59

BRISTOL WARREN

CHILD OPPORTUNITY ZONE FAMILY CENTER
coz Grade Total Percent
Schools Levels Enrollment Low-Income
Hugh Cole Schoo! KS 201 3k
‘ain Seret Schoo! ie 8 me
Childs Sree Schoo! B Ist rt
Advisory Board

[A Siemember Service Comme is compried of 18 agency saf$ schoo! staf and 4 parens The
‘Service Commicee plans programs and coordinates resources co meet the goals ofthe COZ Famiy
Center: inelading the Starting Pons focus on ehiren Irom birth to age Une The Famdy Center
nin the proces of exablshing a Parent Advisory Beard which wil have inreased represenaion on
he Service Commute

Community and School Locations
‘The Bristol Warren Fariy Cencer is located MaryV. Quire Bold. also hnown as he Beto!
Warren Adult Education Community and Family Resource Cente In addion to the COZ Family
Center program components the Quirk Center oflers adult education programs sponsored by the
‘School Disc and fal programs sponsored by Sel-Help Ie. The COZ does nos have fy
center spacein the tree elementary schools Aa akerschool program for eléren in grades KS 6
offered on-ste at the Hugh Cole Schoat for 30 cdren wine attend any of the dee

schools, Mental health counsting services for ehdren and faies are ofered ona a¢ the Main
‘Suret School by Este Bay Mental Heald Cener

Funding 1997-1998: $83,000

{oes ot cent spt fom chose mind sport frm hes ad Pron serie gens. me
‘one uted by ren and comrngy oe

‘Charen Tro Feng

42% COZ Family Cener(Oeparomet of Eaucaton
oe

00 Onn (F545 etth Uneee in)

Sarting Pars (Deparment of Eucabon,

‘Departmen of Hash Unted Woy Carnegie

Program Components
Parent Support and Education

{Car Safery Faeauon Program
cing Skil Serves,
‘Toy and Book Library at che Quirk Center

Infant and Pre-School Programs
Dropsin and Ply Program
Parents as Teachers (School Dswiet COZ)

Child Care
Belore- and After School Chilé Care
“Tralning for Farsly Chad Care Prowders
Faraly Chis Care Prowder Netware

Children’s Learning and Enrichment
‘Sommer Programs for Chitren(Barringron
YMCA)

‘School-Linked Health and Social Services
School-Based Counseing Program (East Bry
Mental Health Center)

Family and Coramunity Development
Fay Recreation (Sel Help/OCYF Farnly
Preservation)

coneace
Joan Ree, Coordinator ——
Participating Schooke:

3 Elemencary Schools

Aunpices

Bristol Warren Regional

Shoo! Diseree

Aion:

School ofthe 21se

‘Century -Yale Bush

Concer

Carmesie Staring Points
Aires

(COZ Fariy Center
Mary¥. Quire Bulcing

190 tin Sreet

Warren, R288

(40H) 247-3720

Sul

Coordinator (hiksime)
Senior Chitd Care

Coordinator (pare-ene)
‘Ansinant Child Care ;

‘Citdren reach

Guarantee quality chil
care choices,

Parents have resources
‘hat wppore thr role a



123

1. INTRODUCTION

Many of the most pervasive and intractable problems faced by young children and
parents in our society today can be traced to adverse maternal health-related behaviors during
pregnancy, compromised care of the child, and stressful conditions in families’ homes that
interfere with parental and family functioning. These problems include infant mortality, pre-term
delivery, low birthweight, and neurodevelopmental impairments in young children resulting from
poor prenatal health;'2" child abuse and neglect, and accidental childhood injuries resulting from
dysfunctional caregiving:* youth violence resulting from a combination of neurodevelopmentat
impairment and harsh and neglectful caregiving;’*” and diminished economic self-sufficiency of
parents resulting from closely spaced pregnancy, educational failure, and sporadic workforce
participation.*

‘Through 1993, we published a series of papers on a randomized trial of prenatal and
infancy home visitation by nurses in Elmira, New York (N=400) that was designed to reduce
these problems through the improvement of maternal health and behavior. ‘The program was
focused on women who were either unmarried, adolescents, or poor. Early results showed
significant promise for the program, and were reviewed in an article on the effects of prenatal,
infancy and early childhood home visitation published in 1993.”

At the time the 1993 review article was written, some of the program effects evaluated
through the child’s fourth year of life had been published. Compared to counterparts randomly
assigned to receive comparison services, women who were nurse-visited experienced greater
informal and formal social support, smoked fewer cigarettes, had better diets, and exhibited
fewer kidney infections by the end of pregnancy. (There also was a non-significant decrease in

the number of hypertensive disorders of pregnancy.) Babies born to nurse-visited women


25

care js guaranteed to working families, T would like to outline a few of our accomplishments
because I believe that they are national models which can be shared by other states. These
programs are preparing our society with for the 21* century by ensuring a strong and healthy
family snd a positive economic future.

‘L_ Children’s Health - The Rite Choice

Health care is vital to every child's growth and development. Studies have shown that ifchildren
lack health insurance, they are Teas likely to receive needed primary and epecialty care~inchuding
Preventive care, treatment for acute and chronic illnesses, mental health services, dental care and.
prescriptions. Regular doctor vite are especially critical during early childhood to receive
necessary preventive health cere, immunizations and anticipatory guidance. In addition, health
coverage is essential is for a vibrant and lively economy. To answer these needs, Rhode Inland
created the Rite Care program in August of 1994 to improve access to and quality of health care
for Rhode Island families. My administration hes devoted countless hours of time and
‘commitment into increasing access for children and enguring some of the highest quality of
health care in the nation.

Tn Rhode Inland, we have scen a change in the health status of children since they enrolled in
Rite Care, the state's health insurance Program. Rite Care provides over 75,000 Rhode Islanders
with access to quality, comprehensive health care.

‘The health outcomes for this program have exceeded our expectations, Results inchude:

+ -a decrease in the number of low birth weight infunts

~an increase in the percentage of infants who were up-to-date on their immunizations

an increase in the percentage of newborns who had their first physician visit within the
first 2 weeks of life


154

VII. POLICY IMPLICATIONS AND PROGRAM REPLICATION

One of the clearest messages that has emenged from this program of research is that the
functional and economic benefits of the nurse-home-visitation program are greatest for families
at greater risk. In the Elmira study, it was evident that most married women and those from
higher socioeconomic households managed the care of their children without serious problems
and that they 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, the use of cigarettes and alcohol and promiscuous
sexual activity. Low-income, unmarried women and their children in the comparison group, on
the other hand, were at substantial risk for these problems and the program of prenatal and
infancy home visitation was able to avert many of these untoward outcomes for this at-risk
population. This led to substantial cost-savings to government when the program was focused on
this higher risk group. Among families at lower risk, on the other hand, the financial investment
in the service was a loss. This suggests that this program will produce its greatest effects when it
is focused on those in greatest need. This patter of results challenges the position that these
kinds of programs ought to be made available on a universal basis. Not only is the universal
approach likely to be wasteful from an economic standpoint, but it may lead to a dilution of
services for those families who need them the most, because of insufficient resources to serve
everyone well.

During the past five years, new studies have been reported that have led us to doubt the
effectiveness of home-visitation programs that do not adhere to the elements of the model studied
in these trials, including the hiring of nurses. These results should give policy makers and

practitioners pause as they consider investments in home visitation programs without careful

3


149

pregnancy, are relatively asymptomatic, and are not easily detected outside of office-based
‘medical settings after pregnancy has already progressed.”

‘The impact of the program on the rates of dysfunctional caregiving among higher risk
families found in Elmira was substantially replicated in Memphis where the population served
‘was at much higher risk overall. Recall that the beneficial effects of the program in Elmira on
dysfunctional care during the child’s first two years of life (reflected in rates of state-verified
cases of child abuse and neglect and on emergency-department encounters) were concentrated on
‘women who were unmarried and from low-SES households. In Memphis, (where 98% of the
sample was unmarried, all were from low-SES families) we found corresponding effects for
health-care encounters in which injures were detected, for observations of the home
environments, and for parents’ reports of caregiving and childrearing beliefs. The beneficial
effects of the program on caregiving-related outcomes, while strong enough to emerge as
program “main effects,” were concentrated among women with lower levels of psychological
resources at the time of registration. The effect of the program on health-care encounters in
which injuries were detected and on the number of days that children were hospitalized with
injuries, for example, was limited to children born to women with few psychological resources.

Moreover, in contrast to children in the comparison group, children of nurse-visited
mothers in Memphis who had few psychological resources were observed to be more responsive
and communicative toward their mothers. Infant-atlachment research suggests that toddlers’
behavior toward their mothers reveals the extent to which their mothers are sensitive and
responsive rather than hostile, intrusive, or neglectful toward them, with toddlers’ behavior being
a better indication of the quality of the parent-child relationship over time than currently

observed behaviors of parents.°°*


COMMITTEE ON GOVERNMENT REFORM AND OVERSIGHT
DAN BURTON, Indiana, Chairman

BENJAMIN A. GILMAN, New York HENRY A. WAXMAN, California
J. DENNIS HASTERT, Illinois TOM LANTOS, California
CONSTANCE A. MORELLA, Maryland ROBERT E. WISE, Jr., West Virginia
CHRISTOPHER SHAYS, Connecticut MAJOR R. OWENS, New York
CHRISTOPHER COX, California EDOLPHUS TOWNS, New York
ILEANA ROS-LEHTINEN, Florida PAUL E. KANJORSKI, Pennsylvania
JOHN M. McHUGH, New York GARY A. CONDIT, California
STEPHEN HORN, California CAROLYN B. MALONEY, New York
JOHN L. MICA, Florida THOMAS M. BARRETT, Wisconsin
THOMAS M. DAVIS, Virginia ELEANOR HOLMES NORTON, Washington,
DAVID M. McINTOSH, Indiana DC
MARK E. SOUDER, Indiana CHAKA FATTAH, Pennsylvania
JOE SCARBOROUGH, Florida ELIJAH E. CUMMINGS, Maryland
JOHN B. SHADEGG, Arizona DENNIS J. KUCINICH, Ohio
STEVEN C. LATOURETTE, Ohio ROD R. BLAGOJEVICH, Illinois
MARSHALL “MARK” SANFORD, South DANNY K. DAVIS, Illinois

Carolina JOHN F. TIERNEY, Massachusetts
JOHN E. SUNUNU, New Hampshire JIM TURNER, Texas
PETE SESSIONS, Texas THOMAS H. ALLEN, Maine
MICHAEL PAPPAS, New Jersey HAROLD E. FORD, JR., Tennessee
VINCE SNOWBARGER, Kansas —
BOB BARR, Georgia BERNARD SANDERS, Vermont
DAN MILLER, Florida (Independent)

RON LEWIS, Kentucky
Kevin BINGER, Staff Director
DantEL R. MOLL, Deputy Staff Director
Davip A. Kass, Deputy Counsel and Parliamentarian
dupirh McCoy, Chief Clerk
PHIL SCHILIRO, Minority Staff Director

SUBCOMMITTEE ON HUMAN RESOURCES
CHRISTOPHER SHAYS, Connecticut, Chairman

VINCE SNOWBARGER, Kansas EDOLPHUS TOWNS, New York
BENJAMIN A. GILMAN, New York THOMAS H. ALLEN, Maine
DAVID M. MCINTOSH, Indiana TOM LANTOS, California
MARK E. SOUDER, Indiana BERNARD SANDERS, Vermont (Ind.)
MICHAEL PAPPAS, New Jersey THOMAS M. BARRETT, Wisconsin
—_— DENNIS J. KUCINICH, Ohio.

EX OFFICIO
DAN BURTON, Indiana HENRY A. WAXMAN, California

LAWRENCE J. HALLORAN, Staff Director and Counsel
J. VINCENT CHASE, Chief Investigator
Jesse 8. BUSHMAN, Clerk
CHERRI BRANSON, Minority Counsel

aD.


9

© 56% fewer days of alcohol consumption.
‘There were very few benefits for higher income, married women and their children.

‘One of the hallmarks of good evidence is being able to reproduce it. The major findings
from the Elmira trial in the early years of the child’s life have now been reproduced in an
urban replication conducted in Memphis.

For example, by the children’s second birthdays, compared to women and children
randomly assigned to comparison services, those who were nurse-visited had:

© 30% fewer hypertensive disorders of pregnancy;
‘© 50% more frequent breast feeding;
‘© 81% fewer days that children were hospitalized with injuries or ingestions;

© fewer conditions in the children’s hospital records indicative of neglectful or abusive
care;

© 30% fewer subsequent births.

During the past decade, the findings from this program of research have been used to
promote a wide variety of home-visitation programs for pregnant women and parents of
young children. Unless programs share the essential elements of the program tested in
these trials, however, those other programs are not likely to produce the same results.

Even when communities choose to develop programs based on models with good
scientific evidence, all too often the programs are watered down and compromised in the
process of being scaled up. We have begun some work to address this problem.

We have been invited by the Justice Department to disseminate this program in high-
crime neighborhoods in different parts of the country. We are using this initiative to learn
more about what it will take, in new communities, to develop the program with fidelity to
its essential elements. We have established the program in 14 communities and are
studying what it will take to successfully develop the program on a much larger scale.

In this initiative, state and local governments are securing financial support for the
program out of existing funds, such as TANF, Medicaid, child-abuse, and crime-
prevention dollars. The program itself requires no new appropriation. Communities are
making these investments in part because the evidence indicates that expenditures in
these budgets will be reduced later on. This means that the cost of this program, which in
1998 dollars is about $7,000 per family for two and a half years of service, can be shared
by a variety of government agencies. This reduces the strain on any one budget.



68

PAWTUCKET
CHILD OPPORTUNITY ZONE FAMILY CENTER
conace
ee ne coz Grade Foual Percent
try Tae Schools tevels Enrollment Low-income
canna Ear Scho! 1S ‘or ‘aoe
Parpatig Shoat e :
, Seen Sarr HighScoal 3 ae
1 ve shoot Kavisory Board
ase Tne Pawct Child Opporuy Zone Fay Cover crested o pacts a workgroups
Pewtchet Pub Seheot needed a plan and mplerne pee projet The COZ Coorinor aces nt td eet
‘sain Cn propam acds rom parent persopsng progr dough cuveich by pret
Camepe String Ponts Coorsntor and rouge arscpton on eng colton inthe commun,
Carnegie Middle Schools ‘School Location
RaterWoad Joon The Chid Opprtony Zone Faby Caner wort wih stedens ad ames se Cnn
Schooled Heath ——_Elmatry Schoo and Sate jor Hig Schl two shod cated aacen co ach tet Bath
ener dre primary eeghborhod schoo. sersg Cre vom he Wicodtan ne borhood of Pouch
etree The COZ Famiy Caner oaed nage datioom n he Conn Sho
CunnogtaniShter COZ
Funding 1997-1998: $268,852
TA cunningham Schoot {dee rec de nnd tppr fm she! kind wpe Fo heath end uments me
{Oui Sect Pooteiss beeen aac arn Oz Fay Cone Ouprireeh
Powe O80 nay Saad bene he Gre iy
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Coordinator (al ime)

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rentally ae emotonaty
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arenes have resources

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eve ec ak force

(chan Tus fun

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(Oeparene
13% Gecarmeat at Heseh Unees Coreg

Corporation

*%
Sec! Dates

Program Components

Parent Support and Education
Parentstorparent mentoring program (URI
CCooperaove Extension): Parenting sks taining
(URI Cooperative Extention) Resource
‘counselor for parents of elven wth abilities
{RI Paren Informavon Necwork). fant toddler
‘ar sen disuibuon: Car and bye salety
‘education: Chid care and transportation £2

{fant and Pre-School Programs
Parents a Teachers (RI Youth Guidance. Sating
Points), Home Instuccon Program for
Preschool Youngsters - HIPPY (Paweucket
Durie Pawtucket Home Viti Programs
Even Start Famly Lieracy Program

(Chitdren’s Learning and Enrichment
‘Akerichool clubs for grades 3-8.Aker school
teeieherent program for grades 3-5 (URI 4-H
Program). Four week summer camp for grades
1A Two-week summer enrichment nrotue for
172405 5.6.7 (UR), Fourswees umm academic

program for grade @ Support forthe tansiuon
te mide schoo! Suppart for the teanition £0
high soot Guaranceee Admissions Programe
swith URI Stadents a Mecatort Gr
Mentoring program (Bown Univers)
School-Linked Health and Social Services
Socal Sal groups (Community Counesing
‘Center: School. based heath center to open
5798 (RI Department of Heath, Blackstone
Valley Heath Cener Memorial Hospaa Lead
poisoning screening and treatment (Sarsing
Polos Fatima Clive)

‘Adult Education

‘Adult Bani Edvcation clases; GED classes ESL
lasses (Swearer Center), Caiensinp esses
AProjec Hope) Summer ixeracy programs
Family and Community Development
“Annual Fay Far Breakas with anc Fay
Fei TripiFamly fn acuvives Bie Rodeo:
Parent coffee hours (Prject Hope,
Americorps)


152

‘equivalent on other major sociodemographic characteristics, such as maternal age, language
preference (English versus Spanish), and marital status. The rates of acceptance into the
research was lower than in Elmira and Memphis, probably because of the large number of
prenatal clinics involved, which meant that many women were invited in writing but did not
have the study explained to them in a face-to-face interview, where their questions about the
study might be answered.

84% of those enrolled were unmarried, 45% Mexican American, 34% Anglo non-
‘Mexican American, 16% African-American, and 5% American Indian/Asian. 87% of the
‘women enrolled were unmarried. The average age at registration was 19.8 years. The
women were randomly assigned to treatment and control conditions using a computer
program that stratified women by sociodemographic characteristics prior to allocation.

‘Women in Treatment } (n= 255) were provided developmental screening and referral
services for the child at 6, 12 and 24 months of age. ‘Those in Treatment 2 (n = 236) were

provided the free screening services offered Treatment 1 plus intensive nurse home-visitation

during pregnancy and the first two years of the child’s life. Women in Treatment 3 (n = 244)
‘were provided the free screening services offered Treatments 1 and 2 plus intensive home-
visitation during pregnancy and the first two years of the child’s life delivered by well-trained
and supervised paraprofessionals.

Both groups of visitors were provided extensive pre-service and on-going training in
the program model and were provided updated visit-by-visit protocols previously tested in
Elmira and Memphis. They also were provided excellent clinical supervision, with the 10
nurses having a single full-time supervisor (a 1:10 supervisor to staff ratio) and the

paraprofessionals having two full-time licensed clinical social workers as supervisors (for a

3


79

Therefore, we asked a second key question: Are these programs jus-
tifiable on economic grounds?

For two programs that we reviewed, which were amenable to this
type of cost/savings analysis, we find that early intervention pro-
grams can generate savings to government that exceed program
costs by severalfold. We also provide evidence that there are added
benefits to other members of society that exceed even these savings
to government that further justify spending on these programs. In
both cases, we estimate that our calculations are conservative be-
cause we are not able to put a monetary value on all of the benefits
that are produced by the programs we review.

It is important to note that these hopeful conclusions rest, how-
ever, on a limited number of carefully evaluated programs in the
literature. The number of scientifically sound studies is limited and
therefore our ability to extend the conclusions that we draw based
on these studies means that there may be many programs out
there today being implemented on a smaller- or larger-scale basis
for which these conclusions may or may not be relevant. Thus, we
believe there are many important questions that remain to be ad-
dressed in this area, such as the ability to scale up model programs
and have them be as successful as they were at a smaller scale;
and the optimal mechanisms for targeting children at risk, identify-
ing who will benefit most from the programs as they are designed.
Therefore, we think it’s important while we proceed that we do so
with caution, drawing on the proven models, where those proven
models have been shown to be effective; and at the same time, con-
tinuing to evaluate both programs that have been implemented on
a small scale and which are implemented now on a larger scale, as
well as evaluating new program models as they go into effect on
smaller and larger scales.

Let me just provide a little bit more detail in the remaining time
on our two key questions and the specific findings in each of those
areas, first, turning to the benefits of early intervention programs.

Given the importance of these early years of childhood, a number
of model programs have been implemented and carefully evaluated
and published in the scientific literature. These programs are de-
signed, as I mentioned earlier, to overcome many of these stressers
in early childhood that can place certain limitations on the ability
of children to grow to be healthy, productive members of society.
Our research focused in particular on nine programs published in
the literature. These programs were somewhat different from many
others in that they had careful evaluations, evaluations that in-
cluded both treatment in control groups, evaluations that also had
in most cases long enough followup so that we would know what
would happen to program participants compared to nonpartici-
pants, not only at the time a program is implemented but years
down the road.

The programs that we reviewed differ in many respects in terms
of their design, the types of children and families who were tar-
geted, and the period during childhood in which the intervention
took place. They ranged from programs that began in the prenatal
period and offered, for example, home visits to young mothers.
They included programs that began later in childhood, for example,


15

Your Child Public Awareness and Engagement Campaign. We

have three primary goals:

1. Raise awareness of the critical importance of the

prenatal period through the first three years of life;

2. Provide parents with information and tools to help
them understand their child's early development,

and

3. Make policymakers aware of the enormous

opportunity to affect social outcomes.

We now clearly know that if we want to make a real impact on
crime, teen pregnancy, drug abuse, child abuse, welfare
dependency, and homelessness, we must make a real

Investment In a child's earliest years.


197

Overview for COMPANY

Welfare To Work Initiatives

DCC’s LifeCare services play a significant role in the welfare to work effort by helping people
‘on public assistance obtain jobs in the private sector. According to welfare to work organizers,
“Lack of child care and transportation are two of the challenges making it tough for recipients
{o stay in the job market.” Recognizing these needs. DCC responds to those specific obstacles
‘and helps employees balance work and personal responsibilities through our combination of
Welfare to Work and LifeCare services.

DCC can work in conjunction with employers. government agencies and job training
specialists—or with an employee directly—to help locate convenient and affordable
transportation services and child care providers in an employee's area. DCC’s advanced
technology, customized mapping software and database of over 2.5 million providers, enable
counselors to provide a customized map detailing convenient transportation routes between an
‘employee's home and office. Counselors can also refer an employee to prescreened child care
providers on or near the employee's transportation route. complete with door-to-door
directions.

‘A DCC counselor responds to the specific needs of an employee by referring only those
providers who meet the employee's budgetary. location, care. and other personal requirements.
Whenever possible. counselors provide information on subsidized or other programs offering
discounts, sliding fees. sibling packages and various forms of financial assistance. DCC also
offers educational materials on child care options as well as licensing and regulation
Fequirements in the state the employee lives. After sending referrals, maps. directions and
educational materials, the counselor can follow up by phone call to address any questions and
concerns, and to encourage the employee to call as often as needed.

DCC’s Welfare to Work initiatives are just another way DCC can help employees balance
work/life responsibilities—and increase overall productivity at your company.

Quality Assurance Program
DCC has an unprecedented and comprehensive quality assurance program which consists of the
following five components

1. Counseling Follow-up and Feedback

DCC counselors call COMPANY employees on a continuing basis throughout the counseling and
referral process to check and monitor their progress. If further assistance with educational
information or additional referrals are required. the DCC counselor responds immediately.

UL. Evaluating Counselor Performance

DCC counselors are evaluated both internally by DCC management and externally by clients.
Quality assurance questionnaires are sent to all clients with their case information and referrals.
‘The questionnaire asks clients to rate the overall DCC service. their counselor and the DCC-
referred providers. and 10 provide additional comments. Internal counselor evaluations consist of
an annual performance appraisal in which performance and salary inctease go hand in hand.

pee :



128

able to focus their caregiving resources on a smaller number of children. The program was
directed toward improving the outcomes of pregnancy, parents’ caregiving skills (and the
corresponding health and development of the child), and the early life course of the mothers.

{In designing the program, we reviewed the literature to determine behavioral and
contextual conditions that were consistently and uniquely associated with the adverse maternal
and child outcomes that we wished to affect. We analyzed the literature to determine the extent
10 which these risk factors were likely to be causally related to the outcomes of interest and
which were simply markers for maladaptive functioning. Those thought to be causally related to
the outcome of interest and that were potentially modifiable with social and behavioral
interventions became the primary candidates for targeted interventions to reduce the adverse
maternal and child outcomes identified for prevention. Theory played an important role in
helping us integrate the epidemiologic data into a coherent developmental framework regarding
the proximity of risk to adverse outcome, the developmental progression of maladaptive
functioning, and how clinical interventions might be applied to reduce risk. It is important to note
that the epidemiologic evidence indicated that some of the problems targeted for prevention early
in the program were also risks for later antisocial behavior. This is best illustrated by reference
to Figure 1.

A. Modifiable Risks for Low Birthweight, Preterm Delivery, and Fetal
Neurodevelopmental Impairment

Epidemiologic evidence on risks for low birthweight indicates that prenatal exposure to
tobacco, alcohol, and illegal drugs are established risks for compromised fetal growth! and, toa
lesser extent, shortened length of gestation.’ Similarly, prenatal exposure to these substances

increases the likelihood of compromised neurodevelopmental impairment.?TM'*"" While the


184

PROGRAM DESIGN
A, Frequency of Visitation

The frequency of home visits changes with the stages of pregnancy and can be adapted to
the mother's needs. Mothers typically are enrolled through the end of the second trimester of
pregnancy. Visits are scheduled once a week during the first month after enrollment, which
assists the new mother and the home visitor to establish a trusting relationship. Thereafter, visits
are scheduled every other week until the birth of the baby. Nurses again visit weekly for 6 weeks
after the baby is born, helping the new mother and newbom adjust. From the child’s 2nd to 21st
postnatal month, visits are scheduled twice a week. From the 21st to 24th postnatal month, visits
are scheduled once a month. In Elmira and Memphis the nurses completed an average of 9
(range 0-16) and 7 (range 0-18) visits during pregnancy respectively; and 23 (range 0-59) and 26
(range 0-71) visits from birth to the child's second birthday. In calculating these rates of
completed visits, all cases assigned to the nutse-visited conditions were included in the
denominator, irrespective of the families’ dropping from the program for any reason. Each visit
lasted approximately 75-90 minutes.
B. Nurses as Home Visitors

This program calls for nurses to be the home visitors. We have chosen nurses because of
their formal training in women's and children’s health and because of their competence in
‘managing the complex clinical situations often presented by at-risk families. We have
hypothesized that nurses’ abilities to address effectively mothers’ and family members’ concerns
about the complications of pregnancy, labor, and delivery, and the physical health of the infant

provide nurses with increased credit

ity and persuasive power in the eyes of family members.

