abuse their children and it goes on and on?
Chief Burack. I certainly cited some statistics that
suggest that, yes, sir.
Mr. Scott. So that if we take your strategy, Chief, not
only do we reduce crime for this generation, but generations to
come and save more money in the process.
I appreciate your testimony, because it seems to me that
you have a much more intelligent approach to crime prevention
than we have done in the Crime Subcommittee and I would hope
that we would review your work and do something a little more
intelligently than we are doing.
Thank you, Mr. Chairman. I yield back.
Mr. Osborne. Thank you, Mr. Scott.
Ms. Musgrave?
Mrs. Musgrave. Thank you, Mr. Chairman.
Well, Chief, I will be easier on you than Representative
Scott was. I wanted to say to you, all of you, that I have
heard ``low income'' mentioned over and over today.
And, you know, some of the most horrific crimes in Colorado
have been committed by young people that certainly did not come
from a low-income home.
So, I don't know, I get a little gristly about that. I
think that sometimes we make the assumption that jus because
people are poor, that they are ignorant when they raise their
children and they are engaged in a lot of negative behaviors.
So now that I got that off my chest, I want to say I agree
so much with the chairman that the presence of the father in
the home is very significant and I don't care where you are on
the political spectrum, I think that the facts are very clear
on that issue.
And I would just like to say that something that is really
been on my heart and the heart of many on this committee is
methamphetamine, and, boy, talk about a challenge that we are
facing.
At times, it just seems insurmountable. And you talk to law
enforcement about what is going on in these homes and these
little children exposed to enormous risk, total neglect, abuse,
and, I mean, it is just overwhelming.
And in Colorado, it is just a scourge and I just have to
say to the chief, and I agree with much of what Representative
Scott said, you know, we have got to have some hope out there.
We have got to have something on the other end to keep you guys
in law enforcement going and all of you other professionals
that are trying to intervene at a time when it can make such a
significant difference.
And could you, Chief, just address the meth issue? I hope
that is being easier on you than he was. But could you talk
about that a little bit and its impact on families and
communities?
Chief Burack. Congresswoman, I appreciate your leadership
in Colorado on this and you have brought your committee back
and testified there.
It is hard to overstate the impact that it has on families.
But I can just tell you, anecdotally, even in the little town
of Milliken, we have a meth problem. It impacts families, it
impacts kids, and it is hard to overstate the impact it has on
communities and the crime problem.
And we can see it on that micro scale and there is no
question that throughout the county and throughout this
country, it is having an impact.
Mrs. Musgrave. How successful do you think professionals
are, whether in law enforcement or social services, in getting
the kid out of that environment as quickly as possible?
Chief Burack. I think the results are mixed. Enforcement
efforts I think are incredibly important. There needs to be
some deterrent.
We need to have ways of keeping those kids, who are the
most susceptible to that kind of behavior, away from that kind
of stuff, and that is the dilemma for us, is to try to figure
out a way to keep those kids, as they age, that they are not
going to start engaging in the use of methamphetamine and every
other kind of illegal substance, including alcohol, and that is
part of our challenge.
Mrs. Musgrave. Thank you. Thank you, Mr. Chairman.
Mr. Osborne. Thank you very much.
Susan Davis?
Mrs. Davis of California. Thank you. Thank you, Mr.
Chairman. And thank you to all of you for being here and to the
sponsors of the bill.
I am actually very heartened that we are discussing this
today, because I know, as a former school board member and,
also, in the state legislature, to me, this was the most
commonsensical thing that we could do, and, yet, there was
always a tremendous amount of pushback.
And I wonder if you could share with us, as we prepare to
hopefully consider a bill of this nature in the coming year, if
there are areas that we need to anticipate that are
problematic.
One of the things that you have presented, and, you know,
it is been a few years since I had a chance to work on this, as
well, is that there is more data out there and that is very
helpful, because we really didn't have a lot of that.
I would look for more data in terms of students' ability to
progress in school and, certainly, longitudinally, in terms of
students who are able to stay out of school, teenage pregnancy,
all those particular issues.
But as you point out, we don't always have that luxury of
long-term data. Is there an area that you could point us to, in
anticipation, that you can see our problems, and sometimes its
ideological and I understand that, call it political, whatever
you want to call it, but how do you feel, in the programs that
you worked with, that you were able to combat some of those
concerns and, realistically, to help people see the benefits in
the long term?
Ms. Daro. As someone that is worked in prevention for 20
years, it is a very hard concept to convey to people. People
think it is intrusive, ``You are trying to interrupt my way of
taking care of my kid and who are you to say that?''
And I like to tell people if you think of someone stopping
you on the street and asking you for $5, you would be much more
put out than if they offered to give you $5.
And the message of prevention is this is a gift, this is
something we need to offer you. I love the universal appeal of
the program, because what I worry about when we keep trying to
target it, we keep trying to say let's just get those bad
parents, let's find those people that don't do the right
things, that is a hard thing to do before something wrong has
happened.
We don't have the kind of methods to say whether a parent
who is simply angry with their child, that will escalate to
something else.
By offering it universally, you say to people there is a
threshold, there is a relationship that all parents need to
establish with their children, that parenting is a difficult
job, and then you go about the business of giving more services
to families that have greater challenges.
You don't try to say there is one dosage that will work for
everybody. You say here is a threshold, here is the bottom line
we want for everybody, and then go about the business of
finding those families and children that are specifically
challenged, and you need to involve a lot of partners in that
process.
Ms. Scovell. I agree with Dr. Daro. And I want to applaud
Congresswoman Musgrave, because she talked about stereotyping
families and the low-income family oftentimes getting the
stereotype of not being able to be the best parent or not
having the opportunity to do that.
We work with a variety of parents and I can honestly tell
you that low-income families have needs and high-income
families have needs and all the families in between have needs.
We work families--I am working with an RN right now who
just had triplets and she actually worked in labor and delivery
at the local hospital, and she just said, ``I just don't know
what to do, never mind with one child. I have a medical model
and I understand what I have to do medically, but I really am
nervous and I really need support.''