Moreover, through their ability to teach mothers and other family members to identify emerging

B


189

Overview for COMPANY

At-Risk/High-Risk Adolescents

Raising adolescents today can be challenging and overwhelming. Due to many factors.
including peer pressure. low self-esteem, underachievement, runaway tendencies. violence and
behavioral issues. depression and suicidal tendencies, substance abuse and gangs, many
adolescents and their families need help. DCC counselors can provide guidance and locate the
following supportive options to improve their well-being and the quality of their lives:

© Transitional living programs © Peer counseling

Peet/group support groups Group counseling

Family support groups Family counseling,

Residential placements Recreational day programs

Day and residential treatment facilities Parenting classes

Positive after-school alternatives Positive social clubs/activities
‘Summer opportunities

Mentoring programs
Alternative schools
Boarding schools
Independent schools
Military schools
EAP referrals

‘Awareness programs
Clinicat services
Outpatient services
In-patient services
Social services

ey

.
.
.
.
.
‘© Community volunteer programs
.
.
.
.
.
°

Academic Services

DCC can provide COMPANY employees with information and referrals on all types of schools
and learning programs for children and adults:

Primary and Secondary Programs
‘Whether clients are relocating to a new community or looking for new educational opportunities
for their school-aged children, DCC counselors can provide information on a variery of academic
Programs from kindergarten to high school:

© Kindergarten programs © Montessori schools
© Before- and after-school programs © Magnet schools

‘© Enrichment programs © Alternative schools
© Tutoring programs © Vocational schools
‘© Day and residential programs © Technical schools

© Public schools © Military schools

© Parochial schools © Schoo! district profiles
© Independent schools

DCG "


178

‘motor skills, language learning, emotional control, social interaction—it’s no wonder that we want
more than ever before to ensure that our children get the care they need to flourish.

‘Toward this end, both the public and private sectors are acting in their own enlightened self-interest by
providing their employees with the types of services that DCC and other companies provide. By
‘helping parents find the resources they need to raise healthy children, organizations like Chesebrough
Ponds, American Home Products, American Electric Power, The Cocoa-Cola Company, The
Department of Justice, The Centers for Disease Control, Hughes Electronics, TRW, The Home Depot
and other corporations and government organizations, have reaped measurable benefits. Workplace
stress, fumover, and absenteeism have decreased. Recruitment, retention, and productivity have
soared. These organizations have discovered that helping employees provide for their loved ones, helps
the botom line.

Private and public organizations must continue to work together to ensure that working parents get the
resources they need to encourage their children’s growth during these critical years. Early intervention
that focuses on improving the lives of parents and their children will help make today’s workforce
‘more productive... and tomorrow's workforce better prepared for the challenges that lie ahead

In close, I would like to thank you, Mr. Chairman and Honorable Members of this Subcommittee. 1
‘would be pleased to answer any questions you may have.
| Families and Work Institute, The 1997 National Study ofthe Changing Workforce, 1997.

‘November 199:

ensus Bureau, Current Population Reports P70-62.
* Census Bureau, Current Population Reports P20-509, April 1998.



74

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New Hampaire Deparment of Education


32

House Testimony - Felicia Pearson - July 16, 1998
Hi. My name is Felicia Pearson se ied to rug, who is now 8

yc
wrth em ones let he hospi T did contact them when I got home, and the Healthy Families
assessment worker came to my home to interview me. My family support worker, Lynn Kossnovich, was
assigned and began to visit me when I was 24 weeks pregnant, she came twice a month at the beginning,
and then weekly as I approsched the seventh month of my pregnancy.

Before 1 had the baby, I was having serious doubis about my ability to be a mother. I was very
scared that I wouldn't be able to love this baby. My visits with Lynn often focused on this. I would
describe what I planned to do once the baby was here, and what I said sounded so harsh, as if I had no care
for this child. Even up until the eighth month, I still had feelings of not wanting to have this baby. Lynn
‘would talk with me, help me plan for whatever happened, and let me know that I could call her at any time
if needed her. I liked that she came to my home and that I was able to be honest with my feelings and my
fears. We talked about how { would respond in various situations, such as ifthe baby wouldn't stop crying,
‘or how I would discipline the child. She brought information about tabor and delivery and helped me plan
for my care and my child's care in case I suffered from postpartum depression. The object of the Healthy
Families program is to support you and I truly felt like I had Lynn's support behind me.

My son was bom on November 3, 1997. Once he was bom, a lot of my feelings changed towards
him, From the moment he came into the world, fell in love with him. I cried my heart out, 1) because
was happy to have this beautiful child, but 2) from thinking about how I could have called this beautiful
baby “the thing” Contrary to my psychiatrists prediction, I did not suffer from postpartum depression and
‘was immediately able to love and care for my child.

‘My Healthy Families support worker has continued to visit me once a week since I came home
from the hospital. At first our visits focused on the needs of a newbom--Lynn would talk to me and also
‘would leave information with me so I could look back onit if needed help when she wast't around. More
recently, we have talked about child development, we have regularly completed developmental screenings
to make sure my son is developing appropriately, we have discussed things like feeding and child care, and
Lynn has brought me information about how to play with and stimulate my son.

Family members often give you advice and tel you what you're doing wrong. Lynn listens to me,
‘mother i

thing. I feel so rich to have Healthy Families in my life and I feet that I have such a wonderful advantage

over others who haven't been so fortunate, ‘The Alexandria Healthy Families program is open to first-time

parents with a lot of stress in their lives who have been enrolled either prenatally or before the baby tums

‘two months old, I think the Healthy Families program should be available to all new parents, regardless

of the amount of res they have or he mnber of cle they akendy have. Ithas muy eniched my ie
my son’s fi


103

Mr. Suays. Dr. Knitzer.

Ms. KNITZER. Thank you. I am Jane Knitzer, the deputy director
of the National Center for Children in Poverty which is part of the
Columbia University School of Public Health. Our mission is to
focus on issues affecting low-income children from zero to 6.

In my testimony today, what I would like to do is talk about a
report that we recently released entitled, “Map and Track: State
Initiatives for Young Children and Families, 1998 Edition,” which
asks the question, OK, we have this wonderful scientific and con-
sistent set of data, empirical data. What are States actually doing?
How are they investing in promoting positive outcomes for young
children and families? I will talk a little about the key findings
from that study, four challenges that the report raises and the im-
plications for some Federal action.

Let me just say that the report really focuses on State invest-
ments; it does not say, what is a State doing with Federal dollars,
with Federal programs like Head Start, et cetera. Nor did we track
child care initiatives or health initiatives, because these are single-
system initiatives. We were really focusing on what you are calling
“early intervention” and what we called “comprehensive programs.”
It is what Representative Towns was talking about, programs that.
combine promoting healthy child development, help parents with
family support and link parents and children to needed. services.

Key finding No. 1: States increasingly are recognizing the impor-
tance of early intervention/ comprehensive programs for young chil-
dren. How do we know this? In the 2 years since the first edition
of the report was released, 26 States now report statewide support
for programs for infants and toddlers; 26 do, 24 don’t. Virginia, by
the way, is one of the States that does not support a statewide pro-
gram. The program that Ms. Pearson was in does not exist
throughout Virginia.

Our framework in Map and Track, however, went beyond looking
for programs for infants and toddlers, because we think the pre-
school years are important and we must not forget about those, so
we also looked at what the States were doing for preschool age chil-
dren. For preschoolers, what we saw was a deepening of existing
programs. Thirty-four States in 1996 reported programs for pre-
schoolers, 34 States in 1998; however, three States, including New
York, Connecticut and New Jersey, have significantly deepened
their preschool programs. New York may eventually have a univer-
sal program. This is the good news.

Not so good was the finding that there appears to be a disconnect
between these comprehensive programs and the implementation of
welfare reform, and this speaks exactly to the point that Mr. Towns
was raising. We are very concerned about that. Only 10 States re-
ported deliberate statewide strategies to link their comprehensive
initiatives with the implementation of welfare reform. We are very
concerned about that. Such integration, we believe is critical to en-
sure that as adults concentrate on moving into jobs, we do not for-
get the importance of giving their children real opportunities.

The second set of findings: The data suggests that there is grow-
ing recognition that a program-by-program strategy is not enough.
This has basically been the strategy that we have used for years.
How do we know this? In two ways. First, over half the States are


39

mate pretty much coaxed me into it, why don’t you just try it out
and see what happens?

I did need the program.

Mr. Suays. At first the program was designed to help you. When
did you realize that the program was going to help your child?

Ms. PEARSON. Of course, after he was born. I was really con-
cerned, wondering if he was going to be the type of child that a
friend of mine has, who was a very difficult baby. There were many
times that he was at the house when I was pregnant with Nico,
and I was like, I don’t want to have this baby because I know this
baby’s going to come out acting like him and I’m not going to be
able to deal with this. He was constantly crying, he demanded his
mother’s attention 24 hours a day. I didn’t think I could do it.

Lynn would bring me information that if certain situations arise
with the crying, that I could do what I could do, and after 10 min-
utes maybe if the baby is crying, go and check on him. J don’t know
whether I answered your question.

Mr. SHays. You answered it perfectly. Let me just delve a little
deeper if you don’t mind.

There is a point where you realized that not only were you being
helped, but that your child would grow up to be a better child be-
cause of the program that you were involved in. When did you start
to see the need for this program for your child, not just yourself?

Ms. PEarsON. Lynn would tell me, one thing it may not be that
big but to me it is, telling me that 15 minutes every day put Nico
on his stomach so he could start strengthening his arms. I didn’t
think that was a big deal until I noticed, when I first started doing
it with him, he didn’t like it, he cried a lot. But I left him there,
anyway, because I really wanted to see if this worked. Then even-
tually Nico stopped crying a lot and he was much happier and he
was moving all over the place. And also the consistency of me doing
the colors with him. I read to him a lot, and now, like I said, he’s
now saying hi, which I think is pretty good for an 8-month-old.

Mr. REINER. It’s amazing.

Ms. PEARSON. Of course that brings tears to my eyes when I hear
that. I do the telephone. These are some of the games that I do
with him. I will just say, “Ring, ring, telephone, Nico.” He is the
type of child who laughs at anything. He’s a very happy baby.
When I do that, he starts smiling because he knows what I’m talk-
ing about. I say, “Hello,” put the phone to him, he looks around;
one day he surprised me and he said, “Hi.” All I could do was sit
back, I was like, “I love this baby,” and I love the program, because
you see the product. And if you’re consistent, and that’s a hard
thing to do, especially since being adults we tend to get tired of
things after a while, but if you keep it up, you start seeing results.

Mr. SHays. This program has provided you wonderful help. You
have developed, from your own words, some tremendous parenting
skills. Did the program also help you get a job?

Ms. PEARSON. I was already employed.

Mr. Suays. So you took a leave of absence from work?

Ms. PEARSON. Yes, I was allowed to take—we have 3 months ma-
ternity leave, and I was able to take an extra month.

Mr. SHays. Was part of your concern about having a child that
this was interfering with your ability to potentially work and have


164

52. Moffitt, T-E., Caspi, A., Dickson, N., Silva, P., & Stanton, W. (1996). Childhood - onset
versus adolescent - onset antisocial conduct problems in males: National history from
ages 3 to 18 years. Development and Psychopathology, 8, 399-424,

53. Olds, D.L., Kitzman, H., Cole, R., & Robinson, J. (1997a). Theoretical foundations of a
program of home visitation for pregnant women and parents of young children. Journal of
Community Psychology, 25, 9-25.

54. Olds, D.L., Pettitt, L.M., Robinson, J., Henderson, C. Jr., Eckenrode, J., Kitzman, H., Cole,
B., & Powers. J. (1998). Reducing risks for antisocial behavior with a program of prenatal
and early childhood home visitation. Joumal of Community Psychology, 26, 65-83

55. Korfmacher, J., O’Brien, R., Hiatt, S. & Olds, D. (1998) Differences in program
implementation between nurse and paraprofessionals in prenatal and infancy home visitation:
a randomized trial. (Submitted for publication).

56. St. Pierre, R.G., Layzer, J.1., Goodson, B.D., & Bernstein, L.S. (1997). National impact
‘evaluation of the comprehensive child development program. Final Report to ACYF,
Contract No. 105-90-1900. Abt Associates, Inc., Cambridge, MA.

57. Rethinking the Brain-New Insights into Early Development, Executive summary, Families

and Work institute, The University of Chicago, June 1996.

43


64

EAST PROVIDENCE
‘Contact, CHILD OPPORTUNITY ZONE FAMILY CENTERS
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Fuscpedngsimch COR Grade
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hanes ne perenepres 3d 4 we epee ohooh conmny ager commun
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Fa ener Schoo! Locations
‘Self Help, Inc. “The East Providence COZ has a community room at che Grove Avenue School. Family Resource:
100 Bullocks Point Avenue Room at che Whiteknact School, and office space and meeting space at che Orlo Aveoue School. The
Ens Proton RI 2915 te shou serve cen rm he srrurdg nepborhews A any Cover Caerdhator'n
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Conor (hittin) cad ares provided as be Oro Avec snd Whine Shoal bythe NewmunYCA Bele
Seaman once tehool ul cre twat sthe Oro ene and Grove Arms cho
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Sehool Diseriee

Serine Ore aay $9% COZFamy Cer Oxprnert Caton,

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Children experience: Program Components Feinstein Good Deeds Program

accent in school

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parents

Famiy members have
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Parent Support and Education
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farnlies

Family Resource Rooms at Grove and
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Information on community services

Parenting skis erasing

Confetrezokiion erasing (School Distr)
Child Care

Before-and afer school cd care (Newman
YA)

Children’s Learning and Enrichment
‘Mentoring and academic sypport (Rhode sang
Children's Crusade} Afterschool tutoring
‘Gubstance Abuse Prevention Tat Force)
‘MashScience night for children and fies
‘Students a8 medators (Schoo! District)

Parent and teacher cureculom dali cream
socal

‘Open houseipiza party for parents and
ceachers

Parentichld knches and catiroom wate
Confit resolution waning for teachers (Schoo!
Barnet)

‘Adult Education

Englah a Second Language classes (RIRAL)
GED castes (RURAL)

CCaizenshp classes (RIRAL)

Family and Community Development
Family field trips

Parent coflee hours

Bike rodeo

Fai fun aeties

Voter regstraton

Fatberdnughter dance


Overview for COMPANY

Communication and Promotional Services

DCC’s communication goal is to continually promote its services so that COMPANY
employees remain aware of their DCC benefits and know how to contact us when necessary.
By following our recommendations. COMPANY will effectively keep employees abreast of our
specific programs and maintain and increase utilization. DCC’s promotional strategy
‘encompasses the following mediums:

Direct Mail

‘We recommend that COMPANY management send a letter, along with a four-color generic or
company-customized DCC brochure and wallet card. to employees and their families
introducing the DCC service. Even afier implementation of the DCC service, this formality
should be performed for all new COMPANY employees.

OnSite Introductory Seminars—ive Or Videotaped

To help COMPANY employees understand, appreciate and use DC's services to the full
extent, DCC will provide at all locations live or videotaped introductory seminars which cover:

Purpose and benefits of the services
Nature and scope of available services and benefits

Program confidentiality

How to access the program and eligibility requirements

What COMPANY employees can expect from the DCC service

Live introductory seminars are generally 45-60 minutes long and are followed by a question-
and-answer session. The videotaped seminar runs approximately 25 minutes long and can be
followed by a teleconferenced question-and-answer session with a DCC representative.
Employees* family members are also welcome to attend

On-Site Communications—Posters, Flyers and Videotapes

In addition to direct mail and implementation seminar initiatives, DCC aiso provides posters.
flyers and videotapes for COMPANY management to distribute throughout their work sites.

DCC’s Ongoing Strategy For Communicating Our LifeCare Services

Following implementation, it is necessary to provide ongoing promotions in order to effectively
communicate to COMPANY employees the nature and timely aspects of DCC’s services. DCC
provides all clients with a monthly promotional schedule consisting of program flyers.
According to COMPANY’ preferences, DCC can also e-mail teasers to employees.
encouraging use of LifeCare Net to explore monthly themes.

DCC *


148

of preterm delivery and low birthweight) -- was equivocal.

In the Elmira trial, the program produced the anticipated reduction in cigarette smoking,
improvemnent in diet, and increases in women’s use of needed social services and informal social
support. There was an increase in the birthweight of infants born to women who were very young
(i.e., less than 17 years of age at registration) and a reduction in the rates of preterm delivery
from 10% to 2% among women identified as smokers (those who smoked five or more
cigarettes per day at registration). It is important to note that 55% of the Caucasian women in the
Elmira trial smoked cigarettes during pregnancy

‘The program impact on preterm delivery and the birthweight of babies born to young,
adolescents and women identified as smokers in Elmira was not replicated in Memphis, although
the program did produce the anticipated effects on women’s use of other human services and on
the rates of Pregnancy Induced Hypertension (PIH). ‘The absence of corresponding effects on
the rates of preterm delivery among smokers in Memphis is probably a reflection of the very low
rates of cigarette smoking among African-Americans. Nine percent of the Memphis sample
overall smoked cigarettes, and only 7% of the Aftican-Americans smoked. Reproductive-tract
infections (another major risk for preterm delivery), on the other hand, were much higher among,
African-Americans.*

‘This lack of correspondence between the results of the two trials emphasizes the
importance of basing preventive interventions on sound epidemiologic evidence -- that is, a clear
understanding of the modifiable risks for the disorder that one wishes to prevent. In this case,
the pattern of risks was quite different for Caucasians in Central New York State than for
African-Americans in Memphis. While the program can reduce cigarette smoking, it is more of

a challenge to affect reproductive-tract infections, given that many infections begin prior to

ca


35

country I think you would find the vast majority of people in the
country would be crying for quality child care, not just people com-
ing off of welfare and people in poverty levels.

ir. Towns. Let me just ask what can we do on this side of the
aisle, you know, to sort of create the kind of atmosphere and cli-
mate, that this is very, very important? You know, what can we do
here from a legislative standpoint?

Because I tl this issue, of course, is a very, very important
issue, and I think that sometimes people don’t realize how impor-
tant it is, and I think we are saying something and then doing
something different. What I mean by that is, if it’s important, then
we should behave like it’s important by putting the resources there.
And in the long run, I think we are fine. We are going to save
money if we are doing what we are supposed to do in the begin-
ning. So I think if we spend the money on the front end, we won’t
have to spend on the back end, and I think if we look at the whole
pattern that we will find we will save money in the long run, along
with all the other things that will happen in the process. And how
do we create that kind of atmosphere?

Mr. REINER. Well, I mean, you have a number of child care
pieces of legislation floating around Congress. Right now, I think
there is something like 40 of them, and there has been an effort
to try to coalesce all those pieces of legislation. But yet we don’t
see any kind of stepped up, you know, revenue stream.

As Governor Almond is pointing out, forget the $8 million that
he deserves. Wouldn’t it be nice to have a revenue stream devoted
to child care that can be block granted to the States to be used in
an integrated way with health care? Because it has to be linked.
It doesn’t work all by itself. You have to link health care and child
care and parent education. All those things need to be linked to-
gether. But if States are willing to participate in an integrated
way, in a comprehensive approach to early childhood development,
why can’t we loosely block grant the money to them? I mean, it’s
floating around.

I worked on the Senate side with John Kerry, Senator Kerry, and
Senator Kit Bond on a bipartisan piece of legislation to devote $11
billion over 5 years for early childhood interventions and child care
and so on, and, you know, we are pressing. But, I mean, it’s dif-
ficult.

We don’t have our priorities squared away, it seems to me. You
know, if science is now clearly telling us that those first 3 years
are the most critical in a person’s life, and Congressman Shays
pointed out about the trajectory, how we can get off course, and if
we don’t start people out right, we are paying for it in prison costs,
we are paying for it in incremental health care costs. We are pay-
ing for it. The only question is, do we want to pay a lessor amount
now or a greater amount later? Because we are going to pay for it
one way or the other.

You will hear testimony later from Dr. Olds and from Lynn
Karoly at the RAND Corp., that will show you conclusively, if you
invest in the right kind of intervention programs like the one that
was testified to here today, you will see, you know, anywhere from
$3 to $4 to maybe even $5 return on your investment for every dol-
lar invested.



67

NORTH KINGSTOWN
CHILD OPPORTUNITY ZONE FAMILY CENTER

coz Grade Total Percent

Schools Levels Enrollment Low-Income oneace

Davie Eemenary Scoot 15 a ax Donna Thempsen

Forest Park Elemenay Schoo! 1-5 281 16x Coordinator
Sehooke

Advisory Board 2 Elementary School

‘Te North Kingstown Child Opportunity Zone has 2 Seerng Commetee of prens.commumty uae

volunteers. and agency repeseneaties Workgroups are created needed 0 plan and implement Norn Kogan Pubhe

Specie projects Ha needs denied 8a pry for the school and the paren, the COZ seeks Out pene

2opropraecommuryparrers to ensure cllborative omer of be program *

School Location Davie Blerentary

‘The Chid Opporuniey Zone wersa wah student and amis in ebe Danse ad Fores Pak Sehoot

ementary Shook Both are primary neighborhood schools Children fom the cannons hoving, $0 Ear Court

proyram for homeless amie located i he neghborhood attend Foes Park School The COZ Nore Kingown,

‘seeks to develop programs shat meet te needs ofall children and fumes, wth spec arena to
the needs of famiis in che wansional housing program The COZ his ofce space nthe Davis

‘School ands planning» communiy-based Famniy Resource Center to be located nthe neighborhood
Funding 1997-1998: $95,509

(Gc ete tp fom ad a nd prt fa tan nen cae ane

‘env bated by pret od corny ok

3X Setoot Darter

(Other (Uncen Ci “
Sotarteabue fax fore

Community Delopment Bok Grant

eral Hes Adacemen Resource
Xe Fax MeKinney Homeless Funds

6% COZ Famiy Cecer(Deparert of Evcabon
Deparoven of Heath Unces Way)

Program Components

Parent Education
Farny resource ieerature and refers
Handbook of educavan erm" Relerence
side to suppor services Scholarships to
parenting conferences: Parendschool afl
‘workshops. Carseat and yc aety

Infant and Pre-School Programe

Parents a Teachers: Pre-school tory hours,
Book bap for babies and parents

‘Children’s Learning and Enrichment
“Tuoring and Academic Support: Afterschool
recreation and mini-courses:Ars enrichment
‘rogram; Summer Schoo! Colaborative-
‘Academic Support Enrichment Camp
‘Scholarships (COZ, School District Recreation
Dept): Reading ails supporvlasroom
‘curriculumAcademic spore and edveation
plan development for chidren in transitions

housing Heat Foods Clubs:“Teachng
tolerance” poserslcuriulu Schoo! breakfse
lt

School-Linked Health and Socal Services
Heath and dena services. munitions
(Bayside Fary Health Services). Professions)
Gevelopmenc on homelesness and chidrens
‘mental health

‘Adult Education

Scholarship for adult education Scholarships for
‘computer sis taining

Family and Community Devalopment
“Welcome to Our Schoo! Tie Ar Murat
Project: Gardens. mature als outdoor
classrooms created by fies and schoo!

staf (Undead Wy, Clazens Bank): Soler/valeing
ud: Fai swim sigh (Local Funes hb):
‘Aerobics (Local ness cub) Parenti ness
cuties (Local faness hb)

ons
(4012044581 one 252
sate

Coordinator (parecime)
Parent Educator (part
time)



190

Overview for COMPANY.

Colleges and Universities

Finding the right college can be a time-consuming process. DCC college counselors can help both
traditional and nontraditional students find the programs and financing that meet theit needs. DCC
provides clients with information on:

(© Two-year and four-year undergraduate © Continuing education programs
programs © Athletic programs
© Graduate programs © Academic planning strategies
© Vocational programs © Admissions testing and procedures
© Specific degree programs © Testing preparation courses
© Programs for transfer students © Financial aid options and strategies
© Programs for nontraditional students © Scholarships
'* Distance learning/correspondence
courses

Emergency/Ternporary Care—Child and Adult Options

‘When a dependent becomes ill or a caregiver is suddenly unavailable, many employees must stay
hhome to care for their loved ones. DCC can atleviate these kinds of work absences by helping
clients pre-plan for an emergency or by accommodating 2 last-minute situation. DCC services
include:

‘© Home health care agencies © Discharge planning

‘© Community resources Sick and drop-in care providers

‘© Nanny and baby-sitting agencies

‘Access Backup Care (ABC) Program

‘The ABC program is for employers who choose to subsidize backup care for their employees.
Backup care subsidies keep employees from having to use sick/vacation days to stay home to
cate for loved ones. or from missing work because the cost of care exceeds their compensation.

DCG °


196

‘Overview for COMPANY

Health and Wellness

Physical and mental well-being plays an integral role in successfully balancing work. family
and personal obligations. DCC can provide education and information on:

© Physician referrals
© Demist referrals
© Health clubs

© Holistic services

Balancing Work/Life

‘Stress management
Overtime and business travel
Time management
Organizational strategies
Easing commuting stress

Pet Care
© Veterinarians
© Insurance
© Pet siting resources

© Obedience craining

© Boarding and grooming
Convenience Services

'* Indoor/outdoor home services
© Chore services

© Transportation/travel services
© Automobile services

‘*  Moving/relocation services

LifeCare Educational Resources

.
.
.
.

eeee

acces

eee

Complementary therapy
Diet and nutrition
Fitness

Health food stores

Career development
Planning a leave and recur
Relocation

Shifi/schedule changes

Pet supplies
Breeders

Membership associations
Pet bereavement services
Animal welfare

Entertainment services
Restaurants/food services,
Security specialists
Emergency services

DCC believes educated consumers make better personal choices and caregiving decisions for
themselves and their families. DCC provides a wide range of educational materials which
employees will find useful in evaluating their work/life options. ataking LifeCare decisions and
‘monitoring thetr caregiver's performance Online, COMPANY employees can peruse LifeCare
Net's library of over 700 educational resources: hard copies are also available and may be

DCG: cae comecrens


104

developing planning and community mobilization strategies that
are seeds for public-private partnerships. Second, we have, as in
Rhode Island, a small number of States mounting multistrategy
initiatives that are weaving together multiple kinds of efforts, lay-
ers of efforts to raise the State’s priority attention to young chil-
dren and families.

Four challenges: One, although many of the States report initia-
tives on behalf of young children, the scope is broad but not deep.
Often a relatively limited number of children have access and fund-
ing levels are low.

Second, the range of public-private partnerships that is emerging
is very positive and does seem to bring new resources to the table.
There has been no systematic evaluation of how can we grow these
so that it’s not just a commitment of the day.

Third, some issues reported by the field remain largely
unaddressed in State initiatives. The one I wanted to talk about
today is how we can help care givers support families with the
kinds of levels of stress that we are actually seeing in the early
childhood community, particularly related to substance abuse, men-
tal health, domestic violence issues and the kind of depression that
you heard about.

The second issue is that we can’t forget about fathers in these
early childhood programs. This is a wonderful point of outreach to
young fathers, particularly through welfare reform.

The fourth issue: Although in many States the programs that are
being implemented are modeled after national initiatives, some of
which have proven track records, there is little evaluation of these
State initiatives, and it is not clear whether the desired effects will
be sustained in these State efforts, as we have seen in the carefully
controlled research.

How can the Federal Government help? That was a question ——

Mr. Suays. I am sorry, I am going to be walking out for about
5 minutes. I didn’t want to show you any disrespect. I will be com-
ing back. I just have to meet with someone.

Ms. KniTzer. Thank you.

This, I think, repeats a theme that was heard this morning ear-
lier, ensure that Federal dollars can be used flexibly. States need
to be able to mix and match funding streams. This, I know, is a
new way of thinking for the Federal Government.

And also I think we need to build in—and the Federal Govern-
ment has a major role—incentives for quality improvement. We are
far beyond just thinking about health and safety licensing require-
ments. We need incentives for quality improvement. We need in-
centives to States to develop community mobilization planning and
networking capacity on behalf of young children and families. We
need incentives to States to promote positive outcomes for young
children and families affected by welfare changes. The changes are
significant.

Programs are hurting, family support programs, Healthy Fami-
lies of America, families that have traditionally been visited during
the day, are out at work. People are saying, the parenting piece is
not important, just go get a job. There is a real need to underscore
the importance of this.


167

Figure 3. Estimated nurse-comparison differences in the number of children’s emergency
department visits during second year of child's life as a function of maternal
sense of control - Elmira, (Reprinted with permission from Olds, D-L.,
Henderson, C.R., Chamberlin, R., Tatelbaum, R. Preventing child abuse and
neglect: a randomized trial of nurse home visitation. Pediatrics. 1986;78(1):65-
78)


126

replicating the program in a major urban area (Memphis, Tennessee) and refining the program
protocols and training. If the program were truly effective, we then could help new communities
develop the program in accordance with the proven model so that they could be reasonably sure
of achieving the effects observed in the randomized trials.

As the results of new randomized trials of other home visitation programs became
available, however, we grew increasingly concemed that the findings from Elmira did not have
broad applicability to all types of home visitation programs. Two reviews of randomized trials
of prenatal and early childhood home visitation programs showed that such programs needed to
adhere to certain standards to produce desired effects on maternal and child health.'**

More recently, in light of the considerable proliferation of programs of home visitation by
lay community health visitors, without solid evidence that such visitors could achieve the same
results as has been found with nurses, we developed a third trial in Denver (N=735) in which
nurse home visitors were contrasted with trained lay community health visitors when both visitor
types were provided the same protocols developed in the Elmira and Memphis trials. This study
was designed to determine the extent to which absence of effects for programs delivered by
paraprofessionals is due to the background of the visitors or to the program protocols typically
followed by paraprofessional visitors.

In this paper, we summarize findings from the Elmira trial that have been published since
1993 ~ the point at which we published the most recent review of this evidence ’- and
summarize findings from the Memphis replication study. Outcomes from the Denver trial are
not yet available, although data on differences between the nurse and paraprofessional home
visitors in implementation of the program are briefly summarized here. Before we summarize

these findings, we outline the epidemiological and theoretical foundations of the program and its


WREXP.WK¢4

45

State of Rhode Island
‘Total Welfare Expenditures.

Actual
1996

Cash Assistance" $127,518,713

Employment and Training 4,343,430

DLT/DCYF Emergency Asst. 16,518,486

DEFRA Payments, 3,200,000
Subtotal $151,580,629
Child Care 15,855,353
Health Care 85,725.123
Total $253,161,105

Planned
1999

‘$107,780.29
10,830,101
18,281,767

2,500,000
$139,092.67
32,368,893
121,977,906
$293,438,966

“Cash assistance cases have been steadity declining since 1984. Recipients totalled 62.624
in 1994, 58,405 in 1996 and are projected at 52,800 for 1989. In order to move recipients to
‘employment mare funds have been invested in training, child care and health care.

08/12/98


87

‘Written Testimony of Lynn A. Karoly 6

For the Elmira PEIP estimates, we followed the approach taken in the evaluation of that project,
which was to split the results into two groups. One contained the higher-risk families (those with
single mothers and low socioeconomic status) and the other the lower-risk families. Costs and
savings for the two Elmira PEIP groups and for the Perry Preschool participants are shown in
Figure 2." Costs are known with a fair degree of certainty. ‘The precision of the savings
estimates, however, depend on the sample sizes, and the vertical lines indicate the 66 percent
confidence band (that is, there is a 66 percent probability that the true benefit level falls along the
vertical line). A vertical line of twice the length shown would indicate a 95 percent confidence
band.

timira PEIP ‘ima PEIP Peny
lowor-tak fariles higher sk tii: Preschool

‘SOURCE: Sae Figure 35 in Investing in Our Chiron.
NOTE: All amounts are in 1996 dolar and are the net present value of amaunts over
‘ire whore uture values are clecounted tothe bith ofthe participating ctl, using 4
percent annual real discount rat,

Figure 2—Program Cost Versus Savings to Government (Taxpayers)

For the Perry Preschool and the higher-risk families of the Elmira PEIP, our best estimates of the
savings to government are much higher than the costs (about $25,000 versus $12,000 for each
participating Perry family; $24,000 versus $6,000 for Elmira). Although there is considerable
uncertainty with respect to the benefit estimates, from a statistical point of view we can be more
than 95 percent certain that the benefits exceed the costs.® It is worth pointing out, however, that
while benefits exceed costs, the costs accrue immediately, while the benefits are realized only as
the years pass and children transition through adolescence to adulthood,

In the case of the lower-risk participants of the Elmira PEIP, the savings to government are
unlikely to exceed the costs. In fact, our best estimate of the net savings is that they are negative:

* Dollars shown have been converted to present value—i.e. future costs and savings have been discounted (at 4 percent per
{year (0 recognize the standard assumption in economics that, even apart from inflation, people attach less value to future
‘dollars than to current ones. “Present” here isthe year ofthe child's birth. All amounts are in 1996 dollars.

+ There are however, lher uncertainties that are not related to sample size and chat cannot be measured with statistical
methods


Mr. Suays. Mr. Barrett.

Mr. BarRETT. Thank you, Mr. Chairman.

Very briefly, I am pleased you are holding this hearing, as a
Member of Congress, but probably more importantly as a father. I
have three young children, ages 5, 4 and 1. My wife is pregnant
with our fourth. I point out that I have run for Congress four
times. Each election year, my wife has been pregnant, an issue that
hits home in a major league way for me.

Mr. SHAYS. It raises the question, it is an election year.

Mr. BarreETT. It is an election year. But I think there is nothing
more important. This is it. This is what it is all about, getting the
world ready for our children. And I am excited to hear from our
panelists today, all of whom are really dedicated to this issue. I am
pleased to be here.

Thank you.

Mr. SHays. My staff counsel on my left said we need natural
term limits.

Let me introduce our panel; and, as they know, we swear in all
of our witnesses. This is an investigative committee, and we even
swear in Members of Congress when they testify as well.

Our first witness is Rob Reiner, part of I Am Your Child Cam-
paign from California. Our second witness is Governor Lincoln Al-
mond from the State of Rhode Island, a great State; and Felicia
Pearson, who has been part of a Program in northern Virginia,
Healthy Families. She is the mother of a 9-month-old child and a
wonderful witness today. We deeply appreciate you being here
today as well, Ms. Pearson. You are all equals in this group, and
we are grateful to have all three of you speak.

At this time, if you would stand and raise your right hand.

[Witnesses sworn.]

Mr. SHays. Thank you.

I am going to also just do some housekeeping and ask unanimous
consent that all members of the subcommittee be permitted to
place an opening statement in the record and that the record re-
main open for 3 days for that purpose, and without objection, so or-

lered.

I ask further unanimous consent that all witnesses be permitted
to include their written statements in the record, and without ob-
jection, so ordered.

We welcome your testimony.

Mr. Reiner, you have the floor first. Thank you.

STATEMENTS OF ROB REINER, I AM YOUR CHILD CAMPAIGN,
BEVERLY HILLS, CA; LINCOLN C. ALMOND, GOVERNOR,
STATE OF RHODE ISLAND; AND FELICIA PEARSON, ALEXAN-
DRIA, VA

Mr. REINER. Thank you. I want to thank Congressman Shays
and Congressman Towns and members of the committee for invit-
ing me here to testify on behalf of America’s youngest citizens.

Many of you may know the story of —

Mr. Suays. Mr. Reiner, before you start, I just wanted to state
how we are going to work so no one is confused. The light is going
to be green for 5 minutes. I will leave it on red for a second, then
we are going to switch it and you will have another 5 minutes.


EARLY CHILDHOOD INTERVENTIONS: PUBLIC-
PRIVATE PARTNERSHIPS

THURSDAY, JULY 16, 1998

HOUSE OF REPRESENTATIVES,
SUBCOMMITTEE ON HUMAN RESOURCES,
COMMITTEE ON GOVERNMENT REFORM AND OVERSIGHT,
Washington, DC.

The subcommittee met, pursuant to notice, at 9:37 a.m., in room
2154, Rayburn House Office Building, Hon. Christopher Shays
(chairman of the subcommittee) presiding.

s, Present: Representatives Shays, Towns, Barrett, Kucinich and
cott.

Also present: Representative Morella.

Staff present: Lawrence J. Halloran, staff director and counsel;
J. Vincent Chase, chief investigator; Jesse S. Bushman, clerk; and
Cherri Branson, minority counsel.

Mr. Suays. Good morning. I would like to call this hearing to
order and welcome our witnesses and our guests.

In calculating the trajectory of an object in space, a course correc-
tion of 1 degree at launch can change the destination by millions
of miles. Today, we discuss human trajectories and changing the
course of children’s lives.

Both physical and social science support the critical role of pre-
natal care and effective parenting in each child’s emotional and
cognitive development. A growing body of research concludes an in-
fant’s earliest encounters play a decisive role in wiring the brain
for learning, for love, for life. Missed opportunities to program the
human navigational computer cannot be regained, and the cost of
later course corrections for children and their mothers increases ex-
ponentially as they go further down the path of low self-esteem,
poor school performance, neglect, abuse, and dependency.

This is our third hearing on early childhood development pro-
grams. Previous oversight of the Healthy Start and Early Head

tart programs offered optimistic, even moving, testimony that
well-designed efforts can have positive and lasting effects on in-
fants and families. Those at risk due to poverty, poor health, teen
pregnancy and substance abuse can be put on the road to better

ealth, better parenting and self-sufficiency. But rigorous evalua-
tion of these programs is still in progress and important questions
remain about the effectiveness, efficacy and sustainability of var-
ious prenatal and early childhood intervention strategies.

We address some of those questions today. Specifically, we ask,
how are public and private investments in early childhood pro-
grams contributing to successful outcomes for infants and mothers?

(D


150

‘The Elmira program produced important effects on a host of maternal life-course
outcomes from the birth of the first child to that child’s 15th birthday. Among women who were
unmarried and from low-SES households at registration, those who were visited by nurses during
pregnancy and infancy had fewer subsequent children, fewer months on welfare. fewer
behavioral impairments from use of alcohol and drugs, fewer arrests and convictions, and fewer
days jailed during the 15-year period afier birth of their first child.

In Memphis, the program reproduced the most important outcome with respect to
‘maternal life-course -- a reduction in the rate of subsequent pregnancy. This is important given
that future maternal life course effects depend heavily upon the prevention of subsequent
Pregnancy and an increase in the interval of subsequent pregnancies. In the Elmira trial, the
beneficial effects of the program on life-course outcomes for teens were not reflected in
increased rates of employment, greater educational achievements, or in reduced welfare
dependence while the program was in operation (i.e., 2 years postpartum), It was reflected
instead in the reduced rate of subsequent pregnancy, which positioned the teen mothers to
‘eventually find work,'? become economically self-sufficient, and eventually avoid substance
abuse and criminal behavior.”

‘There is some indication in the Elmira trial that the program reduced the rates of
neurodevelopmental impairment associated with cigarette smoking during pregnancy.*"*"” Given
the simultaneous impact of the program on the rates of dysfunctional care and compromised
maternal life-course (major risks for early-onset conduct disorder), it is not all that
surprising that the 15-year-old children born to women who were unmarried and low SES
exhibited fewer arrests and convictions, and lower rates of cigarette smoking, alcohol use, and

promiscuous sexual activity.


42

I said, well, who knows about this? They said, well, just the sci-
entific community. I said, I'll take it upon myself to get this word
out, because I’ve always wanted—we've all done this, everybody in
this room has spent their whole life trying to solve social problems.
We come up with little piecemeal ways of doing it. I said, there’s
a direct nexus here between what we put in in those first 3 years
and all of these social ills. I know that we can make that bridge.
Instead of having to spend money on remedial costs and closing the
barn door after the horses have left, this is a way to do it. I took
it upon myself to do it.

I think—it’s going to take a while. It’s going to be a slow process,
but I think ultimately if I can pass this legislation out in Califor-
nia, I think it will be a tremendous shot in the arm.

Mr. Suays. I am going to conclude by boasting about my daugh-
ter, Ms. Pearson. But reinforcing something that I feel very strong-
ly about on this hearing. That is, that I have an 18-year-old daugh-
ter, my only child, our only child. I never took physics or chemistry
in high school. My wife took chemistry and will not show me her
grade. My daughter doesn’t consider science her best subject, but
she got an A in both physics and chemistry.

I said to her—her name is Jeramy—I said, Jeramy, why do you
think you did so well in these programs? She said, dad—she
worked very hard on them. She said, dad, I can’t stand not under-
standing something. And I thought about that. And I thought, my
wife in particular used to read to her all the time, discovery and
new things, but we enrolled her in a Montessori program, a pre-
kindergarten kind of program. The whole program was based on
discovering and learning. I give a lot of the credit to her success
in high school not to the high school, but to that program way back
when.

Mr. Kucinich, you have the floor.

Mr. KuciNicH. Thank you very much, Mr. Chairman. Thank you
also for the sensitivity that you have expressed on this issue in
calling this meeting, as well as your overall commitment to these
issues. I have at least one question for each witness.

I would like to start with Ms. Pearson. Welcome to this commit-
tee and thank you for sharing with us your heartfelt stories. I am
interested, the medical care that you received, the doctor that you
went to, how did you happen to get that doctor? Is this a family
doctor you had for many years or is it a doctor who came through
an insurance plan that you are involved in?

Ms. PEARSON. Insurance, yes.

Mr. KucinicH. What kind of a plan was it just curiously? What
kind of a plan was it? How did you happen to have that insurance?
What kind of insurance plan was it?

Ms. Pearson. It’s an HMO.

Mr. KUCINICH. And so the doctor, did he refer you to the psychia-
trist?

Ms. PEARSON. She did, yes.

Mr. KucInicH. She did. OK. The Healthy Families program, is
that a State-funded program?

Ms. Pearson. I don’t know. Is it?

Mr. KucInicu. Mr. Chairman, could we have—I am interested in
the answer.


26. Gil, D. (1970).

‘Cambridge, MA: Harvard University Press.

27. Quinton, D., & Rutter, M. (1984b). Parents with children in care: Il. Intergenerational
continuities, Journal of Child Psychology and Psychiatry, 25, 231-250.

28. Belsky, J. (1981). Early human experience: A family perspective. Developmental
Psychology, 17, 3-23.

29. Bakan, D. (1971).

Francisco, CA: Jossey-Bass.

30. Kempe, C. (1973). A practical approach to the protection of the abused child and
rehabilitation of the abusing parent. Pediatrics, 51, 804.

31, Egeland, B., Jacobvitz, D., & Papotola, D. (1984, May). Intergenerational continuity of
parental abuse. Proceedings from Conference on Biosocial Perspectives on Child Abuse and
‘Neglect, Social Science Research Council, York, ME.

32. Brafford, L.J., & Beck, K-H. (1991). Development and validation of a condom self-efficacy
scale for college students. Journal of American College of Health, 39, 219-225.

33. Levinson, R.A. (1986). Contraceptive self-efficacy: A perspective on teenage girls’
contraceptive behavior. J Sex Res. 22, 347-369.

34. Heinrich, L. (1993). Contraceptive self-efficacy in college women. Joumal of Adolescent
Health, 14, 269-276.

35. Olds, D.L., Eckenrode, J., Henderson, Jr., C.R., Kitzman, H., Powers, J., Cole, R., Sidora, K.,
Monzis, P., Pettitt, L.M., Luckey, D. (1997). Long-term effects of home visitation on
maternal life course and child abuse and neglect: 15-year follow-up of a randomized trial.

‘The Joumal of the American Medical Association, 278, 637-643.

“0


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82

‘Written Testimony of Lynn A. Karoly 1

THE COSTS AND BENEFITS OF EARLY CHILDHOOD INTERVENTIONS
PREPARED STATEMENT OF LYNN A. KAROLY

‘Around the beginning of 1997, RAND was approached by the “I Am Your Child” Early
Childhood Public Engagement Campaign to conduct an independent, objective review of the
scientific evidence available on early childhood interventions. “Early childhood interventions”
were defined as attempts by government agencies or other organizations to improve child bealth
and development, educational attainment, and economic well-being. The aim was to quantify the
benefits of these programs to children, their parents, and society at large. Funding for the project
was secured from The California Wellness Foundation.

My testimony today draws on the results of our study titled Investing in Our Children: What We
Know and Don’t Know about the Costs and Benefits of Early Childhood Interventions. The
research was conducted by an interdisciplinary research team from RAND's Criminal Justice
Program and Labor and Population Program including wo economists, a criminologist, two
‘mathematical modelers, and a developmental pediatrician.

Introduction

‘Over the last year or So, there has been a renewed interest in the influence of early childhood—
especially the first 3 years of life—on child health and development, educational attainment, and
economic well-being. Public attention has been stimulated by television shows and stories in
national news magazines, and governors and legislators have been initiating programs to direct
budgetary surpluses to services for young children. Much of this activity has been given impetus
by research findings that the great majority of physical brain development occurs by the age of
three. These findings have been interpreted to suggest that early childhood furnishes a window
of opportunity for enriching input and a window of vulnerability to such social stressors as
poverty and dysfunctional home environments. The response has been an attempt to promote
healthy child development, particularly among disadvantaged children, with home visits by
nurses, parent training, preschool, and other programs.

It is unclear what will happen to these programs once the media spotlight moves on and budgets
tighten. Perhaps a public clamor over the next hot issue will draw funds away from early
childhood programs; perhaps it should. The current period of relative largesse provides the
‘opportunity not only to initiate programs but to undertake the kind of rational evaluation of those
programs that will help clarify the choices that must eventually be made. In our recent study,
Investing in Our Children, we assemble the evidence now available on early childhood
interventions to try to answer two questions that will be of interest to policymakers who must
allocate resources and to the public who provides those resources:



EARLY CHILDHOOD INTERVENTIONS: PUBLIC-
PRIVATE PARTNERSHIPS

HEARING

BEFORE THE

SUBCOMMITTEE ON HUMAN RESOURCES

OF THE

COMMITTEE ON GOVERNMENT
REFORM AND OVERSIGHT
HOUSE OF REPRESENTATIVES

ONE HUNDRED FIFTH CONGRESS
SECOND SESSION

JULY 16, 1998

Serial No. 105-170

Printed for the use of the Committee on Government Reform and Oversight

ae

U.S. GOVERNMENT PRINTING OFFICE
51-012 CC WASHINGTON : 1999

For sale by the U.S. Government Printing Office
‘Superintendent of Documents, Congressional Sales Office, Washington, DC 20402

ISBN 0-16-058022-6
a



108

efforts, and Tenabling grants” to communities to design a mix of services tailored
to community needs.

+ Ten states report explicit, deliberate efforts to link these types of comprehensive
programs with the implementation of welfare reform.

These states report three strategies: using TANF and/or state dollars to expand or
target services to families with young children receiving or at risk of receiving
welfare; explicitly encouraging parents to participate in parenting programs
either in lieu of, or in tandem with, work requirements, and giving priority for
enrollment in comprehensive programs to young children in families receiving or
at risk of receiving public assistance.

There is also recognition of the importance of looking beyond support for
individual "programs" to supporting the development of systems of early care and
education. Thus a growing number of states report efforts to engage community
stakeholders in planning processes to better meet the needs of the young children
and families in their communities. Most typically these efforts are linked to state-
level planning and broader systems reform efforts.

+ Just over half (27) of the states report community mobilization strategies linked
with state-level strategies to promote systemic change on behalf of children.
Fourteen of these have a clear focus on young children and families.

‘The process by which states are implementing these new planning and
systems varies, For example, Hawaii has developed Good Beginnings, a public-
private partnership focusing on children that works through a state-level council
with four counties to develop community-based partnerships as well. In Georgia,
much of the planning and community mobilization takes place through the
public/private state Family Policy Council, which works with community
partnerships to achieve five designated results for children, including for the
youngest, ensuring that they enter school ready to leam.

The extent and type of commitment to young children and families varies
considerably from state to state. Some states report only programs, others program
and community mobilization strategies. Only a handfal of states report sustained,
high-level comprehensive initiatives that encompass a variety of state-initiated
strategies.


182

Overview for COMPANY

DCC Single Source Model

DCC pioneered the single source, complete case management model which assesses and
handles each calling employee's specific needs and concerns in an individualized and
‘compassionate manner. The DCC single source approach—no subcontractors are used—
climinates the frustrations and inconsistencies of the calling employee having to rely on several
different counseling and referral groups to complete his or her case. DCC’s centralized model
delivers a more consistent, streamlined and reliable service in a faster turnaround time.

With DCC, calfing employees work with only one counselor throughout the entire case process,
including all case-specific research. A single toll-free call to DCC connects the COMPANY
employee to a counselor—trained and employed by DCC—who immediately conducts a
‘comprehensive needs assessment for the employee's specific case and offers the appropriate
‘counseling. As the case progresses, the employee works exchisively with his/her designated
counselor to ensure quality, consistency and familiarity,

DCCs single source approach provides the following advantages:

Complete case management

Continuity and consistency

Total quality assurance

Customized, comprehensive management reporting

Cost effectiveness and value

Innovative technology

DCC’s highly experienced, trained and compassionate staff

Counselor Qualifications:

AILDCC counselors have a minimum of a bachelor's degree with many having or pursuing
their master’s degrees. All DCC counselors have educational and professional expertise in the
areas they provide counseling. DCC counselors have backgrounds in:

eve ceee

‘© School-age programs © Nursing
© Special education © Rehabilitative therapy
© Higher education © Social work

‘© Early childhood education © Human services

© Elementary education © Counseling

© Child care © Adult care

‘© Adoption © Gerontology

DCC has an extensive and comprehensive training program for all new counselors. The
training program covers all aspects of the DCC program and lasts approximately six 10 ten
weeks. DCC also maintains a continuing education fund to expand and enhance our counselors’
educational and professional experience. In addition. all counselors and other personnel are
required to participate in ongoing in-service training and awareness programs.

DCG-=— ,


181

Human ecology theory emphasizes the importance of social contexts as influences on
human development.TM Parents’ care of their infants, from this perspective, is influenced by
characteristics of their families, social networks, neighborhoods, communities, and the
interrelations among these structures. This theory focuses the home visitors’ attention on the
systematic evaluation and enhancement of the material and social environment of the family.

While this theory provides an elaborated conception of the environment, the original
formulation of the theory tended to treat the immediate settings in which children and families
find themselves as shaped by cultural and structural characteristics of the society, with little
consideration given to the role that adults (in particular, parents) can play in selecting and
shaping the settings in which they find themselves." Consequently, self-efficacy and attachment
theories were integrated into the mode! to provide a broader conception of the parent-setting
relationship.

B, Self-Efficacy Theory

Self-efficacy theory provides a useful framework for understanding and promoting
‘women's health-related behavior during pregnancy, their care of their children, and their own
personal development. This theory distinguishes two cognitive influences on motivation:
efficacy expectations and outcome expectations. Outcome expectations are individuals’
‘estimates that a given behavior will lead to a given outcome. Efficacy expectations are
individuals’ beliefs that they can successfully carry out the behavior required to produce the
‘outcome. Individuals’ perceptions of self-efficacy can influence their choice of activities and
settings and can determine how much effort they put forth in the face of obstacles.

Self-efficacy theory influenced the design of the program by focusing the nurses’

attention on both the mothers’ beliefs about the consequences of their behavior and on building

10


159

8. Musick, J.S. (1993). Young, poor and pregnant. New Haven, CT: Yale University Press.

9. Olds, D.L., & Kitzman, H. (1993). Review of research on home visiting. The Future of
Children, 3, 51-92.

10, Olds, D.L., Henderson, C.R., Tatelbaum, R., & Chamberlin, R. (1986a). Improving the
delivery of prenatal care and outcomes of pregnancy: A randomized trial of nurse home
visitation. Pediatrics, 77, 16-28.