And this is a woman who was married, who had family
supports in the community, but who really got involved in the
program and has been so just excited about it, because she
really said that our parent educator who comes in really gives
her an opportunity to focus on one child at a time and that
child's development, and she is really appreciative of it.
So thank you, Congresswoman, for making that point.
I agree with Dr. Daro. It is a universal appeal and we
would like to have all families to be able to have that
opportunity.
Mrs. Davis of California. Thank you.
Ms. Ridge?
Mrs. Ridge. Congresswoman, I would also like to say that
any kind of home visitation and especially to improve school
readiness for children in this country is really a multi-
pronged sort of problem and issue and has solutions that have
to meet different needs.
And I think in the case of Nurse Family Partnership, 30
years ago, when Dr. David Olds started this program, it was a
case of trying to help a group of mothers who have--it is not
necessarily that they are low-income, but they have few
resources. And if you look at the public health model, they
have many risk factors.
And so I think it is important that all the models be
evaluated and that in certain instances, we need to target our
efforts. I think one of the reasons that I got involved with
Nurse Family Partnership is that it was one of the 11 blueprint
violence reduction programs which we offered to communities in
Pennsylvania in the late 1990's.
And in 1995, when my husband had the special legislative
session on crime and the reform of juvenile justice, he said we
can't just get tough on crime, we have to get smart about it
and that prevention had to be an important strategic part of
any solution to major problems.
So I think part of what I am trying to say is that
prevention is a difficult concept for people to understand. It
is not something that--and it is a long-term investment, which
is difficult in a political arena, where you have terms of
office and you have budgets that are an annual basis.
So I think it is just to keep those points in mind.
Mrs. Davis of California. Thank you. Thank you, Mr.
Chairman.
Mr. Osborne. Thank you very much.
At this time, I would yield to the ranking member, Ms.
Woolsey.
Ms. Woolsey. Thank you, Mr. Chairman.
Congressman Musgrave, you are going to faint, because I
agree with you 100 percent. Honestly, I was sitting here
putting all my thoughts together and we cannot assume that it
is poor families that abuse their children, what a stigma that
is and how wrong that is.
Certainly, having less income is a frustration that causes
actions that aren't always positive, but there are a lot of
other things that do, too. And it is not only low-income
families that need the tools for the first time in parenting.
I mean, a first baby is a first baby, and I can remember
mine. I mean, I never felt so stupid in all my life and that
was 45 years ago. And my daughter, 2 years ago, had her first
child and they sent a nurse practitioner to the house. She just
picks that woman's brains and learns so much. So all levels of
income.
I haven't signed on to this legislation, but I think the
funding is flawed. First of all, it doesn't provide nearly
enough for California. But, second of all, I think we need to
start with low-income, but we should make available, maybe on a
sliding scale, for families that can afford this help, because
that help is very necessary.
We have learned a lot. First of all, we have learned that
investing up front saves a lot more. For a $1 we invest up
front, what is it, $7 or $8 later, at least, and that is
probably undervaluing that $1.
So, Chief, I would like to say to you that it is clear why
you have been the chief for 5 years, you were probably 12 when
you started, you are good.
And I would like all of you, and starting with the chief,
to talk to me not just about moms, but about dads. I know mom
is the one that brings the babies there and that has to be,
but, you know, in today's society, when both parents work, if a
child's lucky enough to have two parents.
In my family, I have three sons and a daughter. My sons and
my son-in-law are full parents. I mean, they change as many or
more diapers than the moms do. They do more learning with the
kids.
But how do we make that happen? How do we get dad involved?
Starting with the chief.
Chief Burack. I guess I agree with you wholeheartedly. They
are clearly an important part of the question.
I am going to have to defer to, I guess, my colleagues
here, who have worked sort of on the delivery, the service
delivery model, exactly how they have engaged that father
figure.
But I certainly can tell you, from the street level, that
is a key element in these kids' upbringing.
But the reality is we have lots of single mom homes and if
we are looking at the risk factors and looking at the folks we
need to focus on, and I can certainly tell you that anecdotally
from the street, that is a good place to start at this time.
Ms. Woolsey. And maybe we shouldn't say dad. Maybe we
should say a male figure in their life.
Doctor?
Ms. Daro. One of the beauties of going into the home is you
are dealing with everybody that is there. And so you are not
asking them to come into a service program, but you go into the
home and when dad's there.
The home visitors that I have worked wit tell me that when
you are there, you can engage them in the process. You can show
them how the child learns. You can show how the child responds
to them.
You can help them get some enjoyment out of this child,
because once people get a feedback, I mean, any father in the
room, when you have held that baby and the first smile you get
or the first connection you get, that is powerful, that is the
communication, and that is what the program can work with, not
only with the moms, but also with the dads.
Second, I think it is reminding the father, the other
partner in the home, about the financial responsibility of
taking care of this family, that it is part of the partnership.
It is not just the emotional support, but the ability to be
there and provide some financial support to the family.
Ms. Woolsey. Well, sometimes it is just the opposite. They
think, ``I brought the paycheck home, that is all I need to
do.''
Ms. Daro. Yes. But, also, many of the families that the
home visitors are going to, there is no paycheck showing up
there. That would be great, but that is not always the case.
So it is really trying to work with both. And I think,
also, going back to high schools and working with adolescent
males, beginning to tell them what it is to have a positive
relationship, a respectful relationship, and programs that have
been doing that around relationship-building with teens are
showing some very positive results.
Ms. Scovell. I think one of the strategies we use at the
local programming level is scheduling. Our home visitors are
available daytime, evenings and weekends.
So we really have an opportunity to try to get those
partners involved as much as possible, if we can.
We also do high school teen groups, as well, and we work
with dads and we have separate dad groups and mixed dad and mom
groups, and they are quite interesting sometimes.
I think one of the stories that I was thinking about when
we were talking about dads was videotaping a family play
session and dad was on the floor. And he was a volunteer
fireman, we have volunteer fire fighters only in Sussex County,
Delaware.
And the mom was saying that dad's never around, ``You are
always out of the house, you are working full-time, you are
always at the fire hall and what not.''
And I was videotaping this playtime and the fire alarm went
off and the dad just up and out and left. And then when I went
back the next time for the home visit, I shared the videotape
and we were talking about the parent-child interaction, and the
dad started crying.
He said, ``You know, for years''--and the child was 3. He
was exiting our program and graduating. And the dad said, ``You
know, for years, my wife was telling me that this was as very
abrupt kind of dismissal and I never really got to say goodbye.
I just left.''
And when he saw it on videotape in one of the play
sessions, it really hit him hard and he said, ``You know, I
understand now. So that when I leave my house, I am going to
say goodbye to my son and I am going to kiss him and I will
tell him that I will be back.''
So that is just one story of many, many, many stories we
have at the programming level. The dads and father figures and
male figures are really, really important.
We do home visits, again, in the home, which is their
territory, and the whole family is invited. We have some family
members with grandparents. You were talking about having a
grandchild.
There is one family that I visit, both grandmoms are there
with the mom and the dad comes, when he can come, to the home
visit.
So it is challenging and we don't have a 100 percent dad
involvement, but we do encourage it as much as we can.
Mrs. Ridge. I would just like to add to Dr. Daro and Ms.
Scovell, the same sort of sentiment, and that is that the
program objectives in the home visitation are to involve both
parents in the birth of this child, the health of this child,
development of this child.
And I think, again, going back to the presence of the
registered nurse, this trained professional, who brings with
her--we have found, and Dr. Olds has done focus groups and done
evaluation, that with the nurses, there is no stigma to having
the nurses come.
I think the one question that was asked by one of the
previous Representatives about the receptivity, I think that
has a lot to do with it.
And so I think the nature of home visitation programs
really gives an opportunity to involve the fathers.
Ms. Woolsey. Thank you. This has been a wonderful panel.
Thank you, Danny. Thank you, Todd. Thank you, coach.
Mr. Osborne. Thank you, Ms. Woolsey.
Mr. Platts asked for a second round of questions and I
think it is my turn, but I will certainly yield to you, Todd,
at this point, if you would like to ask a question.
Mr. Platts. Coach, Mr. Chairman, I am glad to follow your
lead, if you would like to go first.
Well, thank you. Actually, I have very much enjoyed the
dialog and so many points have been hit.
And I think the example or the issue of dads being involved
and Representative Davis--it might have been Representative
Scott talking about the generational benefits.
And in the testimony we hear, and, Chief, you highlighted,
I think, especially in yours, the prevention of child abuse and
the research numbers and what it shows, is what we prevent.
But I think it is also important to emphasize what we
promote is the generational good example, is when the mom or
dad gets that good example of parenting skills and they give it
to their children.
Then when their children become parents--because I say, as
a dad of two, the example I follow is my dad's example to five
of us and how he did it and stayed sane, I don't know.
But he gave me the example of how to be a hands-on dad. I
simply follow his example now, and that is something you can't
quantify. And I think that is the challenge of these programs.
And, Ms. Ridge, you talked about an understanding that the
dollar issue is--what we spend today, the way we score programs
here, is just money out. We don't score the savings in.
So it is always a case that this is going to cost money.
Well, no, we know it is going to save money. But the way we
score funding here, it doesn't show it. And I think that is
something we have to work to overcome as a body, is to say if
we are talking $400 million, well, many billions we are going
to save down the road, you know, is something that we need to
factor in.
On that, I was curious, either in the programs, in a broad
sense, Doctor, you are familiar with or both of the specific
programs, there are tax dollars through the school district,
through the state.
Are there private matches in your program, in an effort to
have private dollars match the public dollars in any way, or is
it fairly pretty much all public dollars, state or local?
Mrs. Ridge. There are a variety of ways that communities
that have Nurse Family Partnership sites in their communities
pay for them. There are public dollars, there are private
dollars.
They raise matching dollars. There are Medicaid dollars
that are used. I mean, there are different varieties. And in
Pennsylvania now, the nurse home visitation program is
administered through the Department of Public Welfare and so
there are state dollars, there are Federal dollars, and there
are private dollars, and, in some cases, there are also local
community dollars.
So it is a real combination.
Ms. Daro. That would be true for all the models I have
looked at. Really getting people to buy into the process is a
strong part of the program development process.
Mr. Platts. With the legislation we have, it is a straight
grant program. Should we be looking at considering a mandatory
match?
In other words, instead of just a grant, should it be 80/
20, 80 us, 20, to ensure--one concern I have of the way we have
the bill drafted is that we are going to provide dollars that
are just going to replace existing dollars being spent, not
complement existing dollars.
So we don't grow the programs, we just more fund them
through the Federal Government. And it is a hard thing to get
at, how to ensure that, without tying the hands of the state
and local partners.
Is that something we should we be worried about or do you
think that the partners in Pennsylvania and Delaware and across
the country, that there is a commitment there that these really
will be additional dollars, not supplanting those dollars
already being spent?
Ms. Daro. I can speak to Illinois. We have made a major
investment in early education, set up an early learning
council. Thirty percent of the dollars that are allocated to
this have to go to the 0-to-3 population.
I don't think there is anything in Illinois that would
shake that resolve. And what this will allow the states to do,
in Illinois, is to do an even better job of what they are
trying to do.
Ms. Scovell. At the local level, we do get state funding
through the Delaware Department of Education. But I know that
in each of the Parents as Teachers programs, we have a waiting
list always for more families to be served.
We also have families who need to be served with more
intensive services and we just have a waiting list. So more
moneys would be really beneficial.
Mrs. Ridge. I would echo what Ms. Scovell said. I think
there are some communities that really don't have resources and
I would hate for those communities not to have the benefit of a
home visitation program because they can't get the local match.
I think local matches do give communities more buy-in and
certainly help to grow the program, but what we have found is
that you also, in some instances, have to really provide the
entire funds for a community, depending on its situation.
Mr. Platts. Just one final comment and, Dr. Daro, you kind
of touched on the importance of the universality.