11, Olds, D.L., Henderson, C.R., Chamberlin, R., & Tatelbaum, R. (1986b). Preventing child
abuse and neglect: A randomized trial of nurse home visitation, Pediatrics, 78, 65-78.

12. Olds, D.L., Henderson, C.R., Tatelbaum, R., & Chamberlin, R. (1988). Improving the life-
course development of socially disadvantaged mothers: A randomized trial of nurse home
visitation. American Journal of Public Health, 78, 1436-1435.

13. Olds, D.L., Henderson, C., Phelps, C., Kitzman, H., & Hanks, C. (1993). Effects of prenatal
and infancy nurse home visitation on government spending. Medical Care, 3}, 155-174.

14, Olds, D.L., & Kitzman, H. (1990). Can home visitation improve the health of women and
children at environmental risk? Pediatrics, 86, 108-116.

15, Kellam, $.G., & Werthamer-Larsson, L. (1986). Developmental epidemiology: A basis for
prevention. In M. Kessler & S.E. Goldston (Eds.), A decade of progress in primary
prevention (pp. 154-180). Hanover, NH: University Press of New England

16. Olds, D.L., Henderson, C.R., & Tatelbaum, R. (1994a). Intellectual impairment in children
of women who smoke cigarettes during pregnancy. Pediatrics, 93, 221-227.

17. Olds, D.L., Henderson, C.R., & Tatelbaum, R. (1994b). Prevention of intellectual
impairment in children of women who smoke cigarettes during pregnancy. Pediatrics, 93,
228-233.




191

Overview for COMPANY

DCC’s ABC program seamlessly administers an employer's subsidy program and provides
Valuable education and counseling to employees. DCC’s ABC packet contains everything an
‘employee will need:

An introductory letter explaining the program
© Backup Care Registration Form

‘© Backup Care Reimbursement Form

© Information on how to contact a DCC counselor

© Emergency Contact Information—A worksheet for documenting critical information for
backup caregivers.

Medical Release Form—A form employees can use to give backup caregivers permission to
administer, arrange and/or call for emergency care in their absence

A LifeCare® Guide To Backup Child Care Options

A LifeCare* Guide To Child Care Options

A LifeCare* Guide To Visiting and Interviewing Potential Providers

A LifeCare® Digest On Helping Children Adjust To New Caregivers

A LifeCare* Digest On Backup Care Options For Adult Loved Ones

Using the ABC program is easy. Employees simply follow four easy steps:

1. Call a DCC counselor at 800-873-4636 to request an ABC kit and have a counselor assess
their situation and refer qualified backup care providers who meet their specific needs.
Complete the Backup Care Registration Form (found in theit ABC kit) and send it to DCC to
pre-qualify for the ABC subsidy from their employer

2. Evaluate potential providers by using their ABC kit as a guide, (The ABC Kit contains
valuable information on types of providers—as well as interviewing techniques to help them
properly evaluate candidates.)

3, Select providers and post their names and telephone numbers in a convenient location so
they can access them when the need for backup care arises.

4, When backup care is used, employees simply complete their Backup Reimbursement Form
including provider's signature) and return it to DCC for reimbursement according to the
specifics of their employer's program.

DCC account managers can help COMPANY customize the ABC program according to the
dollar amount, hours and/or days COMPANY subsidizes for backup care.

DCG==—= °


211

are we seeing children leaving Head Start so they can go into infor-
mal care as reported in newspaper articles in New York. I think
those are all issues. And we really need some support for local
tracking as well as the large-scale studies that particularly look at
the young children issue.

Mr. Towns. All right. Thank you very much.

You know, what we have heard this morning, over and over
again is the fact that we can save money if we really move forward.
And, at the same time some have pointed to the fade-out effects as
a reason not to fund preschool programs. The fade-out effects, can
it be attributed to poor schools and a lack of elementary school en-
richment activities and the transferring of teachers and all of that,
in terms of the area, especially where the poverty index is very

igh?

Mts. KNITZER. Yes. We talk about school readiness on the part of
the young children. I think the question is, also, are the schools
ready for the children? And we need to be focusing on that question
as well. There is no one quick fix at any age time, but I think it
is very clear that the interest and recognition of the importance of
the relationship building during the earliest years and sustaining
that with stimulating quality, early care and education experi-
ences, at least, if we do that, we will be in a position to see what
the results are.

Mr. Towns. You know, France has created zones, and I think
that—and what it really means is that in these areas where there
might be problems because of, you know, poverty or whatever, that
they will give additional resources in the course and special incen-
tives to keep teachers in these areas. Because what happens a lot
of times is that experienced teachers, you know, transfer out of the
areas, and you basically have a lot of inexperienced teachers com-
ing in, and T think, you know, that can be a problem as well.

What do you think about having zones? I am not just picking on
you, but anybody? Because recognizing that there is a problem and
something occurs after they go into the system, something happens.

Dr. OLDs. Congressman, would you repeat the first part of your
question for me? I’m sorry.

Mr. Towns. France has what we call, for lack of a better word,
educational zones, wherein that, as a result of the problems, they
give additional resources into these zones, like I guess it would be
zip codes, you know, sort of, in our case. And then if you have a
percentage of low-income families and at-risk children, what they
will do is they will give additional resources, they will give special
incentives to keep the qualified teachers in these areas, rather
than have them all transfer out, to have all new teachers coming
in and it creates all kinds of problems.

Dr. Oxps. I think that is very sensible, and what I particularly
like about it is it doesn’t single out particular families as being at
high risk but, rather, says there are whole communities where the
resources are deficient to support adequate development of children.
in the early stages of life. And that, in fact, is the very kind of
strategy that we are promoting as a way of identifying how the
particular program we have studied might be allocated around the
country. We think we need to identify communities where there are
high needs, and that these kinds of services ought to be allocated


109

+ In 1998, eight states, Colorado, Georgia, Minnesota, North Carolina, Ohio,
Oregon, Vermont, and West Virginia, met our criteria for comprehensive
initiatives — some combination of high-level leadership, integrated program and
community mobilization strategies, continued commitment to increased funding,
and a framework for state action. These were the same eight states identified in
the 1996 edition of Map and Track.

The Issues

The national picture that emerges then is mixed. The good news is that there is
widespread recognition of the importance of developing supportive early learning
experiences. More and more states appear to be recognizing that promoting the
well-being of young children and families is everybody's business: parents, business
leaders, community leaders, and services providers. There has been an increase in
the number of programs for infants and toddlers and their families, and an expansion
of support for preschoolers in most of the states that have already recognized the
importance of early learning experiences for children.

A trend is also visible toward providing enabling funds to communities (or
sometimes school districts) encouraging them to design services that are tailored to
the particular needs of a community. Further, although overall levels of state
investments in comprehensive programs for young children and families remain
relatively low, the number of programs with increases in funding over a two-year
period outweighs those with reduced funding.

At the same time, there are clear inequities across the states in access to
comprehensive programs, in funding levels, and in leadership. There are still no
statewide programs for infants and toddlers in 26 states, and none for preschoolers
in 16 states. Most troubling, only 20% of the states report deliberate efforts to
ensure a focus on young children in implementing welfare reform. Even fewer states
report any efforts to respond to issues of great concern to practitioners ~ the level of
stress in many families with young children, often related to domestic violence,
substance abuse, and mental illness, as well as challenging behaviors in young
children. A few states, such as Vermont, are partnering with mental health,
substance abuse, and early intervention agencies to invent a secondary support
system to help these most vulnerable families, but special national attention to this
issue is required.

With respect to the use of public-private partnerships focused on the well-
being of young children and families, states are taking a variety of approaches. In

5


30

So I went back to my doctor, and I told her to admit me. So they
put me on the OB floor so that they could get my body back to-
gether. Because I was so dehydrated, they couldn't even put the
IVs in me, so they had to put them in my neck, and that, of course,
didn’t work. At the same time, they were sending psychiatrists to
visit me, and I was just deteriorating more, still not eating and
drinking, and I just wanted the baby out of me. I wanted it to be
in someone else to grow in and not in me. It was a horrible feeling,
and no one ever prepares you for morning sickness.

They moved me to the psychiatric ward. And meeting with my
psych doctor, she had been talking to me about the Healthy Fami-
lies, that after leaving there that they wanted me to get in contact
with them, and I told her that I would. And once I got home and
got better—I was in the hospital for a month and a half—and after
I got better, I did call Healthy Families, and they sent over an as-
sessment worker to me, and she interviewed me, and then later I
received a call from Lynn Kosanovich, my support worker.

At first, I didn’t know if I really wanted the program because I
was feeling much better and I didn’t think I was as depressed. But
as time went on, there were times I was still getting sick, and I
still wasn’t having love for this baby that I was carrying, and I
didn’t know whether or not—if I could love him once he was born
and what I would do to him. Speaking with Lynn, I would tell her
that, if he cried, I would just Teave him there and do what I had
to do, or I would sit him in front of the window and let him watch
outside while I do what I had to do. And I thought it was cruel,
but that’s just how I was feeling and no one can understand that
unless you are in that position and knowing what it’s like.

But once Dominica was born, November 8rd, and he cried this
little innocent cry, and all I could do was just cry and just think
about how I called him the thing, and I saw how beautiful he was.
I fell in love with that baby the moment he came out of me, and
it was a beautiful moment.

After that, Lynn visited me once a week, and we just sat and
talked about things that I would experience now, the crying and
what I would do, and she would bring information for me to read.
And, actually, I felt as though I was a pro, pretty much. I was real-
ly surprised. My mom was there with me, and I really didn’t need
her. After 4 days, I really wanted her to go home because I knew
what to do with my baby and pretty much because, talking with
my support worker of Healthy Families, she prepared me for a lot
of this, but even then, I was like I don’t know, I don’t know if I
can do this. But then after he was born, you pretty much—things
fall into place.

And now doing all the things with Nico that they have prepared
me with, I see so much now. The product is all coming together.
Nico at 5 months started—yes, at 5 months, he started crawling,
and that’s pretty early, and now at 8 months, he can say hi and
he is clapping his hands.

Mr. SHays. You are a typical mother because you are boasting.

Ms. Pearson. I know, but I love him so much.

Anyway, moving on from my son. The program, I feel as
though—my favorite quote is, I feel very rich being involved in the
program with Healthy Families. I just do feel sorry for a lot of fam-


213

will be compromised. And the kind of results I have testified about
here today, we think are much, much less likely to be reproduced.

Mr. Suays. I need to interrupt you here because we are going to
have a series of votes so we are going to finish the panel.

I just want to state for the record, and I want you to correct me
if I am not hearing right, Dr. Karoly, the bottom line is you gave
a number of studies that would illustrate almost unbelievable suc-
cess in early intervention. But your testimony, it seems to me, is
we don’t have enough of these studies. Is that—and I need short
answers—is that accurate?

Ms. KaROLy. It’s both the number of studies and the number of
models that have been carefully evaluated and whether those stud-
ies have been implemented on a smaller or larger scale. So, for ex-
ample, consistent with what Dr. Olds is saying, we may know it
worked in this community with this population. Will it work in
other populations in other communities?

Mr. SHays. But what I am struck with is the studies you did de-
scribe were quite impressive in their outcome.

Ms. KaroLy. I think that’s right, and that’s the very good news.
There is proof of the principle that programs can work.

Mr. SHays. What I hear from you, Dr. Knitzer, you have given
us a pretty good description that some States are headed in the
right direction and some are not involved at all; and, in fact, most
are not involved at all. You described 10 States that seemed to
have some real activity, and by not involved at all—well, why don’t
you respond?

Ms. KNITZER. I think the 10 States were the ones that hinged
welfare reform with the comprehensive initiatives. I actually think
States are increasingly involved in program development for young
children and families, for infants and toddlers and preschoolers.
The point of connections with welfare reform is the issue about the
10 States.

Mr. Suays. I appreciate you making that point.

I would make this observation, that if welfare reform fails, and
it could, it will be the fault of Congress and the White House. Be-
cause we can make it work. That is my view. And, Mr. Burki and
Dr. Olds, you were citing three areas, three various programs
around the country.

Dr. OLps. Yes, three studies we have conducted so far, yes.

Mr. SHAys. But the bottom line on what I am hearing is this
process could take longer. What I am hearing—we have 5 minutes
until we have a vote, and that is why I am talking fast. What I
am taking from this, though, is that we need to measure outcomes
and we need to have science design the program, which is really
the way you started, Dr. Karoly, so we make sure we don’t just
have a day-care-plus kind of program, that we really make sure
that these programs—in other words, I am going to leave this hear-
ing with the strong feeling and conviction that early Head Start
intervention is going to be very helpful, but I am left with the fact
we need to make sure that science designs the program and that
we don’t just have a feel good program. But I want to just make
a comment to Mr. Burki.

Do you want to make a comment?


89

Written Testimony of Lynn A. Karoly 8

intervention programs. One of the big unknowns is why successful programs work—and others
don't. In particular, we do not know the following:

+ Whether there are optimal program designs. There have not been enough controlled
comparisons that can support choices between focusing on parents versus children (or
both), intervening in infancy versus the preschool years, integrating interventions versus
running them independently, or tailoring to individual needs versus treating children the
‘same but treating a greater number.

+ How early interventions can best be targeted to those who would benefit most. It is not yet
known which eligibility criteria would generate the most positive benefiticost ratios. In
addition, whatever criteria are used will have dramatic implications for program cost and
implementation.

‘There are other unknowns:

+ Whether the model programs evaluated to date will generate the same benefits and savings
when implemented on a large scale. The demonstrations have been undertaken in a more
resource-intensive, focused environment with more highly trained staff than is likely to be
achievable in full-scale programs.

+ What the full range of benefits is. Typically, evaluations have focused on those aspects of
development that the intervention was intended to influence. But we know from some
studies that programs can have a broad array of effects beyond their principal objectives.

+ What the implications of the changing social safety net are. Previous demonstrations were
carried out under the now-superseded welfare system. To some extent, those interventions
depended on that system for collateral support of families, and the savings generated were
partly in terms of welfare costs that the government may not now be paying out anyway.

These unknowns will have to be resolved if wise decisions are to be made among early
intervention alternatives and if the programs chosen are to be designed to fully realize their
potential for promoting child development—and saving money. In particular, research is needed
into why programs work. Otherwise, inferences cannot be drawn about new program designs,
and every such design would be unproven until tested and evaluated.

The scope of further research should depend on the specific information sought or the scale of
the program. New demonstrations are needed to answer questions that require variations in
program design or that reflect the evolving society and economy, and broader testing of previous
designs is required to answer questions of scale-up. However, on questions of targeting, benefits
beyond objectives, and other issues, much could also be gained—and less expensively—by
making the most of evaluations already under way—e.g., by further follow-ups and expansion of
the set of benefits measured. Finally, where governments see fit to initiate large-scale public

on the basis of current knowledge, careful evaluation should be a component. Then,
when budgets tighten again and choices need to be made, the worth (or lack of worth) of these
programs will be more firmly established,


199

Overview for COMPANY

DCC links its quality assurance guarantee directly co the results of clients’ rerured
‘questionnaires. now averaging a 25 percent return rate. DCC has a quality assurance team
dedicated to maximizing return rates by following up with clients who have not responded to the
initial questionnaire mailing

LifeCare® Net

LifeCare® Net is the powerful online version of DCC’s LifeCare services. LifeCare Net uses
Internet technology to deliver services to employees struggling to balance their work and
personal lives. As with our traditional counselor services, LifeCare Net is designed to educate

employees and their families on a multitude of dependent care and work/life issues, and to
locate the resources and providers to meet their specific needs.

Used as a stand-alone or in conjunction with DCC’s comprehensive counseling. education and
referral services, LifeCare Net offers the most innovative work/life benefits package available
today.

With LifeCare Net, COMPANY can:
© Provide an affordable work/life benefit to all employees

‘Add value to its work/tife initiatives

Eliminate productivity barriers

Increase utilization of all COMPANY benefits with total benefits integration online

Enjoy access to DCC’s LifeCare services and work/life information 24 hours a day, seven
days a week—all from the convenience of home or office.

Implementing and Accessing LiteCare Net

DCC’s team of LifeCare Net consultants work closely with COMPANY human resources and
information systems staff to smoothly implement and customize LifeCare Net to COMPANY
specifications and goals. DCC handles all administrative and technical maters surrounding
implementation. and provides the necessary promotional materials to herald LifeCare Net's
Jaunch within the company. COMPANY human resources staff will be able to easily customize
the “Forums” and “My Benefits” areas of LifeCare Net: the latter may be changed at any time
as benefits are added. removed or changed

COMPANY employees will have seamless access to LifeCare Net via their World Wide Web
browsers. from either their home or office Accessing LifeCare Net outside the office is easy
with a DCC-assigned username and password, LifeCare Net's URL is hup://www.life-care.net

Welcome Page

Each time a user logs on to LifeCare Net. a Welcome Page appears with the user's name. the
date, and targeted information and links. COMPANY can aiso deliver its own work/life news
and updates 10 its employees via LifeCare Net. From the Welcome Page. users can access all of
LifeCare Net's features: select a community. locate resources. use the search feature. or
provide feedback regarding LifeCare Net to DCC

DCG error ”


‘Written Testimony of Lynn A. Karoly 3

‘matched controls. In most of the programs, controls were selected by random assignment at
rogram outset. We also sought programs with participant and control groups large enough at
program implementation and follow-up to ensure unbiased results, although resource limitations
‘on these programs did not always permit that.

Figure 1 schematically summarizes the results of our review of the effects of these programs on
participating children.' The filled squares show which of a number of developmental,
educational, economic, and health indicators were measured for each program reviewed. Dark
sray indicates a favorable (and statistically significant) result, and black indicates no statistically
significant result; light gray denotes mixed findings.’ As the figure shows, each program
favorably affected at least one indicator, and most of them affected several (that is, participants
had better outcomes on these indicators than did children in the control group).’ Although many
studies did not find favorable outcomes across the full range of effects they examined (especially
in the long run), favorable effects dominate. A companion analysis of program effects on
‘mothers also showed that measured results tended to be favorable, although the ratio of favorable
to null results across all programs was not as high.

‘The programs thus led variously to the following advantages for program participants relative to
those in the control group:

+ Gains in emotional or cognitive development for the child, typically in the short run, or
improved parent-child relationships.

+ Improvements in educational process and outcomes for the child.

+ Increased economic self-sufficiency, initially for the parent and later for the child, through
‘greater labor force participation, higher income, and lower welfare usage.

+ Reduced levels of criminal activity.

‘+ Improvements in health-related indicators, such as child abuse, maternal reproductive
health, and maternal substance abuse.

While many significant differences between participants and controls were found, a statistically
significant difference is not necessarily an important one. The size of the difference also needs
to be taken into account—and the size of many of the differences could be fairly characterized as
substantial. For example, the Early Training Project, Perry Preschool, and the Infant Health and

{ite pin roams a the Ely Tring Poe, Pay Prac, Chicago Chik-Paent Ce (CP), Houton Pace
(id Development Centr (ACDC), Syrcise Faily Development Research Propam (FDRP), Carina Abcearin,

i Education)
Tnfany Piet (PEIP). We also review Prec Head Sar but ens ema summurand in Figure Bosaies
there are multiple evaluations that cannot be readily summarized.

2 A favorable result may be either an increase or decrease in an indicator among program participants relative to controls—
‘depending on the indicator. For example, while a favorable result for 1Q means that the 1Q was higher for treatment children
‘compared with controls «favorable result for criminal behavior occurs when the incidence is lower fr the treatment group.

> In addition, in most cases even when results were not statistically significant black in the figure), the difference between
‘weatmeat and control groups was in the expected direction for the program to produce beneficial results


12

Now we at I Am Your Child have been reaching out to the State
and local governments, to the business community, to the founda-
tion world and, also, to the Federal Government to all come to-
gether and play a part to providing a support system to give our
children the best start in life.

Again, I want to thank you, again, for allowing me to be part of
what I hope will lead to a significant investment in our Nation’s
most precious resource, as the Congressman pointed out, our chil-
dren. Thank you very much.

Mr. SHays. Thank you very much.

[The prepared statement of Mr. Reiner follows:]


205

Overview for COMPANY

Work/Life Coordination

Prior to COMPANY’ implementation date of the LifeCare services. DCC requests information
regarding COMPANY benefits programs. This measure enables DCC to become familiar with
all of COMPANY’s work and family benefits. Counselors will then be able to immediately
assist COMPANY employees and refer them to the appropriate contacts, phone numbers and
information they may need outside of the DCC service. DCC’s database can provide key
information on the following benefits programs that COMPANY may offer to its employees:

'* Employee assistance program © Company discount with
franchise/provider
© Sick/emergency care program

© Tuition Assistance/Reimbursement or
© Prenatal program Scholarship

© Adoption benefits ‘© Student loan program

© Adult care benefits ‘© Long-term elder care insurance plan

Dependent care reimbursement account Family leave

‘© Dependent care financial subsidy Onsite day care cemer
program

Management Reporting

Within forty-five days after the close of each quarter. DCC sends COMPANY comprehensive
utilization reports which track the program usage for the reporting period and provide
cumulative totals to date, These reports inciude both a tabulation of all quality assurance
questionnaires returned to DCC by COMPANY employees during the respective reporting
period and copies of the actual questionnaires coded to ensure confidentiality An annual report
is provided at the end of the year. Given DCC’s sophisticated technology and key company
information. DCC can customize the nature and frequency of reports to COMPANY
specifications. DCC’s client utilization reports are broken down by the following components:

1. Return On Investment Results

As part of management reporting, DCC sends all clients their return on investment (ROD)
results from the DCC service. ROI calculations are based on the number of employees covered.
capitated rate per employee. employee salary. ubiization and the average time we save an
employee. This time saved is based on the feedback we receive directly from clients when they
send us their quality assurance questionnaires. DCC clients have the opportunity to conduct
their own ROL analyses on our web site (hup.//www dcclifecare comvroi html) by completing
our interactive. ontine ROI worksheet. DCC clients can immediately calculate and obtain the
cost-savings results that our services are providing their company

DCG Coe Conrecrone %


[Chidreneneer schoo!
ready to tearn,
Children experience
succes in sehook
‘Children graduate
prepared to ead
productive tres

54

School-Linked Services
in Rhode Island:

Child Opportunity Zone
Family Centers

Child Opportunity Zone Family
Centers are che first statewide effort ro
link schools with comprehensive support
services for childten and families. The
national movemenc toward school-linked
services provides evidence that schoo!-
linked services can be an effective strategy
«co improve the quality of family and
communigy lif. involve parents in their
childrens education, nd improve
outcomes for children. The concept of
“Child Opportunity Zones” was firs.
introduced in Rhode Island in 1992 a5,
part of che Report ofthe 21" Century
Commision. Legislation was passed in
1993 calling for the Rhode Island
Department of Education and the Rhode
Island Children’s Cabinet to develop
‘Child Opportunity Zone Family Cencers
{in communities across the sate.

‘A public-private partnership was
cstablished to oversee the development of
the Family Centers and to provide a poo!
oF fang for aloson ol hoo

and theie community partners.
fos ling partners of the COZ Family
‘Center Initiative included the Rhode
Island Department of Education, the
Rhode Island Department of Substance
‘Abuse (now part of the Rhode Island
Deparment of Health). and the United
Way of Southeastern New England. The
COZ Family Center Initiative is currently
managed by a statewide management team
‘comprised ofthe Rhode island
Department of Education, the Rhode
Island Departmene of Health, the United
‘Way of Southeastern New England, and
local COZ Family Center coordinarors.

Child Opporcunity Zone Family
Centers ae designed to address the

growing health, social and emotional
‘nceds of children in order to reduce
barriers to learning, The goal iso
‘promote school success among children
currently in the education system and
promote readiness for school among,
young children. A comprehensive response
to the health, social and economic needs
of children and families extends beyond
the taditional mission of the school and
requires the investment of social service
agencies and community members. While
the school distrits are aetvely involved in
forging partnerships with community
agencies and families, schools are meant 10
bbea partner among equals.

Guiding Principles

Based on research from school-linked
services nationwide, the COZ Family
Center initiative developed guiding
principles fo use by local sites in program
design and implementation. Schools,
families, and communities are expected to
work as equal partners in planning,
developing, and implementing Family
Center activities and to share resources
and responsibilities. There should be a
focus on the priorities and needs ofthe
whole family, rather than individual
‘members. Families should be assisted in
identifying their capacities in order to
build supports and access resources
Family Cencers are to be located at, or
close to, schools and serve asa hub of
activities forall families. A Center
bbecomes a place that facilitates the
development of neighborhood necworks
and offers families leadership roles in
decisions and governance. Family Centers
area source of information and support to

sand services are flexible,
accessible, nd promote developmental
prevention approaches. *

Tamilies. Activ



W771

&

3

Length of Stay withinfurtes/Ingeetions
§ & § &

§ &

Figure 7. Estimated aurse-comparison differences in number of days children were
hospitalized with injuries/ingestions as 2 function of maternal psychological resources -
Memphis.


Lynn A. Karoly Page 6

RECENT PRESENTATIONS
Testimony and Policy Forums

May 1997, Sacramento, California, “The Costs and Benefits of Early Childhood
Interventions,” presentation for California state legislative and exective branch staff.

July 1997, Las Vegas, NV, “The Costs and Benefits of Early Childhood Interventions,”
‘National Governor's Association Annual Meeting.

July 1997, Washington, DC, “Retiree Health Benefits and Retirement Decisions,”
RAND/Department of Labor Conference on Health Benefits and the Workforce.

May 1997, Sacramento, CA, “Growing Economic Disparities in the U.S.:_ Assessing the
Problem and Policy Options,” testimony before the California Assembly Select
‘Committee on the California Middle Class.

April 1997, Washington, DC, “Growing Economic Inequality in the U.S.:_ Assessing the
Problem and Policy Options,” Conference on the Growth of Income Disparity,
National Policy Association (formerly National Planning Association).

‘October 1996, New York, NY. “Economic Inequality in the U.
Policy Forum.

." RAND New York

October 1996, Short Hills, NJ. “Economic Inequality: Trends, Causes, and Policy
Options,” Committee on New American Realities, National Planning Association.