And, again, from leg experience, I share that and how we
achieve that to have that base level exposure and then you kind
of specialize or broaden the assistance given.
As a first time parent 10 years ago, going to a prenatal
class, my wife and I, with people from all cross-sections of
the community, but we were all in the same boat.
In fact, we run into a lot of them to this day, you know,
as first time parents now 10 years later, and the experience of
being there together from all different walks benefited all of
us then and to this day.
So I agree that if we are able to do it to give that
initial exposure and then build on that to those who have the
greater need is something that we want to try to work at.
So, Mr. Chairman, thank you again for the opportunity to
have a second round.
Mr. Osborne. Thank you.
Just parenthetically, your comments on scoring are well
taken. We have a stop underage drinking bill, costs $40
million, aimed at educating adults on what underage drinking is
doing. It is a $56 billion problem in the country, not to
mention the loss of life, and we are going to have trouble with
that bill, because it costs $40 million to save $56 billion or
parts of $56 billion.
So we tend to get things backwards.
I know that Mr. Davis had a question, so yield to you.
Mr. Davis of Illinois. Thank you, Mr. Chairman. What I
really wanted to do was to thank Mr. Platts and his staff and
to thank you and your staff.
It has really been a pleasure working with you to get us to
this point.
I also appreciate the discussion that we have had this
morning and I was just thinking how much I appreciate the
comments of Representative Musgrave, as I was reflecting and
recalling my own childhood.
And I also wanted to thank my mother, because she,
obviously, had a great deal of interest in this kind of
activity. She had 10 children. I guess we would have been low-
income, more than likely, we didn't have any money.
But she just simply believed that her children ought to
know how to read before they went to school and she also
believed that they should know their ABCs, know how to count to
a 100. But my father thought that you should know your ABCs, he
would say, both forward and backwards.
And they lived in rural Arkansas and they were African-
Americans, at a time very different from the times now. And so,
obviously, they weren't trying to prevent crime, because there
was no crime, not really, but they were trying to enhance
quality of life, I think.
So in addition to the crime prevention aspect, I also think
that quality of life enhancement is a great aspect and a great
component of this kind of activity.
I also appreciate the discussion relative to male
involvement. I recall, in the Head Start reauthorization, we
had an amendment to set aside resources to increase or try and
convince programs to increase male involvement, because that is
such a great lead and a strong component of the early
development, especially of children.
As a matter of fact, I am of the opinion that one of the
reasons that African-American males drop out of school at such
an early age and in greater numbers than many other children is
because they don't come into contact with any African-American
male teachers or involved African-American males during the
early stages of their educational development. They just don't
see them, because they are not there.
And so this has been a great discussion, from my vantage
point, and I want to thank Chairman Castle and I want to thank
you, Ms. Woolsey, for the support that both of you have given
to bring this to the point where we would have a discussion
today.
My last comment would simply be to the panel. Could you
take a moment to explain the whole notion of qualifications?
I mean, when we talk about home visiting, what
qualifications should there be and what should we expect people
to know and be able to do as they go into the homes?
And I thank you very much.
Ms. Daro. Home visitation is a relationship-based program.
It is about setting a connection between a provider and a
participant. So one of the most important skills is the ability
to form relationships.
Crafted on that, though, needs to be a clear understanding
about a set of knowledge and information that comes both from
your own professional training and home visitors are nurses,
home visitors are social workers, home visitors are child
development specialists, and sometimes effective home visitors
are people that come from the community that have life
experience.
They understand what it takes to raise children in very
difficult circumstances.
What we are seeing increasingly, though, in home visitation
programs is the combination of individual. So that you may have
someone going into the home, but a home visitor has access to a
variety of individuals that can help augment their additional
work in the home.
So they come with a set of skills. They come with solid
training in the curriculum or the program they are
implementing, and then, on top of that, they need to have
strong ongoing supervision.
Mrs. Ridge. I just wanted to add, in the Nurse Family
Partnership program, obviously, a registered nurse is the home
visitor, and that is the way the model is developed.
I think nurses have a special skill set to do that
important relationship-building in a very nurturing way. And I
think it is important in any kind of legislation to make
certain that there is ongoing maintenance, training of those
staff that are going into homes, that that is an important
element that should be considered in the legislation.
Ms. Scovell. May I make a comment, Mr. Davis, please?
With our local program, Parents as Teachers, one of the
things I pride myself on, as program supervisor, is that even
though we are funded through the Department of Education in a
local school district, our parent educators are a mix of
teachers and nurses, social workers and counselors.
And I think it is really important to understand that,
because when we come together as a team to do program
development, to do case management on individual families, we
have a lot of the resources right there within our own agency.
And then, of course, we have partnerships in the community
that we need to really continue on. But I just wanted to make
that comment.
Thank you.
Mr. Davis of Illinois. I just want to thank my own staff
person, who has two young children, Dr. Jill Hunter-Williams,
and maybe that is one of the reasons she has been so into this.
But she has really done a great job.
And so, Jill, thank you very much.
Mr. Osborne. Mr. Scott, did you have a question?
Mr. Scott. Thank you, Mr. Chairman.
I noticed that in the comments, there seemed to be two
different models for the home visits, the nursing model and an
educators model. Is that right?
Mrs. Ridge. Well, I think that those are two that are
presented here, but I think probably Dr. Daro can speak to--
there are probably even other models that are out there of home
visitation programs.
Mr. Scott. Are some more effective than others?
Mrs. Ridge. Well, what Nurse Family Partnership has done is
studied its own specific model and has long-term data to talk
about effectiveness, not just the cost part of it, but the
human part of it, which is really the more important part of
it.
Mr. Scott. What objective measures should we look at to
determine whether or not a program is successful?
Mrs. Ridge. I think in the case of this subcommittee, of
this particular committee, the school readiness would be an
important element.
I think one of the most important aspects of any home
visitation program is there has to be, I think, independent
evaluation of the effectiveness of the program.
Mr. Scott. In my other committee, I mentioned I am on the
Crime Subcommittee, we have found that not being able to read
by the third grade is an indicator that you are going to have
to build prisons in a few years, and that is one marker that
the Crime Subcommittee notes.
Are there other markers? You mentioned school readiness.
Being ready for school pre-K?
Mrs. Ridge. Right, and, also, I think you can look at a lot
of the public health models. Dr. Daro is an expert on this.
But I talked about the communities that care strategic
planning framework that we did in Pennsylvania that caused us
to offer blueprint programs to those communities.
There are other factors, family conflict. Academic failures
is a major indicator, a risk factor. And I think probably Dr.
Daro can make a much more comprehensive response to that.
Ms. Daro. Well, the short answer is the appropriate
outcomes are the outcomes the program has targeted for change.
So it is hard to day there is one universal set of outcomes,
because programs may approach this issue differently.
There are also some outcomes that can occur pretty early
on. If it is a parent-child relationship program, you want to
look at the attachment between the parent and child.
You want to look at access to healthcare services. Are they
linked up with a medical home? Are they getting their
immunizations on time? Is mom taking care of her health?
If there are employment issues or a housing crisis, you
want to know they are linked up those other kinds of programs.
Looking forward, then you want to begin to follow that
child and see when they show up at school, are they eager and
ready to learn, are they engaging in the process, is the parent
involved in the education process.
Mr. Scott. Can you measure eager?
Ms. Daro. Eager? You can measure social/emotional health,
which is part of it. That is a big part of it.
You can say how well is this child able to manage their
emotions? How well is this child able to set up a relationship
with teachers and their peers? And how well does this child do
in really motivating themselves to set and achieve certain
goals?
Mr. Scott. That is a measurable outcome that you can
affect.
Ms. Daro. That is a measurable outcome.
Mr. Scott. If their score is low, you can improve the
score?
Ms. Daro. You look at whether they are on task over time
and who is doing well in that domain and who is not doing well
in that domain.
Mr. Scott. Now, you have got, as I understand, about 15,000
school systems throughout America.
If a school system wanted to pick up one of these programs,
do they have to reinvent the wheel?
Ms. Daro. Do they have to?
Mr. Scott. Reinvent the wheel. I mean, do they have to come
up with their own program and do their own research?
Ms. Daro. No, and that is the beauty of this legislation.
It really gives them some really good building blocks to use in
constructing their programs.
They could take a model off the shelf, and there are a lot
of models that are mentioned in the legislation and many are
represented here, or they may say, ``We are going to take a
careful look at what our objectives are and what resources we
have in our community and what does our target population look
like,'' and then craft a program that embraces the most
positive elements of effective service delivery.
And that is, I think, what the research can contribute to.
When we talk about evidence-based practice, that is really what
we mean. It is really practice that has been tested over and
over again and we know that those kinds of relationships with
families have bigger impacts than those that don't have those
features.
Mr. Scott. Thank you, Mr. Chairman.
Mr. Osborne. Thank you, Mr. Scott. I want to thank the
witnesses for their valuable time and testimony and members for
their participation.
If there is no further business, the subcommittee stands
adjourned.
Thank you.
[Whereupon, at 12:06 p.m., the subcommittee was adjourned.]
[Additional material submitted by Dr. Daro follows:]
Response by Dr. Daro to Written Questions Submitted by Congressman
Davis
1. Value of Varied Research Techniques
Home visitation efforts, as with all social interventions, are well
served when they embrace the evaluation process and engage in
continuous program improvement. In general, two lines of inquiry guide
the development of program evaluations and other forms of applied
research--does the program make a measurable difference with
participants (efficacy) and does a given strategy represent the best
course of action within a given context (effectiveness). In the first
instance, evaluators place heavy emphasis on randomized clinical trials
which involve the random assignment of potential participants to the
intervention and to a control group (which may receive an alternative
intervention or no intervention). Such studies are viewed as the best
and most reliable method for determining if the changes observed in
program participants overtime are due primarily to the intervention
rather than to other factors (e.g., the natural learning or improvement
that comes in the course of one's normal development or social
contacts). As noted in my written testimony, a growing number of
randomized trials assessing home visitation programs are surfacing in
the literature, providing increased evidence of the strategy's
efficacy--home visitation programs when well crafted and carefully
implemented produce positive outcomes for children and their parents.
Maximizing the utility of program evaluation efforts, however,
requires more than just randomized clinical trials. This diversity is
needed to improve the quality of home visitation programs and
successful replication. With respect to program quality, program
evaluators are currently engaged in myriad studies to address key
implementation questions--how do families view the home visits they are
being offered, why do they accept or not accept offers to enroll in
these programs, what other support options do new parents want to see
within their community, and how do new parents view their relationship
with home visitors. The issue of program fidelity, central to
randomized clinical trials, takes on new meaning when one goal of the
intervention is to be responsive to a family's needs and a community's
strengths. Even within the context of a well specified curriculum or
service protocol, each home visit represents a unique exchange between
provider and participant, an exchange that is shaped by a family's
immediate needs and a home visitor's service delivery style. By
assuming families who received a similar number of home visits or who
remain enrolled for a similar length of time have had the same service
experience, randomized trials can easily overstate or understate an
intervention's potential and, more importantly, fail to document the
important variations in service delivery that account for differential
impacts. Using only randomized clinical trials to assess home
visitation programs reduces the ability of program evaluations to
generate the types of findings central to achieving continuous program
improvement.
Second, making home visitation programs more widely available means
that the strategy has to successfully enroll and retain an increasingly
diverse pool of new parents. A randomized clinical trial generally
recruits a specific target population and provides them financial
incentives to remain enrolled in the program. If home visitation is to
be ``taken to scale'' within the context of voluntary enrollment, it
will need to be attractive not only to those families who have
successfully used social services in the past but also to those
families who have been unable to utilize support due to a lack of
information, a lack of trust, or a lack of sufficient self-worth to
demand what is needed to support them as parents. These questions
cannot be addressed simply by knowing if a program worked for the
``average'' participant better than it did for the ``average'' control
(the key outcome of randomized trials). To answer these questions, we
need to implement multiple research designs, including randomized
trials but not exclusively randomized trials; utilize multiple methods
of assessment, including standardized measures but not exclusively
standardized measures; and learn from multiple standards of evidence,
relying on statistically significant findings but not exclusively
relying on statistically significant findings. Understanding how home
visits impact families require more than randomized clinical trials.