September 1996, Santa Monica, CA. “Economic Inequality in the U.S.,” RAND Santa
Monica Policy Forum.

December 1995, Washington, DC. “Income and Wealth Disparities in the U.S.: Is There
a Problem?,” Roundtable Discussion, sponsored by Congressman Charles E, Schumer
(D-NY).

October 1995, Los Angeles, CA. “Working for What? Working Families Confront the
End of Affluence,” Roundtable Discussion, California State Assembly Labor and
Employment Committee.

October 1995, Boston, MA. “Income Inequality: Policy Options,” Committee on New
American Realities, National Planning Association.

October 1993, Washington, DC. “The Widening Income and Wage Gap.” testimony
before the Subcommittee on Human Resources, Committee on Ways and Means,
U.S. House of Representatives.


185

Overview for COMPANY

UfeCare Services

DCC's comprehensive and extensive LifeCare services are designed to educate employees and
theie families on any number of dependent care and work/life issues. as well as locate the
tesources and providers to meet their specific needs. DCC strives to create an interactive
relationship with employee clients when they access our LifeCare services throughout

lives.

DCC's LifeCare services include:

© Prenatal © Grandparents As Parents

© Adoption © Adult Care

© Child Care © Disaster Relief

© Parenting © Financial Services

© “Summer Care © Legal Services

© ShareCareTM © Health and Wellness

© Special Needs Personal Services

© AtRisk/High-Risk Adolescents —Balancing Work/Life

© Academic Services —Pet Care
—Convenience Services

‘© Emergency/Temporary Care
Each of these services are described in derail on the following pages

Prenatal

To help expectant mothers receive the proper care and nutrition for themselves and their
unborn child. DCC counselors can provide information and referrals on:

© Birthing method alternatives © Child care options
© Parent education classes - © Support groups

© Nutrition, exercise and diet © Child care pre-planning
Prenatal Kit

A recipient of Human Resource Execurive magazine's 1995 Product of the Year award. DCC’s
‘unique, enhanced prenatal program educates expectant parents on proper prenatal and child care
DCC’s combined educational information and products are designed to help reduce the number of
premanure births and other complications during pregnancy. motivate expectant parents to
proactively and responsibly manage prenatal and postnatal care and minimize employers” health
‘care costs.

DCG--—=



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Web Ste: werw rlodicountorg

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36

Well, it just makes good business sense. You know, the country
is like a big corporation, and there is no CEO in this country that
would eliminate their R&D. That’s the way you grow your com-
pany. I have run companies. I have built companies. You have to
invest in R&D in order to grow your company.

Well, this is investing in R&D. This is our precious resource, our
children. We make that investment, and we will grow our tax base,
reduce our crime, teen pregnancy, drug abuse, child abuse, and so
on. And it is not arguable, I don’t think.

Mr. Towns. I agree with you.

Governor ALMOND. May I also add, in addition to saving on the
issues of drug abuse, crime, special education, et cetera, look what
it would do for the economy. You know, I am from the Northeast
and the chairman is from Connecticut, and we had a tough time
coming out of a recession, but, thankfully, right now we are at full
employment.

There are individuals out there who are on the margin whether
they can have two parents working or one, and we have people at
home taking care of children. There is nothing wrong today to have
both parents working, as long as they have good, affordable child
care that is going to take care of their child’s development. And we
have a lot of individuals who would enter the work force if they
had access to quality, whether they pay it all or not, but it has to
be good child care, and you can build a good child care system if
you do it for all segments of society.

You know, when I go to child care centers in Rhode Island, 40
to 50 percent of the children in those programs are subsidized.
They are altogether. That’s great. That is good for society. It will
help the economy.

Mr. Towns. Let me say, Governor, we really appreciate your
leadership and the kind of things you are doing in Rhode Island.
We just wish more States would follow.

Ms. Pearson, first of all, how old is your child?

Ms. PEARSON. He is 8 months.

Mr. Towns. All right. And, you know, when you leave your child,
I think you are concerned about health and safety and all of that.
You know, do you feel comfortable, in terms of safety and all the
kind of things that a mother is generally concerned with? Do you
feel that?

Ms. PEARSON. I love my caregiver, yes, but you always have that
saying in the back saying, in the back of your mind, no one can
ever take care of your child like you could. I feel like he is safe,
but sometimes there are so many kids there. When does she have
time or can she make time to sit down with all the children and
read to them and sing to them and do the things that you would
do? I mean, her views may be different from mine, and maybe I
may not like it. I mean, I would love it if I could be home with my
son for the first year or so, and then, maybe, once you imbed the
things into them—because, you know, you are teaching them one
thing and she is teaching them something, and I see that there
might be some confusion if you don’t communicate with each other,
and I do try to tell her things I am doing, but is she doing it once
the door is shut?

Mr. REINER. How many children does she take care of?


181

Overview for COMPANY

Introduction and Industry Experience

Founded in 1984, DCC/The Dependent Care Connection Inc.. has over thirteen years of
experience in providing work/life services to employees nationwide and around the world.

DCC offers counseling, education and ceferrat services that can accommodate the diverse needs
of any employee population. DCC not only serves employees with dependent care needs, but
can also provide assistance to employees without any caregiving responsibilities who may need
help locating a support group or balancing their work and personal lives.

DCC has created an organization of exceptional quality and strength. offering its clients
innovation. expertise. personalization, choice and value. Historically. DCC has been a leader
in proactively responding to emerging work/life issues. Proof of this lies in our:

+ Unique team of experienced and caring professionals. available to clients 24 hours a day,
365 days per year

Pioneering of online, real-time work/life solutions with LifeCare Net 3.0

Nationat dependent care database of over 2.5 million providers—America’s largest
Development of a “single-source” case management approach

Exceptional capital allocation for research, development and technology

DCCs LifeCare services benefit both employers and employees by:
Reducing stress

Decreasing work absenteeism and interruptions

Minimizing employee turnover

Creating a more efficient and effective workforce

Boosting employee morale

Cultivating recruitment

Increasing productivity

‘The major components of the DCC LifeCare counseling and referral service are
Child care counseling. education and referral services

Adult care counseling, education and referral services

Specialty counseling. education and referral services

Customized management reporting and ROI analyses

Quality assurance—guaranteed customer service and satisfaction
Promotional and account management services

EAP and work/life benefits integration

LifeCare® Net 2.0 was launched in fall 1997—the industry's first online. real-time work/life
tool. connecting us users with providers and services in any community. both nationally and
internationally. LifeCare Net offers virtually the same overall benefits to employees and
employers as our traditional telephone service

DCC has never lost a corporate client to a competing dependent care counseling and referral
service due to poor performance. We back our ability to deliver the highest quality service by
offering an unprecedented quality assurance guarantee. DCC currently provides LifeCare
services to over 300 employers in both the public and private sectors. covering more than (wo
million lives.

DC GE eon ;


Northenet and Islands

Regional Educstional Leboratory
[AP Tha Eaten Arc Drown Ura

in partnership with
Rhode Island KIDS COUNT

fo ©  School-Linked Services:
Child Opportunity Zone Family Centers

by Catherine B.Walsh

Supporting Early School


ug

Testimony to the House Committee on Government Reform and Oversight,
Subcommittee on Human Resources

Hearing on
“Early Childhood Interventions: Public-Private Partnerships”

Prevention of Child Abuse, Use of Welfare, and Crime with Preventive
Interventions
Early in the Life Cycle

July 16, 198
David Olds, Ph.D.

Professor of Pediatrics. Psychiatry, and Preventive Medicine
University of Colorado Health Sciences Center

Mr. Chairman, members of the Committee, thank you for the opportunity to testify on
this important topic.

For over 20 years, my colleagues and I have been developing and studying a program of
prenatal and early childhood home visitation by nurses that reduces child abuse and
neglect, use of welfare, and crime in low-income families. The program serves low-
income mothers who have had no previous live births, many of whom are unmarried
adolescents.

‘The nurses visit pregnant women in their homes during pregnancy and the first two years
of children’s lives. In those visits:

© they help women reduce prenatal cigarette smoking, and use of alcohol and drugs;

© they help women improve their diets, and identify emerging complications of
pregnancy that can be treated before they compromise the health of the mother and
fetus;

they help parents provide more responsible care for their children; and

‘* they help parents develop a vision for their future and plan subsequent pregnancies,
complete their educations, and eventually find work.

The program has been developed, refined, and tested over a 20-year period so that today
the nurses have structured written protocols and intensive training to guide them in
working with families who live in highly challenging and often dangerous situations.


The Effectiveness of
School-Linked Services

School-linked services ean improve child
and family well-being, Some examples of
indicators thar have been positively

impacted by school-linked family center

Initiatives in other sraes include:

Improvements in
Scudent achievement

Parent participation in che schools
Improved classroom behavior

Enrollment in Medicaid and other benefic
programs.

‘Access to health and dental care

‘Access to child care and transportation,
Parenting skills and family functioning
Reductions in:

Student mobilicy.

School violence.

Suspension rates and unexcused absences.
Grade reention

Unmet needs for food and clothing.

School-linked family centers are most
effective when the following elements are
supported by resource allocation and
program design:

Program Development:

‘There are active and equal parenctships
among schools, families, and community
agencies

Efforts are well-inteprated into the life of
the school.

Parents are mote involved with site

Program Implementation:
Services are wo-generational - focusing on
the child and family.

Services are culturally competent.

‘A mix of both prevention and
intervention programs ae available.
Programs are flexible in responding 10
family needs and work with families over

53

State School-Linked
Service Programs

Efforts are underway in states across the
country to build neeworks of school-
linked family cencers and to foster
‘community partnerships chat make health
and human services more accessible to
Families and scudents, Two examples of
school-linked service efforts chat are
showing promise include:

Kentucky Family Resource and
‘Youth Services Centers

Kencucky’s Education Reform Act of
1990 authorized support for Family
Resource and Youth Service Center in all
elementary and high schools in which

20 percent or mare ofthe students are
ligible for fiee or reduced-price lunches.
The Centers are designed to coordinate a
‘community’ socal and health services for
students and their families. Although the
centers provide some services directly, the
majority of efforts focus on accessing
existing community services For Families
Typical program components include
preschool and after-ichool child care,
information and referral, and family
support services

The School of the 21* Century

‘The School of the 21st Ceneury was
initiated in 1987 by the Bush Cearer on
Child Development and Social Policy at
Yale University. Communities across the
countty follow guiding principles set by
the Yale Bush Center and receive training
and technical assistance through 2n anual
Institue, The basic components ofthe
program - child care, information and
teferal. home Visits to new and expectant
parents, and a neework of family child care
providers - are designed in accordance
with commonity resources and needs.

All over the country,
school and cornmunity
‘people are putting
opether the places to
help schools meet the
vated weds of today’s
sedenes and their
parents cll he product
ot thee collaborative
‘flores hlrservice choot
‘The itaervce school
homegrown produc chat
‘an ake many shapes:
community school,
lighted school houses
Called Beacons, chook
bated cline, fariy
resource centers” oy
Dryfoos, "Full-Service
School", Edvceonat
Leader, 1996



‘Overview for COMPANY

‘The monthly promotions include the following, but can be customized to meet the specific
creative and program needs and timetable of COMPANY.

‘© GAN) Prenatal Services © (AUG) Adult Care Services
© (FEB) Tutoring Services © (SEP) Emergency Child Care Services
© (MAR) Summer Camp Services © (SEP) Colleges and Universities

© (APR) Child Care Services © (OCT) Preparing for Furure/Adult Care
© (MAY) School Services © (NOV) Adoption Services

© GUN) Special Needs Services © (DEC) In-Home Adult Care Services

‘© GUL) Back to School Services

Internet Initiatives

For added ease and convenience. DCC promotes and offers its services online via our public
Internet address at hutp.//www.declifecare.com. Chents may request a call from a DCC
counselor and order a variety of educational materials from the public site.

DC's online forums house counselors’ monthly tips on all of our LifeCare services. Obtain
valuable information, hints and help on many dependent care and workilife topics. Our forums
also allow clients and users (0 network with one another (o share caregiving experiences and
advice. Clients and users can post messages (0 groups at-large of individuals to resolve their
LifeCare issues and concerns.

Clients may also check out DCC’s library which contains position papers. press releases and
research studies on work/life issues and trends. Other library contents include a consultants”
directory and a return-on-investment calculator. enabling users to see first-hand the cost savings
that the DCC service can bring to their organizations

EAP and Work/Life Benefits Integration

EAP Coordination

DCC has extensive experience in working with client EAPs. Prior co implementation. DCC
will meet/discuss with COMPANY management and/or EAP administrators to integrate and

coordinate the services provided by both DCC and the EAP. These discussions outhne the
clearly-defined roles of DCC and the EAP. as well as the protocols to be followed.

DCC develops and maintains a customized data file of all pertinent information about each
client’s EAP. It includes the toll-free number. the name of the EAP account representative(s)
and a description of services. With this online information, all DCC counselors can
immediately refer COMPANY employees to their EAP under the appropriate circumstances

DCF rr


138

visited at-risk women and their children, on the other hand, consistently exhibited lower rates of
adverse outcomes indicative of grossly deficient care of the child.

{As noted in our earlier reports, nurse-visited children born to low-income, unmarried
teens had 80% fewer verified cases of child abuse and neglect during the first two years of the
child’s life. Moreover nurse-visited children, irrespective of risk, were seen in the emergency
department 56% fewer times for injuries during the second year of the child’ life. As indicated
in Figures 2 and 3, the effect of the program on child abuse and neglect and emergency-
department encounters was greater among children whose mothers had little sense of control
over their lives (measured at registration during pregnancy).

‘The impact of the program on health-care encounters for injuries endured during the two-

‘year period after the end of the program: irrespective of risk, children of nurse-visited women
were less likely to receive emergency room treatment (1.00 vs 1.53 visits, p<.001) and to visit a
physician (0.34 vs 0.57, p=.03) for injuries and ingestions than were their comparison-group
counterparts." The impact of the program on state-verified cases of child abuse and neglect, on
the other hand, was attenuated during the 2-year period following the end of the program.*

We hypothesized that this pattem of results was probably duc to increased surveillance
for child abuse and neglect in the nurse-visited group, given that nurses were mandated to report

suspected maltreatment and that they linked fami

with needed community services -- where
their parenting needs were likely to be more completely assessed by other service providers.”
‘An examination of the living conditions and emergency-<department encounters for the
“maltreated” children showed that nurse-visited “maltreated” children lived in homes that were
more conducive to children’s development, as indicated by higher HOME scores; their homes

were substantially safer; and the children themselves had far fewer emergency-room encounters

”


School-Linked src
Child Opporunity Zone Fanily Cncersis
the First in a series of reports focused on
school-linked services, family support
programs, and schoo famly-omimusiny
parteships in Rhode Island. School
feadines hea child development, nd
school success are goals that can best be
achieved by working across sectors.
Improving outcomes fr chien demands
that schools, families, service providers,
and commoniy leaders work ogther 0
‘craft comprehensive solutions to complex.
problems.

‘There is increasing pressure on che
public education system to monitor
tutcomes for children at school entry. in
the fourth grade, and beyond, A school
‘ysem siving for excellence more
likely tobe successful when academic
strategies are complemented by efforts 10.
improve the quality of family and
Community if. Many cdr and
families have complex needs that cannot
‘be met by the education system alone.
School-tinked service initiatives across the
counery ate proving tobe vable and
encouraging vehicles co improve school
success through active paenerships among
schools. families, health and human
service agencies, and uber community

This seties of reports will highlight
promising effors in Rhode land that go
Beyond insiaional boundaries inorder
to improve the health, safery, education,
and economic well-being of families. The
programs highlighted by che series have

49

taken on the challenge of working across
the health, education, and social service
systems. It is hoped tha the lessons
learned fom these innovative efforts will
stimulate dialogue on how to best develop.
support. and sustain progrants and
Jnsitutions that will enprove outcomes
for children and fails,

“School-Linked Services”
A seategy 0 improve educational, mental
Iheath, health, and social outcomes for
childeea and families. Schoo!-linked
services connec families with a wide range
of informal supports. community
activities, health care and socal services

“Family Center”

A friendly, welcoming place n oF neat
school where parents and orherfarily
members can go 10 receive information.
suppor, services or teferrals. The program
design for school-linked services often
includes a Family cence.

“Family Support”
Away of working with families thac builds
‘on chee strengths and interests, focuses on
the healthy development ofthe parent 28
well asthe child, connects families with 3
wide-range of informal supports and
‘opportunities in the community and
helps families access services as needed.

A strategy used to improve the educational
achievernen¢ of children. Schools, families,
and community agencies work cogether 10
address the educacional. health, socal. and
economic well-being of children and
families The most effective partnerships
focus on esults, make a commitenent fo
shaced decision-making, and allocate
resources for activities that meet mutually
identified needs.

Deverbes Rhode sand’
Child Opportunity Zone
(COZ) Farty Center
Fran.

High the current
status of the initiative
bsed onsite vse and
Ircerviews inthe 13
Rhode Mand
communities with COZ
Family Concer.

Suggest program and
poy implications,


Overview for COMPANY

A Final Note

Neither DCC counselor assistance nor LifeCare Net are intended to provide any user. with
specific authority, advice or recommendations. The information obtained through counselor
assistance or LifeCare Net is for informational purposes only. While DCC makes every effort
to ensure the accuracy of the information provided, accuracy and appropriateness of
information cannot be guaranteed. Likewise, DCC does not endorse. sponsor or guarantee any
service or product mentioned on LifeCare Net or through counselor assistance. In all instances,
users should verify all information received. All final decisions on the appropriateness of
information, the quality of a product, or the qualifications of a service provider must be made
by the user.

30

Deo


78

this morning to speak to you today about early childhood interven-
tions.

Just for the record, I’m a senior economist and director of the
labor and population program at RAND, a private nonprofit re-
search organization based in Santa Monica, CA. The testimony I
am presenting today draws on my own research experience and
does not necessarily represent the position of RAND or RAND's
sponsors.

I want to focus my remarks this morning, in an abbreviated for-
mat from my written testimony, on a study on the costs and bene-
fits of early childhood intervention that I just completed with a

roup of colleagues at RAND. Our study is titled Investing In Our

hildren and was motivated by the body of evidence that you have
heard referred to already today, focusing on the importance of the
early years of childhood, not only from birth to age 3, but in the
early years before school entry. We know that the research increas-
ingly has identified the important factors that determine whether
those early years are productive years that lead to individuals who
are successful in school and later in life.

With funding from the California Wellness Foundation, RAND
constructed an interdisciplinary team of researchers that examined
the evidence regarding the benefits and costs of targeted earl;
intervention programs, those programs that were designed to ad.
dress stressers in early childhood such as impaired emotional rela-
tionships or reduced levels of cognitive stimulation or inadequate
resources to meet basic needs. Our aim was to provide an objective
assessment of what the research to date can tell us both about the
benefits of early childhood intervention programs, their costs, and
the perspective that one might care about as policymakers in terms
of the returns for investing in those programs.

A book reporting on our findings, which I am going to summarize
this morning is available from RAND both in hard copy and in
electronic form. Let me just give you a brief overview of our find-
ings.

Our study set out to address two questions that we thought were
particularly important for policy. The first question is, can early
intervention programs targeted at disadvantaged children benefit
those children and their families? After carefully reviewing the lit-
erature on well-designed and evaluated early intervention pro-
grams, we find consistent evidence that early intervention pro-
grams can yield significant benefits both to participating children
and to their families. These benefits accrue in several key domains,
including the emotional and cognitive development of the children,
the emotional and cognitive support of parents, educational
achievement for both children and parents, economic outcomes for
children and their families, and the health status of family mem-
bers. While some improvements are shorter lived, many of these
gains do persist well into later years of childhood and even into
early adulthood.

Now, for some, these benefits, which I will say a little bit more
about in a minute, would be enough to justify spending money on
early childhood and, particularly, well-designed programs. For oth-
ers, it is important to compare the costs of these programs with the
benefits that they generate, particularly the savings to government.


‘Writen Testimony of Lynn A. Karoly 7

The government savings, while positive, are not enough to offset program costs. This result
illustrates the importance of targeting programs to those who will benefit most if the hope is to
realize government savings that exceed costs.

‘We emphasize, however, that while we included the full costs of the programs, we could not
account for all benefits. The Elmira PEIP, which has followed participating children only to age
15 so fat, provides no basis for calculating the amount these children may save the government
in welfare costs, or the extra taxes they may pay as adults. We might expect such savings even
for the lower-risk participants, although the Jonger-run savings may be less than those generated
by children in the higher-risk families. The Perry savings may also be underestimated because
benefits to mothers were not measured.

Furthermore, the programs generate additional benefits to society beyond the government. These
include the tangible costs of the crimes that would eventually have been committed by
participating children, had they not participated in the program. The benefits also include the
‘extra income generated by participating families (not just the taxes on that income), which can be
reckoned as a benefit to the overall economy. We estimated these two benefit sources combined
as roughly $3,000 per family in the case of the lower-risk Elmira participants, about $6,000 per
family for the higher-risk Elmira participants, and over $24,000 per family in the Perry case.

While the net savings and other benefits from these programs appear promising, caution must be
‘exercised for various reasons in drawing generalizations for public policy. We explain most of
these reasons below, but two relate specifically to the cost-savings approach. First, because
these are the only two programs whose evaluation characteristics permit estimates of long-term
savings with any accuracy, we cannot say that different programs would also generate such
savings (by the same token, we cannot say that they wouldn't). Second, because there was some
variation between the two programs in the indicators of success measured, we cannot conclude
from the different net savings numbers that one program is better than the other.

One final caveat: Cost-savings analysis is a useful tool because, when the results are positive, it
Provides strong support for program worth. That i, it shows that only a portion of the benefits—
those easily monetizable—outweigh the program's entire cost.’ However, because only some of
the benefits are taken into account, a negative result does not indicate that a program shouldn't
bbe funded. Policymakers must then decide whether the nonmonetizable benefits—e.g., gains in
1Q, in parent-child relations, in high-school diplomas—are worth the net monetary cost to the
government.

‘What Remains Unknown and What Does It Mean for Policy?

On the basis of research conducted to date, we know that some targeted early intervention
programs have substantial favorable effects on child health and development, educational
achievement, and economic well-being. We also know that some of these programs, if targeted
to families who will benefit most, have generated savings to the government that exceed the
costs of the programs. There is still much that we do not know about these programs, however,
and this limits the degree to which these conclusions can be generalized to other early

“A decision as to whether to fund a program must, of course, also tke into account budgetary constrains and other uses for
the money.


43

Mr. Suays. We are not going to swear you in only because you
are identified, but we will have you come up. Just state your name
and tell us what the program is.

Ms. Wayne. My name is Nicole Wayne. I work for Healthy Fami-
lies, a northern Virginia family service.

Mr. SHays. Your question.

Mr. KuciNIcH. The question, thank you. How do you receive your
funding?

Ms. Wayne. It’s a public-private partnership. Northern Virginia
family service is a private, nonprofit agency. Funding for our
healthy families comes—for example, leadership support is given to
us by the Freddie Mac Foundation. Then there are funding streams
that include, in some cases, up to 20 different revenue streams,
some public, some private, that go into our annual budget. You can
see it is a tremendous process every year.

Mr. KucinicH. How many clients do you serve?

Ms. WAYNE. Over 500 families in northern Virginia.

Mr. KuciNicH. Annually?

Ms. WayNnE. Yes.

Mr. KucInicu. Thank you very much.

Governor, welcome. One of the things I think we are all going to
be watching is whether welfare reform contributes to lowering or
increasing the child poverty rate, since we know that two-thirds of
welfare recipients, at least the figures that I have seen, have been
children. And, of course, in the reports that I have seen, Rhode Is-
land has done very well as compared to other States in terms of
the overall reduction in the past 20 years in the rate of childhood
poverty. The national average is a 12 percent increase; Rhode Is-
land has a 17 percent decrease. But in addition to that, what I am
interested in, have you yet had enough information to submit your
State report that was, I think, required by the Personal Respon-
sibility and Work Reconciliation Act?

Governor ALMOND. We have, I believe. My director is not with
me this morning, but I’m positive we have submitted that.

Mr. Kucinicu. If you have, do you know offhand whether or not
you have seen a continued reduction in childhood poverty or has
there been an increase?

Governor ALMOND. I would say we have had a decrease, but keep
in mind we have expanded the programs considerably, so that our
caseload will be increasing, because our program is aimed at the
working poor. Keep in mind the people on welfare are the worst in
poverty, the issue of getting them off welfare. So most of our pro-
grams, whether it’s the health care or the child care programs, the
money goes to the working poor.

Mr. KucinIcu. The programs that you have, are they targeted for
the parents as well as the children?

Governor ALMOND. Oh, sure.

Mr. Kucinicu. Are they for people whe are not employed?

Governor ALMOND. Oh, sure, we have a lot of people who are get-
ting the child care subsidy who may be in education programs, in
transition from welfare.

Mr. KucINIcH. In terms of the expenditures that may have been
made per capita on welfare, is there any difference between the
amount of money that may have been spent before on welfare and


129

evidence on these risks was not as coherent at the start of this series of trials 20 years ago as it is
today, we chose to promote a reduction in use of all of these substances as a precaution.

Evidence also indicated that other prenatal behaviors, such as inadequate weight gain,”
inadequate diet,” inadequate use of office-based prenatal care,” and unattended obstetric
complications, such as genitourinary tract infections and hypertensive disorders” increased the
risk for low birthweight, preterm delivery, and compromised neurologic development.

‘These observations guided the development of the content covered in the prenatal
program protocols.
B. Modifiable Risks for Child Abuse and Neglect and Injaries to Children

‘We made an explicit inventory of risks for child abuse and neglect and organized them
according to their levels of immediate proximity to parental behavior. At a proximal level, risk
assessment focused on the mother's psychological immaturity and mental health problems that
affect parents’ competencies in caring for their infants." At a more distal level, risks focused
‘on those environmental conditions that create stressful conditions in the household that interfere
with parents’ care of their children, such as unemployment,TM poor housing and household
conditions,” marital discord,” and isolation from supportive family members and friends.” A
history of punitive, rejecting, abusive, or neglectful caregiving on the parent's own part was
considered a risk factor, especially if it occurred in the presence of other risks.“
C. Modifiable Risks for Welfare Dependence and Compromised Maternal Life-Course
Development

(One of the major risks for compromised matemal educational achievement and workforce
participation is rapid, successive pregnancies, particularly among unmarried women. Proximal

risks for rapid successive pregnancies include women’s having limited visions for their futures in


118

evaluation of statewide comprehensive programs for young children and families.
Implementing such an agenda would go a long way to support the states in their
efforts to ensure that the next generation does in fact, as the national goal calls for,
enter school ready to learn.