Equally important is the information that can be gleaned from the
stories participants and providers tell in response to structured
interviews, well-developed single cases studies and in response to
well-developed theories of change models. Knowledge development and
responsible public policy needs both randomized clinical trials and an
array of well-developed process and implementation studies.
2. Key Qualifications for Home Visitors
Limited data exists on the relationship between a home visitor's
profession or status (e.g., nurses, social workers, child development
specialists, community resident, etc.) and program outcomes. Very few
studies have been developed to test the relative merits of different
types of providers in delivering the same intervention. One study based
on this methodology did find nurses more effective than para-
professionals (i.e., high school graduates from the community).
However, it is difficult to generalize this finding to all home
visitation programs in that the home visitation model being test was
designed as an intervention for nurses. Home visitation models which
embrace a different set of program goals and employ other types of
professionals have demonstrated positive findings. Also, significant
variation exists in the degree to which home visitation programs are
linked to other services and the extent to which programs adopt a
``team approach'' to staffing cases. Many home visitation and parent
education programs partner with other agencies offering specific health
or child development services, resulting in a multidisciplinary
approach to assessing and managing direct services for families. Within
such systems of care, a parent's home visitor may be only one of
several professionals or community supports addressing the family's
needs. Given the growing trend among prevention services to offer
multiple components and hire diverse staff, a unique focus on a home
visitor's educational background or professional identity may become
less salient in the future.
Rather than focus on the narrow issue of professional status or
education, the more productive discussion may lie in identifying the
personal skills and quality of the home visitor and the training and
supervision these providers receive in the course of their work. Home
visitation programs are, in large part, an intervention that hinges on
the relationship between the service provider and new parent. As such,
the qualifications of the service provider are central in both
retaining the participant in voluntary prevention services and
producing more consistent outcomes. Evaluations of various home
visitation programs have observed better retention rates and more
robust outcomes when home visitors are successful in establishing a
strong relationship with the participant, one that is characterized by
mutual respect and opportunities for joint problem solving and case
planning (e.g., being able to set appropriate expectations for the
parent's own behaviors and for their interactions with their child).
Independent of the educational and personal qualifications of home
visitor, a strong theme emerging from repeated evaluations of these
efforts is the critical importance of solid initial training and
ongoing reflective supervision. Regardless of an individual's degree or
prior experience, all new home visitors need to be provided specific
initial training on the home visitation model's theory of change,
curriculum and target population. Reflective supervision is focused on
learning from work with families and is supportive and collaborative in
nature. It occurs on a regular and reliable schedule and is
characterized by active listening and thoughtful questioning by both
supervisor and supervisee. The process can involve multiple strategies
including group supervision, individual supervision, and peer
supervision. Organizations that embrace this type of supervision have
clearly articulated goals and insure that all staff share the program's
goals and commitment to excellence.
3. Home Visitation's Cost Effectiveness
Home visitation programs as well as models that include home
visitation as one of several services provided young children and their
parents have demonstrated the potential to save significant dollars
over time. Comparative reviews of multiple interventions completed by
Washington State Institute for Public Policy and the RAND Corporation
find that early investment in strengthening parent-child relationships
and supporting an infant's healthy development through home visitation
programs and other early interventions can produce notable savings in
terms of increased tax revenues due to increased employment; decreased
welfare outlays; reduced expenditures for education, health, and other
services; and lower criminal justice system costs. However, these
studies also note that not all early intervention programs reap
significant savings and that most savings are realized only if one
takes a long-term view of program effects. As I noted during the
hearing, program expenses occur in ``real'' time while the savings from
such investments are found only in the future. Just as one does not
expect an immediate return on any economic investment, investments in
children will require patience. The available evidence suggested the
investment is a sound one but not without a certain level of risk.
Maximizing the return on a substantial investment in supporting new
borns and their parents will require the investment in programs that
embrace quality standards and marrying this investment with a
commitment to continuous program improvement.
______
[Additional material submitted by Mrs. Ridge follows:]
Supplemental Testimony of Mrs. Ridge and Responses to Questions
Submitted by Congressman Davis
In addition to my written testimony, I would like to address
several aspects of the Nurse-Family Partnership program model that were
illustrated and questioned throughout today's hearing.
The Nurse-Family Partnership (NFP) serves first-time, low-income
mothers and their families as a strong and effective method to end the
cycle of poverty. NFP has over 30 years of data that show multi-
generational outcomes--the program has demonstrated outcomes that
improve the health and well-being of first-time mothers, their children
and families.
A cornerstone of NFP is the extensive research on the model
conducted over the last three decades. Randomized trials were conducted
with three diverse populations beginning in Elmira, New York, 1977; in
Memphis, Tennessee, 1987; and Denver, Colorado, 1994. All three trials
targeted first-time, low-income mothers. Dr. David Olds' research
continues today, studying the long-term outcomes for mothers and
children in the three trials. This research demonstrated how the
functional and economic benefits of the NFP model are greatest for
families at greater risk. In the Elmira study, most married women and
those from higher socioeconomic households managed the care of their
children without serious problems and were able to avoid lives of
welfare dependence, substance abuse, and crime without the assistance
of the nurse home visitors. Similarly, their children on average
avoided encounters with the criminal justice system and the use of
cigarettes and alcohol. In contrast, low-income, unmarried women and
their children in the comparison group in Elmira were at much greater
risk for these problems, and the NFP program was able to avert many of
these outcomes for this at-risk population. Cost analyses suggested
that the program's cost savings for government were solely attributed
to benefits accrued by this higher-risk group. Among lower risk
families, the financial investment in the program was a loss in one
RAND analysis. Similarly, although evidence from the Memphis and Denver
trials support the impact of the NFP model on improving elementary
school readiness, improvements in language development and executive
functioning at child age 4 were most significant among low resource
mothers in Denver. Due to this pattern of results, NFP recommends
targeting high risk mothers for NFP services. In the current political
climate where the resources for universal access to the NFP model are
unlikely to be made available, the evidence from the trials indicates
that resources should target the highest risk populations.
NFP works closely with local public health agencies, community
health centers, schools, etc. to refer first-time mothers to a NFP
program site within their area. NFP serves a diverse population--some
urban, some rural--but each mother enters the NFP program looking for
resources on how to take care of herself and her first child. NFP
nurses and parents make a 2 and 1/2 year commitment to each other,
starting no later than the 28th week of pregnancy and continuing until
the child's 2nd birthday. NFP enjoys strong retention rates, as most
parents develop a close, personal relationship with their nurses
throughout the approximately 64 schedule visits over the course of the
program, often referring to them as ``my nurse''.
An important component of the NFP program model is the
qualifications and training of NFP nurses. All nurses are highly
educated, registered nurses, many of whom have experience in the public
health sector and enjoy being able to work within the community. Many
NFP nurses left the nursing field after becoming ``burned out'' and
have returned because NFP's work relates to the reasons why they became
nurses in the first place. NFP nurses undergo a rigorous 60 hour
training course closely monitored by the NFP National Service Office's
professional development team. Currently, over 750 registered nurses
are administering the NFP program model nationwide.
Most of the local NFP implementing agencies are county health
departments. The NFP National Service Office has a contract with each
local implementing agency that delineates each party's obligations, and
specifies what the local agencies must do to meet NFP quality and
reporting standards. Subject to regional salary variations, it costs
approximately $500,000/year/100 families to deliver the NFP model, with
some efficiencies of scale achieved for programs with over 200
families.
NFP outcomes are not limited to only the mothers and their first
child but extend to the entire family involved in caring for the child.
NFP encourages the involvement of the child's father or father figure
within the household. Additional family members are encouraged to
participate in the home visits and learn about caring for the new baby
as a family. NFP nurses work to improve families' economic self-
sufficiency by helping parents to envision their own future, plan
future pregnancies, continue their education, and secure long-term
employment.
Due to the Subcommittee's strong interest in early school
readiness, the following information provides additional context on
NFP's positive impact in this area. Overall, the results from the 3
trials show that the NFP model may increase children's academic and
behavioral adjustment to elementary school. A more detailed discussion
of why the program has a growing impact on children's cognitive and
language development is presented in a Pediatrics article by David Olds
and his colleagues (published in 2004). A key excerpt from that article
reads as follows:
In interpreting the program's impact on children's development, it
is important to note that the combination of compromised neurologic
development attributable to poor prenatal health and harsh punitive
parenting can be particularly damaging to children's cognitive and
behavioral development and this program affected these earlier risks.
Moreover, closely spaced subsequent pregnancies and lack of financial
resources are associated with compromised child development. We have
hypothesized that the beneficial effects of the program on child
outcomes are attributable to the combination of improved prenatal
health, improved parental caregiving, and improved maternal life
course. Preliminary analyses suggest that parental caregiving and
maternal life course are likely to play important roles in explaining
the enduring effect of the Memphis program on children's cognitive
functioning and behavioral adjustment.
Dr. Olds' research demonstrates that the NFP program model
dramatically decreases these earlier risk factors.
Responses to Questions Submitted by Congressman Danny K. Davis
1. When I explain home visiting to people, some people have asked
how home visiting is useful given that most families work and won't be
at home. What have your experiences revealed about how these programs
work given parental work schedules?
Home visits are conducted at times when clients are available--
evenings and weekends if necessary, sometimes even at school when
dealing with teens who go back to school. Moreover, many of our working
clients work at part time jobs and with highly varied hours. Often
their day off is on a weekday or they are working shift work. One of
NFP's goals is to assist clients with securing adequate and appropriate
child care given these non-standard work hours. In addition, many of
NFP's clients are not working when they first meet their NFP nurse and
only develop the skills and resources to seek and sustain employment
over the course of the NFP program. Finally, the NFP visit schedule is
somewhat flexible by design to accommodate our programmatic goal of
clients returning to work and school. If the clients have maintained a
strong relationship with their respective nurses and are resilient
enough in terms of their development, NFP allows fewer visits, or more
phone contact, to occur for short periods of time in order to
accommodate the parents' schedules.
2. As you know, the Education Begins at Home Act has a required
data collection and evaluation component. From your experiences, how
best can we ensure that the data we collect is most helpful to the
providers?
We appreciate the importance of the data collection and evaluation
components of the Education Begins At Home Act, and commend the efforts
of Representative Danny K. Davis to improve the Act earlier this year
by clarifying the characteristics of a ``quality early childhood
visitation program'' and identifying central parameters for evaluation
to improve our understanding of program success. In order to maximize
program quality and fidelity to the research model as we have moved
from science to practice during the replication process nationwide, NFP
has placed great emphasis on developing an effective data collection
and evaluation system, described in more detail in my written
testimony. From NFP's experience, the following considerations and
design elements ensure that the data we collect is productive for our
nurses.
First, the data elements collected by NFP serve as markers for
important aspects of program implementation that NFP local supervisors
and administrators continually track to assure that the program is
being effectively implemented. We just make that oversight easier by
providing quarterly, or more frequently if needed, reports from the
National Service Office (NSO) to our local partners.
Second, the NFPNSO provides technical assistance to local sites on
quality improvement and building a community of practice. In that role,
the NSO reviews those evaluation data to determine where individual
local programs are thriving and where they need assistance. Regular
consultation calls with local NFP nurse supervisors focus on
interpreting the data and determining strategies for improving program
performance, both in nursing practice with families and in program
administration or management. NFPNSO provides assistance to local sites
on tracking program implementation and collaborates with site
administrators toward solutions where improvement is needed. Therefore,
help is provided to local sites can on how the data can be used.
Finally, the National Service Office gathers input at the front end
as well. Currently, data collection changes are underway largely in
response to what we have heard from the field--changes requested by
local supervisors and nurses. The NFP NSO balances requests from the
local sites with the expertise of our NSO staff and our research
partners to guide the data collection process. This is an ongoing
process--we continue to collect feedback from the field, review these
findings internally and with the experts, and revise our data
collection and reporting system as needed.