122

IN PRESS - THE FUTURE OF CHILDREN

Prenatal and Infancy Home Visitation by Nurses:

Recent Findings

David L. Olds
University of Colorado:

Charles R. Henderson, Jr.
Cornell University

Harriet Kitzman
University of Rochester

John Eckenrode
Cornell University

Robert Cole
University of Rochester

Robert Tatelbaum
University of Rochester

Word Count: 10,057


210

Mr. Suays. I have committed a great sin, given that, Mr. Burki,
you are from Westport, CT, that I wasn’t here for your entire testi-
mony, so I do apologize. We are working on campaign finance re-
form and we have 3 weeks left, and we are hard pressed to know
how we can finish it, and we just needed to deal with the issue,
and I am back.

You have the floor, Mr. Towns.

Mr. Towns. Thank you very much, Mr. Chairman. I want you to
know that being as I was the chairman at one point, I was able
to just carry on in grand style, Practicing for the next session.

ir. SHays. The record will note that the gavel was pressed
against the ranking member’s head.

Mr. Towns. Thank you, Mr. Chairman.

On a serious note, though—

Mr. Suays. Excuse me, sir. Your time is up. I'm sorry.

Mr. Towns. I don’t want to put you on the spot, Dr. Knitzer, but
I noticed that your report tracks child well-being, which is impor-
tant, so I am not going to put it where you would be responding
to HHS. I don’t want to do that. I don’t want to take that away
from you. But I want to say that the Department of Health and
Human Services cannot seem to determine ways to track child
well-being under welfare reform. For some reason, they can’t do
that. So am not going to ask you to respond directly to that. I
don’t want to create that kind of problem.

However, I do want to ask you, what do you think that HHS
should consider as indicators of child well-being? I do want to ask
that.

Ms. KNITZER. Let me tell you what indicators we used in Map
and Track, which we used because we wanted to have indicators
from each State. The truth is we have a major problem with young
children because, basically, we can talk about poverty rates, family
structure. We can talk about health care to pregnant women, the
timing of it, the not timeliness of it. We can talk about low birth
weight and immunization. Then there is a huge gap. Then the kids
hit school. So we need to develop some indicators about school
readiness that we can really use across this country.

I think it’s a shared problem. It is not just HHS. I think concep-
tually, the researchers, the entire community concerned with out-
comes for young children has to figure out how to track that. We
all want school readiness. What does that really mean?

In terms of the welfare connection, what we did is we conceptual-
ized, we tried to think about, the key decisions that States could
make that have implications for young children and families. So we
asked a series of questions of the States. Now these only indirectly
measure young child well-being, but, certainly, Medicaid eligibility
levels has significant impact on child well-being. And, in fact, while
States in general are raising Medicaid eligibility rates for infants,
they are not raising them for children from 1 to 6.

e are at a position of really describing the options that States
are choosing in their welfare implementation that we think have
special implications for young children before we can even get to
outcome on a large scale. Now that doesn’t mean I think we need
some very detailed studies, community by community, of what is
really happening to young children. Are we seeing more hunger,


127

content and methods. It is important to understand these features of the program in order to

interpret its effects.

DEVELOPMENTAL EPIDEMIOLOGY

The program tested in this series of randomized trials has been firmly grounded in
epidemiology and theories of child development. Kellam has referred to the integration of these
disciplines in guiding prevention science as developmental epidemiology.” In planning the
original Elmira trial, we noted that although the problems identified above cut across all
segments of U.S, society, they were more common among children born to poor, adolescent, and
single parents. This observation led to our decision to focus recruitment on women bearing first
children who were either adolescent, unmarried, or from low-income families. Any pregnant
‘woman bearing a first child was accepted into the study, irrespective of her age, marital status or
income, however, in order to avoid creating a program stigmatized because it served only the
poor or people with problems. Given that the beneficial effects of the Elmira program (described
below) were concentrated on women who were unmarried and from low-income families, we
modified the sampling designs in Memphis and Denver to focus more exclusively on low-income
‘women, the vast majority of whom were unmarried and adolescent.

All three of the trials focused on women who had no previous live births because we
reasoned that offering them services during the transition to parenthood would increase their
receptivity to offers of help. Moreover, from the standpoint of a public health strategy, this
approach held the promise of improving the life chances of subsequent children because parents
who received these services were hypothesized to have better skills for managing the demands of
pregnancy and early care of subsequent children after they had been helped with their first child.

In addition, to the extent that the rates of rapid successive births were reduced, parents would be


151

VI. PROGRAM IMPLEMENTATION IN DENVER TRIAL

‘The Denver trial was designed to gain insight into the reasons that previous trials of
home-visitation programs that employed paraprofessionals either failed or produced very modest
effects. °** In the Denver trial, the paraprofessionals hired as home visitors were required to have
a high school education, but no advanced training in the helping professions. We set this
requirement because many programs employ paraprofessionals who come from the communities
they serve on the premise that shared backgrounds and experiences will increase the visitors”
ability to form effective relationships and promote adaptive functioning among the visited
families. To further enhance the test of this theory, all of the paraprofessional visitors in Denver
were required to be parents themselves. The nurses, on the other hand, all had bachelors degrees
in nursing and were not required to be parents, although many were. Both groups were provided
essentially the same training and program protocols, although, as one would expect, the nurses
were provided more in-depth training regarding physical health and were expected to deal with
health issues more extensively. *
Denver Design and Methods

From March, 1994 through June, 1995, 1178 consecutive low-income pregnant
‘women with no previous live births were invited to participate from 21 antepartum clinics in
the Denver metropolitan area. Low-income status was operationalized by the women's
having no private insurance or their qualifying for Medicaid. Medicaid status as the time
extended to women at or below 133% of the federal poverty guidelines.

Compared to women who either actively refused (n=244) or were invited but not
contacted before delivery (n=199), those who accepted (n=735)were more likely to be of

Mexican-American descent and were less likely to smoke cigarettes. These groups were

30


155

consideration of program structure, content, and methods. With the increased focus on brain
development in the first three years of life, ” there is increased pressure to fund programs at this
stage in the life cycle. It would be a mistake to do so, however, without solid scientific evidence
that the particular mode! promoted is able to achieve its intended effects, given the failure of
‘most programs that have been carefully tested.

It is increasingly clear that the evidence from the Elmira and Memphis studies cannot be
generalized to programs that do not conform to the model tested in those trials. Even if the
results of the Denver trial show benefits for the paraprofessionals, the beneficial effects must be
understood in the context of the thoroughly developed program protocols and excellent clinical
supervision they were provided. The difficulties faced by other home visiting programs tested in
the past may be due to the particular program models tested or to the background of the visitors
‘employed (or both). The outcomes of the Denver trial and randomized trials of other model

programs (e.g., Parents as Teachers, Healthy Families America, Comprehensive Child

Development Program summarized in this issue) as well as the Early Head Start program
‘currently under investigation in the Head Start Bureau should provide additional guidance to
policy makers in the near future. Even when communities choose to develop programs based on
‘models with good scientific evidence, all too often the programs are watered down and
compromised in the process of being scaled up. We have recently begun work that addresses this
problem.

In 1995, we were invited by the US Department of Justice to develop the program studied
in Elmira and Memphis in several high-crime neighborhoods around the country. We accepted
the invitation because the results from the Memphis replication study and the Elmira follow-up

were promising. We intend to use the Justice Department initiative to learn more about what is

34


CONTENTS

Hearing held on July 16, 1998 .
Statement of:

Karoly, Lynn A., RAND Corp.; Jane Knitzer, director of program and
policy analysis, national center for children in poverty, Columbia School
of Public Health; David Olds, professor of pediatrics and preventive
medicine, University of Colorado; and Peter G. Burki, chief executive
officer, Dependent Care Connection, Inc ..

Reiner, Rob, | Am Your Child Campai i incoin
C. Aimond, Governor, State of Rhode Island; and Felicia Pearson, Alex-
andria, VA .

Letters, statements, etc., submitted for the record by:

‘Almond, Lincoln C., Governor, State of Rhode Island:

School Linked Services: Child Opportunity Zone Family Centers
Total welfare expenditures ...
Burki, Peter G., chief executive officer, Dependent Care Connection, Inc.,
prepared statement of .
Karoly, Lynn A., RAND Corp., prepared statement of
Knitzer, Jane, tor of program and policy analy
for children in poverty, Columbia School of Public
statement of
Olds, David, professor of pediatrics and preventive medicine, University
of Colorado, prepared statement of ....
Pearson, Felicia, Alexandria, VA, prepared statement of
Reiner, Rob, I Am Your Child °E,
statement of
Shays, Hon. Christopher, a Representative in Congress from the State
of Connecticut, prepared statement of
Towns. Hon. Edolphus, a Representat
of New York, prepared statement of ..

is, national center
Health, prepared

‘ampaign, Beverly Hilis, CA, prepared

di)

106

117
32

13


145

degree of program participation.

1, Prenatal Findings. There were no treatment main effects on birthweight, low
birthweight, length of gestation, spontaneous preterm delivery, indicated preterm delivery, or
Apgar scores. Nevertheless, by the 36th week of pregnancy, nurse-visited women were more
likely to use other community services than were women in the control group (p= .01). They
also were more likely to be working (p = .06), an effect that was particularly strong among
‘women who were not in school when they were randomized (8% vs. 2%, p=.01). There were no
program effects on women’s use of standard prenatal care or obstetrical emergency services after
registration in the study, but nurse-visited women who were in school at the time of registration
had twice as many pre-delivery hospitalizations as their counterparts in the comparison condition
(0.18 versus 0.09, p = .003). This difference was not explained by any coherent pattern of
diagnoses associated with those hospitalizations.**

In contrast to women in the comparison group, nurse-visited women had fewer yeast
infections after randomization and fewer instances of Pregnancy-Induced Hypertension (PIH)
(p=.05 and p=.02, respectively). Women with PIH who received a nurse home visitor had mean
arterial blood pressures during labor that were 3.5 points lower (p=.05) than those in the
comparison group, an indication of less severe cases."

2. Dysfunctional Caregiving and Child Development. During their first 2 years,
rnurse-visited children overall had fewer health-care encounters in which injuries and ingestions
were detected than did children in the comparison condition (p = .05), an effect that was
accounted for primarily by a reduction in outpatient encounters (p = 02). Nurse-visited children
also were hospitalized for fewer days with injuries and/or ingestions than were children in the

comparison condition (p <.001). The program effects on both total health-care encounters and

or


106

Testimony of Jane Knitzer, Ed.D.
Deputy Director
National Center for Children in Poverty
Columbia University School of Public Health
New York, New York

Hearing on “Early Childhood Interventions: Public-Private Partnerships”
Congress of the United States
House of Representatives
Committee on Goverament Reform and Oversight
Subcommittee on Human Resources
July 16, 1998

My name is Jane Knitzer. I am the Deputy Director of the National Center for
Children in Poverty (NCCP) and, on behalf of the Center, I very much appreciate
the opportunity to testify before you on how states are seeking to enhance the well-
being of infants and toddlers, preschoolers, and their families.

The National Center for Children in Poverty is a nonpartisan research
organization that is part of the Columbia University School of Public Health. Our
mission is to identify and promote strategies to reduce poverty and to improve the
life chances of low-income young children (from birth to age six) and their families.
NCCP conducts state-by-state demographic analyses of young child poverty rates
(see Appendix A), and carries out research intended to improve policies and
Practices for young children and their families. For example, we are part of the team
documenting the lessons learned from Starting Points, the initiative of the Carnegie
Corporation to help states and communities focus attention on young children and
families.

Every two years, NCCP also issues a report entitled Map and Track: State
Initiatives for Young Children and Families. This report identifies existing state
programs for young children, if individual states are encouraging community
planning efforts on behalf of young children, and if states have made enhancing
outcomes for young children a priority at the highest levels of government. The
report also provides state-specific information on demographic indicators of young


Conca:
[Cheistine Arouth, Family
Center Director
Parccpating Schools:

| Elementary Schoo!

Aunpleee
New Vision of Newport
Couney

Newport Public Schooks
Atatione

‘Camegie Starting Poinee
Adress

Family Center
Sutvan Schoo!

Denter Seeee
‘Newport Rt 02840
(401) 045.8579

Son

Farnly Center Director
(tome)

‘Bilingual Outreach
‘Works (parttime)
Family Development
‘Speciale (tale)
Program Austant (par
ime)

Parente are involved in

‘her children’ education,

Parone eve resources
that support thie roe a
parents.

66

NEWPORT
CHILD OPPORTUNITY ZONE FAMILY CENTER
coz Grade Tou! Percent
School Levels Enrollment Lowincome
Sullan School pees woo

Advisory Board

‘The Famty Center has a [3:member Governing Council made up of $1% parents and 49% agency.
School and business cepresenctives The governing board proms input ino che stratege direction
‘of ehe Fam Cencer. makes tnkages with existing programs thax support the Family Centers mission

and ensures that actives meet the priorities of parents in che school community

‘School and Community Locations

‘The Sulvan School Farnly Cener i located na trae ached tothe schoo! and shares space 1a
and resources with the Even Sart Family Lteracy Program Recent an addonl room was
renovated inthe Sullan School balding for & Parent lformason and Resource Center incloding
lending ibrary and resource staf A blingaal oureach worker and program sssatat provide outesch
and tanslavon services (0 Spansh-speakong parents The communty tte forthe Suan School
Family Cente seh Florence Gray Center ocated aero the hil from the schoo! a the Tonomy Hi
Publec Housing Development. The Florence Gray Center i large community canter with assrooms.
fice space. and resources for a vaety of amy and commundy programs

Funding 1997-1998: $113,200
aoe ne ede nd pp
‘eit by pret nd conan out)

theron rae
Samant ere Lapa Gea)

Cres re Fan

Fm coo asic. sport fam neo on human ere apres. a tne

4% Unted Way - Jn Cae Trust Fn

BIK COZ Famiy Center (Deparemer of Edveston,
Deparment ol Heath Uncea Way)

19% surung Pons (Deparment Educaion
Btfrbnct of esth UrceeWay arepe)

2% School Davie

Program Components
‘Parent Support and Education

Famiy Center a Slivan School Parent
Resource and lnformation Center Sulivan
Schoo: tformatnrlerral.and follow-up
MotherfonMother mentoring program (Chid
and Family Services): Translation se-wces
Lending Horary of toys. books, puppets, pues,
Parenung workshops (Famy Networks
Program, Middletowa and Newport COZs)
Infant and Pre-School Programs

Pareoes as Teachers Books-Are-Us tory hour:
Kindermush

Children’s Learning and Enrichment

Reading mentors: Ttoring (Chid and Farity
Serees);Mencoring and academe support,

cory project (Children's Cusade
‘Aker school scat for grades K-2
‘Americorps Ci Year) Aker tchool programs
for grades 15.Art program with Newport Art
‘Museum, Orama program with Newport
‘Chideens Theater Hip-Hop dance program
‘School Linked Health and Social Services
Heats Centar a Florence Gray Center (New
sons), Developmen searing for chide
‘enrolled in Even Stare Bingual Cid Oucreach
screening (Even Sure Seroo! Dutt)

‘Adult Education
(GED eats and ESL clases (Even Sure)

Family and Community Development
‘Adal heath and aerobics (Ch and Fumi
Serves, United Wy) Family fan actives



(From School-Linked Family Center
Efforts in Other States)

“The most successful school linked
service progeams reflect active and equal
‘partnerships among schools, Families, and
‘community agencies." While schools have
an enormous influence on and unique
access to children and families, succesful
programs enlist ll community
stakeholders and coordinate existing
tesoutces 0 improve educational, health,
and social outcomes,

Research actoss the country has
demonstrated that school-tinked
integrated services can promote school
readiness and student suecess. School
tinked services can help to increase student
achievement. save money and reduce
overlapping services, reach chose childcen
and families most in need, make schools
‘more welcoming to Families, increase
communigy support forthe school. and
help at-nsk Families develop the capacity
co manage their own lives succesfully

‘There ts no single made! of chool-
linked services that is acepred as most
effective. Rather, school inked services are
based on che atribuces of effective practice
that have been documented inthe
lieratute. The most effective school-
Finked service models across the country
connect families wth services and
supports that are family-focused,
comprehensive, integrated, culturally
diverse and responsive. preventive,
communicy-based, and accountable for
resuls”

Experience in several scates indicates that
school-lnked family centers ae a cost-
effective way 0 provide supports to
farsilies and to link families to needed
services. School-based programs for

Families with young children provide
families with support and educational
services such as parenting clases literacy
education. and referrals co other agencies,
Increased collaboration beeween schools
and human service agencies is most
fective when families are involved in 2
watety of roles. For example, a recent
‘valuation of the California Healthy Stare
‘School-Linked Services Initiative found
that when parencs are mote involved,
schooblinked services tended to be more
accessible, integrated into the life ofthe
school, and more culcually relevant.*

Successful programs rly on a flltime
«coordinator oF program director, who
builds a team of personnel sensitive 0
issues related ro youth development,
Family support, cultural diverse, and
‘community empowerment. In many
locations, bilingual staff are essential. A
designated space such a aclinie or 8
center in a school acts a a focal point for
bringing in services from the community.
One of che most importans outcomes of
developing school-linked services isthe
abiligy to leverage resources to improve
outcomes for children and families!"

Effective school-linked service programs
emerge out of extended negotiations with
health, social service, and other agencies
Each agency has a specific contribution 10
make, chrough eelocating personnel,
training, supervision, o accepting
referrals. Experience has shown the
importance of having a full-xime person
designated as coordinator ofthe program
ata very cay stage in development.
‘Communities have a much better chance
of developing school-based centers in
states that stiraulate program development
with grants?


173

ceive educational materials they need to understand their child’s
developmental needs during the critical early years.

These types of services are a necessity, not a luxury for parents
today. Without said services, parents cannot effectively work.

Research continues to provide clear evidence that what happens
in the first few years of a child's life really does matter and has
an enormous effect on a child’s ability to learn, relate to others and
function in the world for the rest of his or her life.

We have learned that young children are far from passive ves-
sels, that they actively interact with their environments and in fact
influence the behavior of those around them. We now know that
what young children see, hear, smell, touch, and do shapes not only
what they know but how they learn. For good or for ill, what hap-
pens to young children in the first years of life is critical to their—
and our—futures.

As Mr. Reiner mentioned earlier, the human brain achieves 90
percent of its total growth before the age of 3. The brain of a new-
born baby has about 100 billion nerve cells, more, actually, than an
adult. The difference is babies’ nerve cells aren’t wired up at that
time. It’s kind of like a stereo or a computer without the wires
being hooked up. You won’t get much out of it until you connect
the wires. In babies, the wiring is connected with experience, inter-
action, and nurturing.

Neural connections are formed when impulses trigger the release
of brain chemicals. Every time a baby’s brain is stimulated by a
hug or a smile or a song or the taste of milk or the smell of flowers
or the feel of a toy, new connections are formed. With repeated ex-
perience, those connections are strengthened.

In fact, by the time a baby is 3 years old, the little brain has
formed more than 1,000 trillion connections among its nerve cells.
These connections allow the baby to learn, grow and develop cog-
nitively, socially, emotionally and physically. These connections
help determine what kind of person that baby will become. Without
appropriate stimulation, a baby’s brain won't develop properly.
With optimal stimulation, it will develop better than it might have
otherwise.

In light of these discoveries, child care becomes more than a
holding place for children while their parents are at work. Child
care has an enormous impact on the future of our children’s phys-
ical and emotional well-being and their social and intellectual po-
tential.

As these scientific findings have been made public, parents, edu-
cators, legislators and others who share a concern for the future
and well-being of our Nation’s children have come to see that we
need to pay a lot more attention to what is happening to our chil-
dren. Since early experience is so critical to future development, we
must consider what kind of experiences we are giving our youngest
children. We must think more about who cares for them and how.
We must teach parents and other caregivers that what they do and
how they do it really matters. And, most importantly, we must help
our little ones get the very best care possible by educating their
parents, by helping the parents find quality care and by making it
easier for parents and caregivers to find the information and serv-
ices they need.


101

LYNN A. KAROLY
FEDERAL CONTRACTS AND GRANTS SINCE OCTOBER 1, 1995

U.S, Department of Labor, Pension and Welfare Benefits Administration, Contract No.
J-9-P-7-0045, Co-Principal Investigator, “Retiree Health Benefits and Labor Force
Transitions of Women,” March 1998-February 1999. Total budget: $150,000.

National Institutes of Health, National Institute of Child Health and Human Development,
Grant No. 2P01-HD28372, Principal Investigator, “Schooling Choices and Outcomes in
Economic Development,” March 1998—February 2003. Total budget: $390,000 (direct).

Social Security Administration, Office of Research Evaluation and Statistics, Contract No.
0600-96-27335, Co-Principal Investigator, “Policy Evaluation of the Effects of the 1996
Welfare Reform Legislation on SSI Benefits for Disabled Children” August 1997-July
1999, Total budget: $620,000.

National Institutes of Health, National Institute of Child Health and Human Development,
Principal Investigator, Grant No. T32-HD-07329, “RAND Postdoctoral Training Program
in Population Studies,” May 1997—April 2002. Total budget: $300,000.

U.S. Department of Labor, Pension and Welfare Benefits Administration, Contract No.
J-9-P-2-0017, Co-Principal Investigator, “Retiree Health Benefits and Labor Force
Transitions,” November 1996-October 1997. Total budget: $125,000.

U.S. Department of Labor, Pension and Welfare Benefits Administration, Contract No.
4J-9-P-2-0017, Co-Principal Investigator, “Retiree Health Benefits, Changes to Medicare,
and Retirement,” November 1995-April 1997. Total budget: $150,000.

National Institutes of Health, National Institute on Aging, Co-Principal Investigator, Grant No.
2PO1-AG08291, “The Indonesian Family Life Survey of Aging Dynamics,” October 1995—
September 1998. Total budget: $900,000.

National Institutes of Health, National Institute of Child Health and Human Development, Co-
Principal Investigator, Grant No. RO1-HD33778, “The Indonesian Family Life Survey of
Mothers and Children,” July 1995—June 1998. Total budget: $900,000.

U.S. Department of Labor, Pension and Welfare Benefits Administration, Contract No.
J-9-P-2-0017, Co-Principal Investigator, “Firm Decisionmaking and Retiree Health
Benefits,” April 199S—April 1997. Total budget: $150,000.

Agency for Health Care and Policy Research, Grant No. RO1-HS07048, Co-Principal
Investigator, “Health Insurance for Older Americans,” April 1995~-March 1998. Total
budget: $845,000.

National Institutes of Health, National Institute on Aging, Principal Investigator, Grant No.
32-AG00244, “RAND Postdoctoral Training in the Study of Aging,” September 1994—
August 1999. Total budget: $300,000.


26

an increase in the percentage of infants who waited less than 2 weeks for a specialty care
appointment

8 decrease in emergency room visits and hospital utilization and an increase in primary
care physician visits

-98 percent of parents who have children carolied in a Rite Care health plan were
‘satisfied or very satisfied with the quality of care received

‘Those positive early intervention programs and cutcomes are deslgned to ensure a healthier,
skilled, workforce with healthier chikiren.

2. Starting Right- Ihe Right Future

‘As | said earlier, my administration is preparing the business community end our frmilies for the
21* century. This moans that we are ensuring that business and government work together as
partners to create a dynamic working and living environment in Rhode Inland. By investing in
early education and child care we are laying the groundwork for families to have access to care
and ence for our economy to thrive. With greater accessibility and quality health care in place,
‘parents can enter the workforce with the peace of mind that their children are in excellent hands.

In January of this year, I snnounced an aggreasive initiative called Starting Right, which picks up
where Rite Care left off. I am happy to say that with the state legislatures assistance Starting
Right is now law. Starting Right which will be implemented over three yours is designed to
provide a comprehensive child care and early education program focusing on the issues of
quality, affordability, and accessibility. My goa! with this isto ensure tht all children in the
state sre well prepared and able to enter schoo! ready to lear.

‘This innovative program will expand the state's child care subsidy program to include working
farnilies earning up to 250% of the federal poverty level (FPL), or about $34,000 a yoar for a


22

‘Testimany of Lincoln C, Almond, Governor of the State of Rhode Island
Before the Committee on Government Reform and Oversight
sub-committee on Human Resources
Auly16, 1998

Introduction

Good Moming, Mr. Chairman, and distinguished members of the Committee on Government.
Reform and Oversight. It is en honor to be here today to speak with you on one of the most
important innues facing our nation, early childhood interventions. Also, itis « pleasure to be
‘speaking with 1 group of some the great national leaders and academica of our time on this traly
vital issue, In fact, just yesterday I had the distinct pleasure to host Mr. Reiner in Rhode Island.
for our first statewide early childhood summit focusing on these very inmuea. Mr. Reines's
compelling and dynamic address to the Rhode Island business community and statewide
eadership will undoubtedly lead to meaningful partnerships between business and government.

‘Let me just add thet many of us “outside the beltway" appreciate your willingness to review this
issue and work toward a shared vision because how individuals function from the pre-schoo!
years all the way through adolescence and even adulthood hinges, to a very significant extent, on
their experiences before the age of six. This is why our experience in Rhode Island has been to
compelling.

Rote land fo tke many others across the nation, are experiencing a child caro crisis.
‘With welfare reform underway and our increased understanding of brain-devolopment in young
children, itis clear that having quality child care available forall working families is of extreme
importance. As the Governor, Ihave charged my administration with providing affordable and
accessible quality child care and early intervention programs to low and middle income families
20 that tomorrow's generation is equipped to live in a technologically advanced and complex
world. And I can say, that under the capable leadership of my Director of Human Services,
Christine C. Perguson, Rhode Island is well on its way to leading the nation in early intervention


105

Fourth, we need the Federal Government to help develop fiscal
and programmatic consultation and other strategies to support
those home visitors, for example, so that they can cope with the
kinds of needs that families are bringing to them.

Fifth, we need to encourage the evaluation of statewide programs
for young children and families so we know what we have gotten.

I will stop there and respond to any questions later.

Mr. Towns [presiding]. Thank you very much.

[The prepared statement of Ms. Knitzer follows:]


162

36. Olds, D., Henderson, C.R. Jt., Cole, R., Eekenrode, J., Kitzman, H., Luckey, D., Pettitt, L.,
Sidora, K., Morris, P. & Powers, J. (1998). Long-term effects of nurse home visitation on
children’s criminal antisocial behavior: 15-year follow-up of a randomized trial. JAMA,
under review.

37. Tygart, CE. (1991). Juvenile delinquency and number of children in a family: Some
empirical and theoretical updates. Youth & Society, 22, $25-536.

38. Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and
design. Cambridge, MA: Harvard University Press.

39. Bronfenbrenner, U. (1992). The process-person-context model in developmental research
principles, applications, and implications. Unpublished manuscript, Comell University,
Ithaca, NY.

40, Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change,
Psychological Review, 84, 191-215.

41, Bowlby, J. (1969). Attachment and loss: Vol I. Attachment. New York: Basic Books.

42, Main, M., Kaplan, N., & Cassidy, J. (1985). Security in infancy, childhood, and adulthood:
‘A move to the level of representation. In I. Bretherton & E, Waters (Eds.), Growing points of
attachment theory and research. Monographs of the Society for Research in Child
Development, 50(5-2, Serial No. 209), 66-104

43. Bamard, K.E. (1990). Keys to caregiving. Seattle, WA: University of Washington Press.

44. Dolezol, S., & Butterfield, P.M. (1994). Partners in parenting education. Denver, CO:How

to Read Your Baby.


165

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34

make certain our children have the kind of education and support
and to be able to compete with other countries, that we need to
make the investment now. So isn’t there some way we can make
the case that we actually are not spending more money. By doing
it we probably will be saving money in the long run?

Governor ALMOND. I agree. And look at it from the standpoint of
the nonprofits, for instance, who are providing child care. You have
low wages in the industry. One of the things we do in Rhode Is-
land, which is very unique, for home care child caregivers, we will
give them Rite Care Health Insurance. Because many of these peo-
ple who are staying at home and taking care of five or six of their
neighbors’ children so they can work are paid so low they don’t
have health care, and so we are doing that.

In the RIte Care Program, we are going to be subsidizing health
insurance for day care providers. You know, they need resources in
order to be able to do more than just baby sit. They have to hire
professionals. They have to get individuals who are just as quali-
fied as the first and second grade teacher. If you are going to have
quality child care it’s expensive. So those are some of the issues.

What I hear, and I am sure that I know I have heard Rob Reiner
say this, if you have day care where you are having a change in
staff on a weekly basis or a monthly basis because your wages are
low, that isn’t good for the children because there are no attach-
ments. So you have to look at this as something very important.
And you want the best staff, you got to pay them, and you got to
give them benefits. That’s the issue. So it’s expensive. Somebody
has to pay the bill.

Mr. Towns. All right. Let me move to—I guess I want to ask you
this, Mr. Reiner. Thank you very much, Governor.

I am concerned that preschool enrichment programs will not be
universal until they are designed to benefit children from the mid-
dle income families as well as children from poor families. I am re-
minded of the Medicare program, which provides health care for all
seniors. Many believe that Medicare only continues because so
many middle income seniors actually benefit from it. Do you share
my concerns that maybe the best way to assure preschool for the
poor is to provide preschool for the middle class?

Mr. REINER. Absolutely. And as the Governor pointed out, we are
now living in a country where there is 60 percent of families have
two wage earners, and I would bet that, of the 60 percent, a very,
very high percentage of those really need those two incomes to sur-
vive. And we are talking about people in the $45,000, $50,000 a
year category. Those are middle income. Those are middle class
people.

And the fact of the matter is, brain growth and development is
the same for a poor child as it is for a wealthy child or a middle
income child. It is the same process. We are still wanting to create
the best minds: to compete in the global economy. And we are in
the information age. There is no getting around it. We are going
to need better educated people.

So regardless of whether or not it’s poor people or middle income
people—now wealthy people can afford their own child care, and
they can do that, and they are lucky enough to do that. But middle
income people need it as well. And I think if you surveyed this


175

DCe--—~

‘Mr. Chairman and Honorable Members of this Subcomumiaee:

Tam Peter Burki, Chief Executive Officer of DCC Inc., a leading global provider of critical workplace

services that increase productivity and efficiency, and reduce absenteeism, turnover and stress. [ am

pleased to have been invited to appear before you today to discuss what we believe to be one of the

day's most important issues. The subject of this hearing corresponds with DCC’s ongoing efforts to:

1, Provide early childhood intervention services to working parents

2. Raise awareness of the connection between these resources and a child's cognitive, emotional, and
physical development; and

3. Demonstrate how children, parents and all organizations can profit from these services.

In the past several years, businesses have had to adjust'to a rapidly changing social landscape, which
will continue to change as we approach and prepare for the 21” century.

Consider the facts:

‘* 78% percent of working parents live in dual income households, compared to 64% twenty years
ago."

‘* In 1994, 10.3 million preschoolers had mothers who worked. Almost 30% of preschoolers and
‘over 18% of children under one were in organized child care."

‘© Today, one out of every five employed parents is single. Since 1970, the number of single female
families has increased by 133%, from 5.5 million to 12.8 million. Single male families grew by
213%, from 1.2 million to 3.8 million."

‘These trends highlight critical issues that we in the public and private sectors must address in order to

promote a healthier, better-prepared, and more productive workforce... for today and the furure.

The daily challenges for employees are becoming al too familiar:

‘© A-young mother needs to find affordable child care and transportation so she can make the
transition from welfare to work.

‘© A single dad needs critical early intervention services to address his daughter's developmental
delays.

DCC® UteCare® Services 1

ALifetime Of Smart ChoicesTM

POBox 278, Westport. CTOEEED » rb) Zab 2680 « ex: 0) 2a:2882 « wow dectocare. com Pinted On hecycied Paper ©


115

tions and violations of probation and 56 percent fewer days of alco-
hol consumption. There were very few benefits for higher-income,
married women and their children.

One of the hallmarks of good evidence is being able to reproduce
it. The major findings from the Elmira trial in the early years of
the child’s life have now been reproduced in an urban replication
conducted in Memphis. For example, by the children’s second birth-
days, compared to women and children randomly assigned to com-
parison services, those who were nurse-visited had 30 percent
fewer hypertensive disorders of pregnancy, 50 percent more fre-
quent breast feeding, 81 percent fewer days that children were hos-
pitalized with injuries or ingestions, fewer conditions in the chil-
dren’s hospital records indicative of neglectful or abusive care, and
30 percent fewer subsequent births.

During the past decade, the findings from this program of re-
search have been used to promote a wide variety of home visiting
programs for pregnant women and parents of young children, but
unless they share the essential elements of the program tested in
these trials, those other programs are not likely to produce the
same results.

Very few programs have been scientifically proven to improve
high-risk parents’ early care of their children. Brain development
is rapid in the first 3 years. But the science of learning how to ef-
fectively improve at-risk parents’ care of their own children is in
its infancy. We need continued investments in research in this
area. Even when communities choose to develop programs based on.
models with good scientific evidence, all too often the programs are
watered down and compromised in the process of being scaled up.

We have begun to address this problem. We have been invited
by the Justice Department to disseminate the program in high-
crime neighborhoods in different parts of the country. We are using
this initiative to learn more about what it will take in new commu-
nities to develop the program with fidelity to its essential elements.
We have established the program in 14 communities and are study-
ing what it will take to successfully develop the program on a much
larger scale.

In this initiative, State and local governments are securing finan-
cial support for the program out of existing funds, such as TANF,
Medicaid, child abuse and crime prevention dollars. The program
itself requires no new appropriation. Communities are making
these investments in part because the evidence indicates that ex-
penditures in these budgets will be reduced later on. This means
that the cost of the program, which in 1998 dollars is now $7,000
per family for 2¥2 years of service, can be shared by a variety of
government agencies. This reduces the strain on any one budget.

We have recently been invited by a major philanthropy to de-
velop a system of regional replication centers based in schools of
nursing and public health to develop this program on a national
scale. We have estimated that it will take 20 additional years to
develop this program for all low-income parents in our society, if
we wish to preserve those elements of program quality that are
necessary to reproduce the results I have just summarized on a na-
tional scale. This is because quality programming requires recruit-
ing qualified staff, intensive training and excellent supervisors, ca-


194

Overview for COMPANY

Disaster Relief

When natural disasters occur (earthquakes, tornadoes. fires. floods. etc.), DCC counselors can
help employees put their lives back together by locating the following assistance:

© Temporary care © Counseling services
© Safety inspectors © Alternate housing

© Emergency shelters ‘© Support groups

© Home visits © Outreach programs
© Food and clothing assistance © FEMA assistance

© Home-delivered meals © Hotline numbers

Financial Services

DCC can provide employees with extensive personal and financial planning services that are
tailored to their income levels, needs and goals. Trained specialists gear educational materials,
referrals and seminars to the options and strategies that employees wish to pursue. While
choosing a personal and financial plan is ultimately the employee's responsibility, DCC's
financial planning services can help with the following:

© Financial planners © Buying vs. leasing a car
© Budgeting © Saving and investing
© Investing ‘® Estate planning

© College savings ‘© Mortgage and home
© Debi consolidation © Retirement planning
© Credit issues © Tax services

© Insurance © Financial institutions

DCC can additionally offer employees a wealth of financial information and services ontine via
its private Web site. DCC’s LifeCare Net houses financial educational digests and
accompanying calculators on college savings. estate planning. insurance. home mortgages.
retirement planning, savings and investing. and taxes.

DCG==—= *


136

Comprehensive Interdisciplinary Developmental Services, Inc.

Pregnant women were actively recruited for the study through their sources of prenatal
care if, at intake, they had no previous live births, they were at less than 26 weeks of gestation,
and they had any one of the following characteristics that predispose to infant health and
developmental problems: (i) young age (<19 years); (i) single parent status; and (iii) low
socioeconomic status. Any woman who asked to participate was enrolled, however, regardless
of her age, marital status, or income, if she had no previous live birth. This approach avoided
creating a program that was stigmatized as being exclusively for the poor and created sample

heterogeneity, enabling us to determine if the effects of the program were greater for families at

higher risk. Five hundred women were invited to participate and 400 enrolled, 85% of whom
were either low-income, unmarried, or <19 years of age at registration; none had a previous live
birth. Eighty-nine percent of the sample was Caucasian. There were no sociodemographic
differences between those who enrolled and those who declined, although participation was
higher among African-Americans. We stratified the sample on a number of demographic factors
and then randomly assigned participating women to one of four treatment groups.

Families in Treatment 1 (nr=94) were provided sensory and developmental screening for
the child at 12 and 24 months of age. Based upon these screenings, the children were referred for
further clinical evaluation and treatment when needed. Families in Treatment 2 (n=90) were
provided the screening services offered those in Treatment 1 plus free transportation for prenatal
and well-child care through the child's 2nd birthday. There were no differences between
‘Treatments | and 2 in their use of prenatal and well-child care (both groups had a high rate of
completed appointments). Therefore, these two groups were combined to form a single

comparison group. Families in Treatment 3 (n=100) were provided the screening and

1s


17

‘won't get much out of it until you connect the wires. In babies, the wiring is connected with
experience, interaction, and nurturing.

Neural connections are formed when impulses trigger the release of brain chemicals. Every time a
baby's brain is stimulated, by a hug, or a smile, or a song, by the taste of milk, or the smell of
flowers, or the feel of a toy, new connections are formed. With repeated experience, those connections.
are strengthened.

In fact, by the time a baby is three years old, that litle brain will have formed about 1,000 trillion
connections among its nerve cells. These connections allow the baby to learn and grow, to develop
cognitively, socially, emotionally, and physically.

‘These connections help determine what kind of person that baby will become.

Without appropriate stimulation, a baby’s brain won't develop properly. With optimal stimulation, it
will develop better than it might have otherwise.

In light of these discoveries. child care becomes more than a holding place for children while their
parents are at work. Child care has an enormous impact on the funure of our children’s physical and
emotional well-being, and their social and intellectual potential.

[As these scientific findings have been made public, parents, educators, and others who share a concern
for the furure and well-being of our nation’s children, have come to see that we need to pay a lot more
attention to what's happening to our children.

Since early experience is so critical to future development, we must consider what kind of experiences
‘we're giving our youngest children. We must think more about who cares for them and how. We must
teach parents and other caregivers that what they do and how they do it really matters. And most
importantly, we must help our little ones get the very best care possible, by educating their parents, by
helping those parents find quality care, and by making it easier for parents to find the information and
services they need.

Today, the concept of early childhood intervention, once reserved for families at risk, has been
extended to all children and parents as a means of providing the best possible start. When you consider
all the learning and development that takes place during the first three years of life: cognitive and


Aa otthe 1997-1998
schoo! ear, COZ Farniy
‘Center ware connected

Srcal Waren Program Profiles


112

rigid eligibility, and funding criteria make developing supportive communities for
young children more complex. States need to be able to mix and match dollars to
help communities create the needed system of supports to young children and
families that are tailored to community need.

¢ Building community support structures on behalf of young children and families
takes time, technical assistance from the states or others, and seems to work best
if there are clear objectives. Support for these activities can come from public or
private funds, or some combination, but is crucial to the success of program
efforts.

e Incentives to states to promote positive outcomes for young children and their
families in the context of welfare reform is important, since so much of the effort
to implement welfare reform is adult driven.

© Identifying and testing new strategies to help programs serving families with
young children better meet the needs of the most troubled families would
strengthen their efficacy.

¢ Investments are needed in evaluations of program, community mobilization or
comprehensive state strategies on behalf of young children and families, Further,
although states are setting outcome based goals, in many places, administrative
data systems do not have the capacity to track these outcomes. The few
evaluations that do exist, however, are encouraging.

© Sustaining systems-change efforts poses a challenge across the states. Efforts to
expand understanding of the importance of investing in early childhood at all
levels oF government and with public-pivate parinshipd many be ey to
ensuring that the efforts that are now underway will withstand changes in
administrations.

Taken together this suggests ways in which federal initiatives might support
state efforts; such an agenda might include ensuring that federal dollars can be used
flexibly to enhance developmental outcomes for young children and families;
providing incentives to states to develop comprehensive community mobilization,
planning and networking capacity on behalf of young childrea and families;

promoting positive outcomes for young children in families affected by welfare
pani developing consultation and other strategies to promote the well-being of
young children at risk of poor learning and behavior disorder, and encouraging the


76

Mr. REINER. I was also involved with Governor Whitman in New
Jersey of doing exactly the same thing in the west ward of Trenton
where we do a one-stop shopping kind of thing, again, all family
support services in one place.

Mr. Kucinicu. Thank you, Mr. Chairman, for your indulgence. I
appreciate it very much.

Mr. Suays. Thank you. It is wonderful to have your participa-
tion. We are going to get to the next panel, but we would welcome
any closing comment from any of you.

Governor ALMOND. I just thank you for the opportunity. It has
been very enlightening for me, the questioning. We will be very,
very happy to supply you with some more information. We thank
you very, very much for having the hearing.

Mr. SHays. Thank you. Governor Almond, we are going to work
with your staff and your Washington representative because we
want to be sensitive. The last thing we want to do is punish a State
that has taken an initiative. I want to say that one of the ways we
look at the States is as 50 individual laboratories where interven-
tion can happen.

Mr. Reiner, when you and I were talking, I was thinking three
may be great, four in some States.

Mr. REINER. It has to be flexible.

Mr. SHays. We do need that flexibility.

Ms. Pearson, do you have any closing comment you would like
to make?

Ms. PEARSON. Yes, one thing I would like to state, one thing
about Healthy Families I liked and I didn’t know about, when I
met with the First Lady, Mrs. Clinton, she had mentioned to me
that it would be best if I could go and check on my child from time
to time. I told her that I thought about that, but I felt like I would
be a little sneaky doing it. And then Lynn said, she is required—
she can do that. When she told me that, I was like, really?

So that’s a good thing, too. That Lynn went and checked on my
son and that my care giver was, of course—I think she would take
my son a little bit more seriously knowing that someone is coming
into their home and that he has some love there and someone be-
hind him, not just me, but outside people as well. I just wanted you
to know that.

Mr. Suays. So the First Lady is your friend as well?

Ms. PEARSON. She came into my home. It was a wonderful day
for me.

Mr. Suays. She is a wonderful woman. Her advice is very sound.

Mr. Reiner.

Mr. REINER. One last thing. If you don’t think that early brain
development is important, I want to do a little experiment. It has
probably never been done in a hearing room before. Everybody who
took a second language, studied a second language in high school,
raise your hand, everybody in the room. Everybody.

Ox, keep your hands raised if you can speak that language flu-
ently.

The point is——

Mr. Suays. Let the record note that about 100 people raised their
hand and about 4 left their hands up.


28

of 0 to 6 largely determines the outcomes of « child's life. All of us, federal, state, and private
sector need to partner together to build a bridge toward maximizing the investments that we are
all making in health care, child care, education and early intervention programs.

Families today face unprecedented challenges in raising their youngsters. Low earings require
many families to resort to raultiple wage earners, moonlighting, and overtime, leaving them less
time for their families. Growing numbers of young parents resort to extraordinary messures to
‘make ends meet and arrange their child eare. Concem about balancing work and fumily life is
not confined to those with low incomes; fully balf the population report that they have too little
time for their famities. This is why from the begioning of my tenure as Governor I have tried to
make an integrated continuum of care for Rhode Island families a top priority of my
admninistration.

‘The current needs for our great nation are many, However, in onder to ensure the future, we must
intelligently invest in the present. The most effective investment we can make is in the
development of young children,

Thank you very much.


94

Lynn A. Karoly Page 4

Klerman, Jacob Alex, and Lynn A. Karoly, “Trends and Future Directions in Youth
Labor Markets: Implications for Army Recruiting,” in Mark J. Eitelberg and Stephen
L. Mehay, eds., Marching Toward the 21st Century: Military Manpower and
Recruiting, Greenwood Press, 1994, pp. 41-65 (also available as RAND Reprint RP-
310).

Karoly, Lynn A., and Jacob Alex Klerman, “Using Regional Data to Reexamine the
Contribution of Demographic and Sectoral Changes to Increasing U.S. Wage
Inequality,” in J.H. Bergstrand, T-F. Cosimano, J.W. Houck and R.G. Sheehan, eds.,
The Changing Distribution of Income in an Open U.S. Economy , Elsevier Science
Publishers, 1994, pp. 183-216 (also available as RAND Reprint RP-277)..

Asch, Beth J., and Lynn A. Karoly, The Role of the Guidance Counselor in the Military
Enlistment Process, MR-315-P&R, Santa Monica, California: The RAND
Corporation, 1993.

Dertouzos, James N., and Lynn A. Karoly, “Employment effects of worker protection:
Evidence from the U.S.,” in Christoph F. Buechtemann, et al., eds., Employment
Security and Labor Market Behavior: Interdisciplinary Approaches and
International Evidence, Ithaca, N.Y.: Industrial Labor Relations Press, Comell,
1993, pp. 215-227.

Karoly, Lynn A., “The Trend in Inequality Among Families, Individuals and Workers in
the United States: A 25-Year Perspective,” in Peter Gottschalk and Sheldon
Danziger, eds., Uneven Tides: Rising Inequality in America. New York: Russell
‘Sage Foundation, 1993, pp. 19-97 (also available as RAND R-4206).

Dertouzos, James N., and Lynn A. Karoly, Labor Market Responses to Employer
Liability, R-3989-ICI, Santa Monica, California: The RAND Corporation, 1992,

Karoly, Lynn A., "The Widening Income and Wage Gap Between Rich and Poor:
Trends, Causes and Policy Options,” in James B. Steinberg and David W. Lyon, eds.,
Urban America: Policy Choices for Los Angeles and the Nation. Santa Monica,
California: The RAND Corporation, 1992, pp. 55-81.

Karoly, Lynn A., “Changes in the Distribution of Individual Earnings in the U.S.: 1967-
1986,” The Review of Economics and Statistics, 74(1), February 1992, pp. 107-115
(also available as RAND Reprint RP-173).

Oakes, Jeannie, Molly Selvin, Lynn A. Karoly, and Gretchen Guiton, Educational
Matchmaking: Toward A Understanding of High School Curriculum and Tracking
Decisions, R-4051-NCRVEJ/UCB, Santa Monica, California: The RAND
Corporation, 1992.

Rogowski, Jeannette A., and Lynn A. Karoly, “Retirement and Health Insurance
Coverage,” in Health Benefits and the Workplace. Washington, D.C.: U.S.
Government Printing Office, 1992, pp. 117-138.


9

Then after 10 minutes, we would seek to go to the next speaker.
But that is how it works. So the first time you see a red light, don’t
panic.

OK. You are on.

Mr. REINER. OK. The story many of you may know is about the
stream of babies that you see floating down the river, continuous
stream of babies heading toward the waterfall, and there is this
concerned citizen feverishly yanking these babies one by one out of
the river.

A second guy comes up, and he looks and says, what is going on
here? He says, well, these babies, they are going down the river.
They are going to fall over the waterfall. They are going to die.
Please help me, help me. And he looks at this, the second guy, and
he starts running up river. And the first guy says, well, what are
you doing? I need help here. And he says, I am going upriver to
see who is throwing the babies in the water. I want to stop that

guy.

And I think that is why we are here today. It’s about stopping
the loss of our children to failure in schools and drugs and teen
pregnancy and welfare dependency and violent crime before it
Starts. That is what this, in my opinion, what this hearing is all
about.

Now, we know through efforts of the I Am Your Child Campaign
and efforts of early childhood development groups around the coun-
try that, in no uncertain terms, the human brain grows to 90 per-
cent of its adult size in the first 3 years, that’s undisputed, and
that the emotional and physical and intellectual environment that
a child is exposed to in those first critical years, vis-a-vis parents
and primary caregivers, has a profound physiological effect on how
that child’s brain will develop. That is undisputed brain research
and brain development.

Now whether he or she will be healthy and enter school ready
to learn and subsequently succeed in life or will become a toxic and
very costly burden to society is in a very large part determined by
his or her earliest experiences.

Almost 15 years ago, I started thinking about how a child’s early
development could affect social outcomes, and 4 years ago, my wife,
Michele Singer Reiner, myself, and Ellen Gilbert of the Inter-
national Creative Management Talent Agency in Los Angeles, we
began the I Am Your Child Campaign, and it was a public aware-
ness and engagement campaign and we had three goals.

The first goal was to raise awareness of the critical importance
of the prenatal period for the first 3 years of life. What I had come
to understand was this information had been available but had
only been disseminated in the scientific community. It had been
known for 15 years.

I took it upon myself to get it out to the public. To that end, we
coordinated an effort with a White House Conference on Early
Childhood Brain Development. This was in April of last year.

We also went to Newsweek Magazine, and we asked them to give
us a special edition. They published a special edition of Newsweek,
which was the single largest selling edition in their history, solely
devoted to the period zero to 3.


17

Mr. REINER. The point is, we know that early on is when the
brain gets wired for a lifetime of learning. When you learn a lan-
guage in the first, up until age 10. After age 10 it is very difficult
to learn a language. Early childhood brain development is critical.
There is no escaping that.

Mr. Suays. The one thing I would want to leave this hearing
with, though, is to say that, for those of us who were under-
achievers at an early age, there is still hope.

Mr. REINER. Absolutely. Absolutely.

Mr. Suays. I learned to speak Fijian in the Peace Corps because
they started us at 6 a.m., and went until 9 p.m. And in 3 weeks
I learned what college couldn’t teach me in 3 years.

Mr. REINER. You can learn. Obviously you can learn after age 10.
But the point I’m making is it is much more difficult after—it has
to be done at the age-appropriate time.

Mr. SHays. I am almost tempted to invite you to ask the other
witnesses questions and come up here, but I don’t have that au-
thority.

Mr. REINER. I understand that. I have to get elected. I under-
stand that.

Mr. Suays. Thank you. You have been a wonderful panel, all
three of you. Thank you so much.

We are going to call our next panel and welcome the second
panel much as we have welcomed our first: Dr. Lynn Karoly,

D Corp., Santa Monica, CA; Dr. Jane Knitzer, director of pro-
gram and policy analysis, National Center for Children in Poverty,
Columbia School of Public Health, New York City; Dr. David Olds,
professor of pediatrics and preventive medicine, University of Colo-
rado, Denver; then finally, Mr. Peter Burki, chief executive officer,
Dependent Care Connection, Inc. And that is where?

Westport, CT, of course. There is no coincidence to the fact that
I represent Westport.

e are going to start with Dr. Karoly, then Dr. Knitzer, then Dr.
Olds, then Mr. Burki. If you would remain standing, because I will
swear you in.

{Witnesses sworn.]

Mr. Suays. For the record, all four of our witnesses have re-
sponded in the affirmative.

Dr. Karoly, we are going to start with you. We really appreciate
all three of you being here and appreciate the fact that you listened
to our earlier panel. I might add that if you want to paraphrase
your statement and comment on things you have heard, be our
guest; we have your written testimony. But if you want to pursue
your written testimony, that is fine as well. You are on.

STATEMENTS OF LYNN A. KAROLY, RAND CORP.; JANE
KNITZER, DIRECTOR OF PROGRAM AND POLICY ANALYSIS,
NATIONAL CENTER FOR CHILDREN IN POVERTY, COLUMBIA
SCHOOL OF PUBLIC HEALTH; DAVID OLDS, PROFESSOR OF
PEDIATRICS AND PREVENTIVE MEDICINE, UNIVERSITY OF
COLORADO; AND PETER G. BURKI, CHIEF EXECUTIVE OFFI-
CER, DEPENDENT CARE CONNECTION, INC.