In conclusion, the Nurse-Family Partnership data collection and
evaluation process is a dynamic and responsive system that is tailored
to both the best science and how best to meet the practical needs of
our provider partners on the ground. One of the central features of
this system is the ability to provide reports in real-time to our local
partners. Ongoing, regular communication between the providers and the
data team is an essential component of the NFP system that ensures
relevance to providers. Another essential feature is the detailed
nature and scientific rigor of the data collected.
______
[Newspaper article submitted by Mrs. Ridge follows:]
[From the Columbus Dispatch, September 3, 2006]
Nurse-family Partnerships Coming to Columbus
The newest Nurse-Family Partnership site will be at Children's
Hospital's Center for Child and Family Advocacy.
The partnership provides nurses who try to teach young, poor,
first-time mothers how to be good parents and, in turn, improve the
health of their children. It seems to be a perfect fit at the center,
said Dr. Philip Scribano, the center's medical director.
The center focuses on the treatment and prevention of child abuse
and domestic violence, and it was looking for a home-visiting program
that fit its goals, Scribano said.
A nurse visits a woman in her home during her pregnancy and
continues until her child turns 2. Those visits often create close
relationships, so that nurses have influence in their clients' lives.
``The client needs to trust that this person has her best interest
at heart,'' Scribano said.
The center chose the Nurse-Family Partnership instead of other
home-visiting programs because of how rigorously it studies itself in
an effort to improve, he said.
The partnership has collected data since its beginning in 1977 to
see how well it does its job. Longterm studies at the first site in
Elmira, N.Y., as well as in Memphis, Tenn., and Denver have found that
the partnership improves the lives of the mothers and children.
The Columbus site will add to that knowledge, David Olds, the
founder of the Nurse-Family Partnership, said in a presentation to
Columbus-area social-service and health agencies last week.
The Columbus site will contribute heavily to a Nurse-Family
Partnership study on domestic violence, which will try to find ways to
decrease violence among clients, said Jack Stevens, a Children's
Hospital psychologist who will be the Columbus site's principal
investigator.
Columbus will have Ohio's fourth partnership site, but it will be
funded differently from those in Cincinnati, Dayton and Hamilton.
Those sites get most of their money through Help Me Grow, a state
Health Department program. That funding is steady, but it requires more
paperwork and client oversight than the Columbus program.
The Columbus site will cost $1.3 million for the first three years.
The money is coming from the Columbus Foundation, Cardinal Health,
Central Benefits Health Care Foundation and the federal government.
One of the Columbus program's challenges, officials said, will be
to find money after those first three years.
``We would not be starting this program unless we believed we could
sustain it,'' said Yvette McGee Brown, president of the Center for
Child and Family Advocacy.
For the first three years, the Columbus site will have four nurses
and one supervisor. Each nurse will have no more than 25 clients, which
is what the Nurse-Family Partnership wants. (The 15 nurses in Dayton
have more than 30 clients each).
The mothers will be identified through Ohio State University
Medical Center, which already has 800 potential clients.
``Demand will exceed capacity,'' Scribano said.
The Columbus site is hiring nurses, he said, and should be
operating by November.
______
[Additional material submitted by Ms. Scovell follows:]
Supplemental Testimony of Ms. Scovell in Responses to Questions
Submitted by Congressman Davis
Question 1--When I explain home visiting to people, some people
have asked how home visiting is useful given that most families work
and won't be at home. What have your experiences revealed about how
these programs work given parental work schedules?
Parents as Teachers parent educators routinely meet with families
during the day, in the evenings and on weekends to better accomodate
busy parents' work schedules. This flexibility encourages both parents,
if available, and other family members to participate in the home
visit. Furthermore, our parent educators are available to conduct
personal visits outside of the home, at alternate locations, that are
most convenient for the family.
In rural Sussex County, Delaware we have many parents doing
seasonal work on farms or at the shore and some parents who do shift
work in the poultry industry. One of the most important elements of
home visiting is the development of a trusting, reciprocal relationship
between the home visitor and parent. We sometimes refer to this as
``the dance''. Once a relationship is established, scheduling a time to
meet becomes less complicated because both the home visitor and parent
are flexible with their time in order to assist one another. Times for
home visits may change from month to month depending on the parents,
and the home visitor's, schedule.
Question 2--As you know, the Education Begins at Home Act has a
required data collection and evaluation component. From your
experiences, how best can we ensure that the data we collect is most
helpful to the providers?
Data collection and analysis already play a critical role in
Parents as Teachers service delivery, so I fully support the data
collection and evaluation component of the Education Begins at Home
Act. On the local level, the data we collect helps us better understand
the characteristics of the families we are serving which in turn helps
us identify opportunities to enhance services to families or reach out
to other cohorts of families. Evaluation helps us achieve our goal of
continuously improving the quality of our service delivery so that it
aligns with Parents as Teachers quality standards. Collecting data from
other home visiting programs would provide us with valuable
benchmarking information, both nationally and locally, that would
further enhance our ongoing quality improvement goals.
I feel strongly that information on quality and outcomes should be
collected in an efficient and streamlined way with maximum support and
resources for service providers. To this end, I think it is critically
important to get the input of the front-line home visitors when
determining the data collection and evaluation requirements. Local
programs do not want multiple or redundant data reporting mechanisms
that ultimately take time away from serving families. Furthermore, it
would be ideal if the data could be summarized in real time so we can
access the data on an ongoing basis which will allow us to respond more
quickly to the needs of families, rather than relying on outdated data.
Finally, I believe it is important to collect data that connects
directly to the true objective of the Education Begins at Home Act--
school readiness and parental involvement. Parent educators across the
country can provide vivid examples of how they have made a difference
in parents' and children's lives--increasing children's school
readiness and promoting parent involvement in their children's
education. We now look forward to the opportunity to measure and
demonstrate these outcomes for the Education Begins at Home Act.