Ms. Karouy. Good morning. Thank you very much, Mr. Chair-
man and members of the subcommittee. I am delighted to be here


‘Written Testimony of Lynn A. Karoly 2

+ Do early interventions targeted at disadvantaged children benefit participating children
and their families? After critically reviewing the literature and discounting claims that are
not rigorously demonstrated, we conclude that these programs can provide significant
benefits.

+ Might government funds invested early in the lives of some children result in compensating
decreases in government expenditures? Here, we examine the possibility that early
interventions may save some children (and their parents) from placing burdens on the state
in terms of welfare, criminal justice, and other costs. Again, after updating and refining
earlier estimates, we find that, at least for some disadvantaged children and their families,
the answer to this question is yes.

We use words like “can” and “might” deliberately. We cannot freely generalize these
conclusions to all kinds of targeted early interventions, especially not to large-scale programs,
because of various limitations in the evidence collected to date. We pay special attention in our
analysis to these limitations, which have important implications for future initiatives. In
particular, these limitations suggest that better evaluations of new and continuing intervention
efforts would be of great value to future decisionmaking.

‘What Are the Benefits?

The term “early intervention” can be broadly applied. It can be used for services generally
available to and needed by many children, such as immunizations and child care, and to
programs not specifically aimed at children, such as Food Stamps and Medicaid. In Investing in
‘Our Children, we restrict its application to programs targeted to overcome the cognitive,
emotional, and resource limitations that may characterize the environments of disadvantaged
children during the first several years of

Even the term “targeted early intervention” is a broad concept. It covers programs concerned
with low-birthweight babies and those concemed with toddlers in low-income familie
interventions targeting children as well as those targeting their mothers; services offered in
‘homes and those offered in centers; programs aimed at improving educational achievement and
those aimed at improving health; and services as diverse as parent skills training, child health
screening, child-abuse recognition, and social-services referral.

This diversity makes it impossible to draw overall generalizations about “targeted early
intervention” and limits us to inferences as to what some programs can do, depending on the
characteristics of the program and the families it serves. Furthermore, given the shortcomings
and limitations in the design of many early intervention evaluations and the measures omitted
from them, what we don't know about the effects of early childhood intervention may exceed
‘what we know (more on this appears below). Nonetheless, our review supports the proposition
that, in some situations, carefully targeted early childhood interventions can yield measurable
benefits in the short run and that some of those benefits persist long after the program has ended.

We reached that conclusion after examining a set of nine programs in which evaluations had
been performed that assessed developmental indicators, educational achievement, economic
well-being, and health for program participants and compared them with the same measures for


5

Mr. Towns. Thank you very much, Mr. Chairman, for holding
this hearing.

The future of our Nation depends on the education of our chil-
dren. Early intervention assures that each child begins school with
an understanding of basic concepts, learning in a group setting, co-
operating with others, and following instructions. These concepts
are key in school, society and life.

We in Congress fund these programs as if they are not impor-
tant. A total of $4 billion has been appropriated for Head Start for
fiscal year 1998 and $279 million for Early Head Start. These pro-
grams provide a comprehensive preschool experience for low-in-
come children. However, Head Start only meets for part of the day.

Part of the welfare reform mandate is that parents of preschool
children work for 20 hours per week. Most of these parents will
only find work in service occupations. Hotels, restaurants, and re-
tail stores, do not run on a 9 to 5 schedule. They are open almost
24 hours a day, 7 days a week. Finding decent, affordable child
care for this kind of nonstandard work schedule is very, very dif-
ficult. Finding an enrichment preschool program that fits this kind
of schedule is almost impossible. Therefore, the child care promised
by many during the welfare reform debate will not be the kind of
care that will help families succeed.

According to the Inspector General of the Department of Health
and Human Services, so far child care under welfare reform has
only produced a voucher system that requires parental co-pay-
ments. Most of the care is given through informal arrangements.

Mr. Chairman, in Denmark, France and Italy, preschool teachers
are public employees who receive salaries, pensions, leave and
health benefits. ‘These countries have decided that the care and
education of preschool children is important, and they have made
it a priority. In America, we call children our greatest natural re-
source, but we do not act as if they are. Therefore, while we discuss
these wonderful State and private programs here today, let us not
forget that most of America’s poor children, the children who need
these programs the most, will not participate in any kind of enrich-
ment activities and will receive second-class care.

Let me again, Mr. Chairman, thank you for holding this hearing
today, and I look forward to working with you to demonstrate that
our children are important. And I agree with you. They are only
27 percent of the population, but they are 100 percent of our fu-
ture. And I yield back.

Mr. Suays. I thank the gentleman very much.

[The prepared statement of Hon. Edolphus Towns follows:]


lll

with a state-level Family and Children First Council, then invited counties to
develop their own councils. Initially in a few counties, such councils now exist in
each of Ohio’s 88 counties, with the state providing technical assistance and
support. These councils are now beginning not to just plan, but also to manage
resources. All have family members as part of them. The state has also invested
significantly in a state-funded Head Start program, and most recently, in Early Start,
an early intervention home visiting program for young children and families at risk
by virtue of environmental and biological risk factors. (Particularly noteworthy is
that the state has targeted TANF dollars for this program and made it available to
those receiving or at risk of receiving welfare.)

The states providing the strongest leadership on behalf of young children and
families share several characteristics. (1) The effort is bipartisan and involves
leaders from both inside and outside the government. (2) Efforts to build community
support co-exist with efforts to fund programs and increase resources for effective
services. There is an interweaving of multiple, deliberate strategies. (3) In most
instances, there is a clear framework for action, reflected in statements of basic
goals for young children. (4) The states all started in different places, with different
mixes of services and leadership, but the vision and the commitments have
continued to evolve. (5) The need for more resources is critical; infrastructure
development and community mobilization is necessary, but not sufficient. 6) New
partnerships do bring new resources to the table.

Iplications and Recommendations

Taken together, there are two central messages from Map and Track. First,
states are making progress focusing on young children and families, but with some
exemplary exceptions, neither state leadership nor state investment is deep enough
across all the states. Second, Map and Track not only documents the current state of
the art of early childhood initiatives but it also points to new directions that might be
supported either by the states or the federal government or both, which are provided
in detail below.

© Distinctions among different types of program approaches are blurring as states
strive to create program approaches, whatever the age focus, to address
parenting issues, child development issues and adult development issues,
including literacy and employment skills.

© Flexibility in how dollars can be used, along with careful planning processes and
accountability mechanisms, are critical. Program-by-program funding streams,

7


81

for the savings to government both by improvements in mothers’
outcomes as well as in the children’s outcomes. In this case, the
program, which costs about $6,000 per mother-child pair, generated
savings that were about four times as large, roughly $24,000. In
this case total savings to government, therefore, exceeds expendi-
tures by a ratio of about 4 to 1. Moreover, since the savings to gov-
ernment accrued largely due to changes in the mother’s behavior,
these were savings that were generated very early on, soon after
the program ended, so that the program payback period was rough-
ly 3 years; in other words, the savings generated paid back the
costs within a 3-year timeframe.

In other cases, the savings to government will take longer to ac-
cumulate, particularly if the benefits accrue to participating chil-
dren. Many of those benefits will not be realized until those chil-
dren are in school, until we see the savings because of lower special
education costs, reductions in crime ‘and delinquency, as well as
savings later on as those children become adults. In the Perry Pre-
school example, we estimated that the program costs, which were
about $12,000 per child, generated savings to government of about
$24,000 per child, a ratio of 2 to 1, but that those savings took
longer to accrue, so that the payback period was closer to 20 years
rather than the shorter period we saw for the Elmira program.

In addition to these savings to government, I mentioned as well
that there are benefits to other members of society. Other members
of society benefit from savings in terms of reduced levels of crime
that benefit potential crime victims, as well as the increase in in-
come to program participants.

I would like to emphasize that these studies do pertain to dis-
advantaged children, so that program targeting is a critical issue.
The ability to target individuals who will benefit most from these
programs is likely to generate the greatest amount of savings to
government.

In conclusion, I think that we can identify proven models, pro-
grams that have been carefully evaluated, that have demonstrated
successful track records in terms of the benefits to participating
families and children, as well as in terms of savings to government.
But also we have much yet to learn in this area, so that continued
evaluation is critical as we implement new programs or take exist-
ing models and extend them on a larger scale. Only in this way can
we make sure that these investments produce the greatest return
for our dollar.

Thank you very much.

Mr. SHays. Thank you, Dr. Karoly, we are going to be asking a
question or two about those studies. Thank you very much.

(The prepared statement of Dr. Karoly follows:]


188

Overview for COMPANY

Special Needs

DCC counselors can provide a full-range of assistance for children with physical. cognitive and
‘emotional impairments or conditions, as well as for those who have exceptional abilities.
‘Counselors can also provide information and referrals on services for other family members.

Special needs services can pertain to and include:

© Allergies

© Asthma

© Cerebral Palsy

© Diabetes

© Seizure disorders

© Traumatic brain injury

© Blind/visual impairments

© Physical/orthopedic impairments
© Medically fragile/high-risk infants
© Injuries

© Common childhood illnesses
© Terminalty/chronically ill

© Genetic disorders

© Down Syndrome

© Obesity

© Multi-handicapped

© Developmental delays

© Deat/hearing impairments

© Autism

© Amention Deficit Disorder
(ADD/ADHD)

¢ Menvally challenged

Learning disabilities
Dyslexia

Speech/language impairments

English as a Second Language (ESL)
Assistive devices

Merually il

Social/emotional disturbances
Behavioral difficulties
Physician/specialst referral lines
Parenting education classes

Suppon and advocacy

Laws and legislation

Funding and financial guidance

Child, respite and hospice care

Early intervention services

Day treatment centers

‘Therapeutic programs

Recreational. residential and educational
programs

Gifted and talemed programs

Testing/assessment information

DCG-==


107

child and family well-being and information about welfare decisions of special
relevance to young children. All 50 states provide data and review the profiles
before publication.

In my testimony today I would like to do four things: first, describe briefly the
overall findings from the 1998 edition of Map and Track, second, highlight some of
the states’ major strategies, particularly giving examples of public-private
partnerships; third, identify some of the critical issues the report raised; and fourth,
talk about the implications for future state and federal policies.

The Overall Findings

There is growing recognition across the states about the importance of
developing comprehensive programs for infants, toddlers, and preschoolers. These
programs are comprehensive in the sense that they seek to enhance the young
child's development, help parents meet the challenges of parenting and link both
parents and children to other needed support services (See Appendix B for an
overview map).

+ Almost half of the states (24) report supporting statewide comprehensive
programs for infants and toddlers. Since 1996, ten states have started or added
new programs. These new programs appear to be at least in part developed in
response to the emerging information about the importance of early brain
development in young children. Funding levels range from one or two million
dollars to $31 million.

Program strategies include: outreach to new parents (typically, these aim to
be universal); comprehensive programs for high-risk infants and toddlers;
parenting education and family support initiatives to provide basic information to
families and to strengthen infant-parent relationships; and, initiatives to meet
special needs (for example, programs to meet the needs of parents with mental
illness or substance abuse).

+ Thirty-four states report expanding or supplementing existing programs for pre-
school age children. State expenditures for these programs range from $300,000
to $200 million.

Program strategies include comprehensive prekindergarten programs, state
support for Head Start, parent education, family support and family literacy


92

Lynn A. Karoly Page 2

PUBLICATIONS

Karoly, Lynn A. and Jeannette A. Rogowski, “Retiree Health Benefits and Retirement
Behavior: Implications for Health Policy.” in Health Benefits and the Workforce,
Volume 2, U.S. Department of Labor, Pension and Welfare Benefits Association,
Washington, D.C., pp. 43-71, 1998.

Rogowski, Jeannette A., and Lynn A. Karoly, “COBRA Continuation Coverage: Effect
‘on the Health Insurance Status of Early Retirees,” in Health Benefits and the
Workforce, Volume 2, U.S. Department of Labor, Pension and Welfare Benefits
Association, Washington, D.C., pp. 73-93, 1998.

Karoly, Lynn A., Peter W. Greenwood, Susan S. Everingham, Jill Houbé, Rebecca
Kilburn, C. Peter Rydell, Matthew Sanders and Jim Chiesa, Investing in Our
Children: What We Know and Don't Know about the Costs and Benefits of Early
Childhood Interventions, MR-898, Santa Monica, California: The RAND
Corporation, 1998,

Dertouzos, James N. and Lynn A. Karoly, “The Implications of Employment Liability
for Welfare Reform," Journal of Labor Research , XIX(2), Spring 1998, pp. 295-
311.

Karoly, Lynn A., “Growing Economic Disparities in the U.S.: Assessing the Problem
and Policy Options,” in James A. Auerbach and Richard S. Belous, eds., The
Inequality Paradox: Growth of Income Disparity, Washington, D.C.: National Policy
Association, 1998, pp. 234-259,

Karoly, Lynn A., “Anatomy of the U.S. Income Distribution: Two Decades of Change,”
Oxford Review of Economic Policy, 12(1), Spring 1996, pp. 76-95 (also available as.
RAND Reprint RP-512).

Frankenberg, Elizabeth and Lynn A. Karoly, The 1993 Indonesian Family Life Survey:
Overview and Technical Report, RAND DRU-1175/1, December 1995.

Karoly, Lynn A. and Gary Burtless, “Demographic Change, Rising Earnings Inequality,
and the Distribution of Personal Well-Being, 1959-1989,” Demography, 32(3),
‘August 1995, pp. 379-405,

Klerman, Jacob Alex and Lynn A. Karoly, The Transition to Stable Employment: The
Experience of U.S. Youth in Their Early Labor Market Career, MR-564, Santa
Monica, California: The RAND Corporation, 1995.

Karoly, Lynn A., and Jeannette A. Rogowski, “The Effect of Access to Post-Retirement
Health Insurance on the Decision to Retire Early,” Industrial and Labor Relations
Review, 48(1), October 1994, pp. 103-123 (also available as RAND Reprint RP-360).

Karoly, Lynn A., “Trends in Income Inequality: ‘The Impact of, and Implications for,
Tax Policy,” in Joel B. Slemrod, ed., Tax Progressivity, New York: Cambridge
University Press, 1994, pp. 95-129.


Table of Contents

Section
Introduction and Industry Experience
DCC Single Source Model

Counselor Qualifications

‘Case Management Process

LifeCare Services

LifeCare Educational Resources
Welfare To Work Initiatives

Quality Assurance Program

LifeCare® Nero

‘Communication and Promotional Services
EAP and Work/Life Benefits Integration
Management Reporting

Client References

A Final Note

180

45

617

17-18

18-20

20-24

24-25

25-26

26-28

29


183

Overview for COMPANY

Case Management Process

Il of DC's counselors and LifeCare services are available to client employees 24 hours a
day. 365 days a year. through one toll-free number. DCC also has a second toll-free number
for the hearing impaired. With DCC’s extensive single-source, in-house database, counselors
can access service providers specific to a client's needs at anytime.

COMPANY employees go through these steps with DCC counselors during the case process:
Day Step _| Description of Activity

Day 1 ‘Step 1_| Toll-free telephone call or contact via LifeCare® NewTM
Step 2_| LifeCare needs assessment

‘Step 3 | LifeCare education and counsel

Days2-5__| Step 4 | Referral research

‘Step 5__| Referrals are phoned. faxed or e-mailed to employee
‘Step 6 | Referrals, educational materials and quality assurance
jstionnaire are mailed to employee

Days 6-24 | Step 7_| DCC counselor follow-up (employee designates timetable
Days 31+ | Step 8 | Compilation of case information for COMPANY
management reporting

Each step outined in the above charts explained below.

‘Step One:
A.COMPANY employee makes a toll-free call to a DCC triage counselor. Based on the calling
employee's needs, he or she is immediately forwarded to a DCC LifeCare counselor who will
work with the employee throughout the entire case process (this includes performing case-
specific research). COMPANY emplovees may also e-mail their caregiving requests from the
Internet or LifeCare Net.

Step Two:

The LifeCare counselor then conducts an intake and needs assessment with the calling
employee. which lasts an average of 25 to 30 minutes. During this time, the DCC counselor
assesses the employee's LifeCare needs. A dialog of questions and answers. informative
descriptions and definitions helps the employee to determine the most appropriate care type

Step Three:

[At this point, the DCC counselor advises the employee on dependent care selection and
‘evaluation. The counselor is available to answer questions and address all concerns.

Step Four:

‘The DCC counselor uses our comprehensive database of over 2.5 million providers to identify
appropriate dependent care in the employee's geographic area. The counselor calls each
Jicensed provider to find a match for the employee's needs. When the counselor has found the
most appropriate care providers for the case. he or she generates referrals which detail the
program and all case-specific information. .

DCG--—



Aedren
‘Contra Falls COZ,
Coneral Fale Scoot

Department
21 Hedley Avene
Connra Falla RI O263
on nrr100

‘Sate

Coordinator (part-ime)

‘Chron reach
indergartan ready
sear.

‘Parent are lvotved in
‘heir chldrees education.
(Chihdren and fries are

‘emotional beak,
Parents have resources
‘hae support thei ole as

60

CENTRAL FALLS
CHILD OPPORTUNITY ZONE
coz Grade Total Percent
‘School Levels Eneollment Low-Income
(Captain Hune Ear Schoo! pre and K 39 100%
Advisory Board

‘The COZ/Famiy Support Center Parent Adiiory Board, comprised of 20 parens gives advice and
eas on programs tobe offered and publaher a parent newslerer Representatives of 9 pariner
gence the Captain Hunt School principal and 4 Captain Hunt teachers and seaff paricpate lx
panning meetings and dscusions but donot vote.
‘School Location and Community Location
‘Acuvies of the Central Fails COZ ae inked with the Captain Hunt School. The COZ does ot have
famay cener space tthe schoo! Stull for the COZ andthe communty-based COZ sie ae
frequently atthe school working with eachers, parents, and children The Family Support Cente.
‘operated by Childrens Friend and Services the community-based ste forthe Cental Fall COZ The
Farly Support Center offers incense home, center and school-based services to children under five
1 hel famies. Services are avaiable in Englsh and Spanish The contac forthe Family Sepport
‘Center in Cerra Falls is Fatma Marans 729-0008.

Funding 1997-1998: $91,456

‘ae eed pr fers ve td spe fr el nha iene enn ng
‘Reto Span Come pb Cnt nd on ence cas ae

cox ten ee om
secret

Ssarng Poets (Deparumen of Education.
eparonen of Hash Usted Wy Coreg

ia

Stool Ditret

Program Components
Parent Support and Education

Far Support Center operated by Childrens
Friend and Service provides information relera.
and fotow up for indidual tris: Crisis
‘neervenvon for fades Early Sart - intensive
home-based faty support services Parenuing
“suppor groups emergeney clothing dapers.
Formula Resource Counselor for parents of
<thdren wi are dnable (RI Parent Information
Nerwork) Transporation’ chil care 22
programs (Sarting Poe)

Infant and Pre-School Programs

Parents ar Teachers (Schoo! District RIYouth
Guidance; Buking Bridges (School Drie):

Famiy Support Center provides: Consolation
with teachers on chlden's mancl heath,
Expressive therapy group for children: Support
foc parens and children in the transition to
kindergrce:The Right Quescon Proje,
Teacher referral of eileen wih signs of
‘emovoral problems.

School-Linked Health and Socal Services
‘Child Outreach screening at she Family Support
Center (School Dstt) Incensive home-based
amy support. cid counseling serace kage
(Farly Suppore Cente): Lead polsoning
prevention education (VNA};Lead polsoning
‘Screening and teeaument(Sarng Poin, Fatma
‘Cine Payground safety project

HIPPY (School District): Summer story hour: Adult Education
Healy body curricukem a Caprain Hone School GEDY ESL classes (RIRAL Literacy Volunteers)
cc Learning and: Family and C

LGteragy aight and lending library at Capain
Hunt Sehoot

Parent Newsleer. Far eld eps Fl fur;
"May breafast Pot luck suppers


“Toes! nding ver five
year lnclding Starting

—
is

‘Total Ring 1997-1998,
Including Searing Poe:
sear.00

56

Child Opportunity Zone Famity
Center Funding 1993-1998

‘The initial funding to launch the Child
Opportunity Family Centers in 1993-
1994 was a partnership among the Rhode
{sland Department of Education, Rhode
Island Department of Substance Abuse
(integrated into the Rhode Island
Department of Health in 1995), and the
United Way of Southeastern New
England. The Department of Health
joined the funding partnership in 1995-
1996, Since that time the Child
Opportunity Zone Family Center
statewide iniciative has been funded by a
partnership of the Rhode Island
Deparement of Education, the Rhode
Island Department of Health and the
United Way of Southeastern New
England. Other funders ofthe initiative
hhave included the Department of
Children. Youth, and Families and the
Rhode Island Foundation

In 1996-1997 and 1997-1998, the Stare
‘of Rhode Island received funds from the
Carnegie Corporation of New York 0
integrate che Starting Points focus on
children bith to thice into Rhode Island's
‘COZ Family Cencer initiative. Carnegie
provided $150,000 over wo yeas 10
support early childhood work in nine
communities with COZ Family Centers.
‘The Starting Points funding was
supplemented with $215,000 in
additional funds over two years from the
United Way of Southeastern New
England, che Rhode Island Department of
Health, the Rhode Island Department of
‘Education, and the Rhode Island
Department of Children Youth and
Families. The Scaring Points funding has
«enabled the nine Stating Points
communities co focus increased arcention
con issues of childcare, eatly childhood
education and the transition co
kindergarten, and parent support and
education

‘Statewide Funding of Child Opportunity Zone Family Centers

1993.

1998

United Way of Southeastern New England

4x

‘Carnegie Corporation of New York
RIDCYF 2x,
“The Rhode Island Foundation /
58%. RI Department of Education

Ri Department of Health 20%

‘Total funding over five years= $2,915,775

(does not nchide funds rated local school district match or non-COZ Family Cent rants to
toca communities; does inclade SeartingPoins funding of $365,000 over two years)


18

. Missouri, under then-Governor Bond, started Parents
As Teachers, an Internationally recognized early

childhood family education and support program;

. in Rhode Island, Governor Almond helped create
Rite Care as well as Starting Rite, an expansive
effort to make quality child care more accessible

and affordable;

. And the National Governors’ Association, under
Governor Miller and Governor Voinovich's
leadership, has made early childhood development

a top priority for the nation’s governors.

| myself have taken what I've learned in the last four years and
helped craft, and am chatiring, a California Initiative called the
California Children and Familles initiative, which has recently
officially qualified for the November ballot. It proposes the

creation of a comprehensive, integrated approach to early


AT

difficulty in areas where there is a high degree of poverty is, there
might be programs there——

Mr. REINER. But they can’t access them.

Mr. Kucinicu. Exactly. Talk about outreach for a moment.

Mr. REINER. That’s one of the wonderful things that Healthy
Families of America does. They engage the community. By the way,
this has to be done on a community-by-community basis. It doesn’t
work any other way. If you have the right kind of intervention pro-
grams, you find the right entry.

I know what Healthy Families does, I know the programs it does
because of the one we did in Hampton, VA. They take up with the
churches, with businesses, with schools, with libraries, with the
health care organizations, and State-run agencies and find many,
many points of entry into the system. They look to find families at
risk. They identify families at risk.

What I have experienced, and I don’t know if Felicia will tell you,
is 90 to 95 percent of the people who are approached, when they
are identified and approached properly, say, yes, they want to be
involved. Nobody wants to be a bad parent. They just don’t know
that it’s available.

So you need the right kind of intervention program that under-
stands the concept of outreach and is able to do it effectively.
Healthy Families of America, I think—you will correct me—has
about 260, 300 now, communities around the country and they are
very successful. But we need to proliferate that, and it can be done.

Mr. Kucinicu. Mr. Chairman, I want to thank you. I think this
overall point about outreach is critical, because no matter how
many resources might be marshaled, we have to make sure that
people can have a chance to be lifted out of the circumstances of
their poverty, which includes such a degree of social disorganiza-
tion that they may not even know that some service may exist,
even though it is on the same block.

Mr. REINER. One of the things you are wrestling with is you have
8 million children eligible for Medicaid who don’t get it because
they don’t know it exists. That’s why we need an integrated system
of health care, child care and parent education, so that we can link
people up; so that whatever point of entry they make into our so-
cial system, they can be linked up; so that churches and schools
and hospitals and pediatricians—one of the things we do is we
have 154 national organizations which are trying to do that, link
up with other organizations, so they’re not working so piecemeal.

Mr. Kucinicu. Mr. Chairman, I want to thank you again.

Governor ALMOND. I was just going to add, in Rhode Island, we
have what we call COZYS, child opportunity zones. They are in the
urban areas. It is one-stop shopping; we integrate all the social
service programs in the schools, working with the parents and with
the children from health care to child care to every other service
that’s available. We provide that.

Mr. Kucinicu. If I could ask, Mr. Chairman, I would particularly
be interested and I am sure the committee would.

Governor ALMOND. We will send you the material on that.

[The information referred to follows:]


Rationale for
‘School-Linked Services

Promoting School Readines and School
Succes

Recent brain research has heightened
awareness ofthe critical effects of the early
‘environment on children’ social
‘emotional, physical. and cognitive
readiness for school.’ Babies cased in safe
and stimulating environments are bevcer
learners later in life than those raised in
Jess stimulating environments. In order to
develop pre-reading skills, children need
to have caring telationships wich adults
who listen and talk co them, tell them
stories, share books and music, nd play
with toys, crayons, and writing material

Studenes’ economic conditions, home
ceavitonmenss. and cueural backgrounds
‘an profoundly affect their adjustment 10
and performance in school, Children’s
academic achievement is higher when they
live in communities chat provide
supportive environments for parencing
and havea vaiery of out-of choot
learning opportunites for both adults and
childre.* Schools ae finding that they
‘ean best serve che needs of chkdren by
becoming more family-centered and by
increasing collaboracion with support
services in che community?

CChildeen who stat school poorly
prepared for formal schoolwork often fll
further behind — until poor performance,
low self-esteem, alienation, and frustration
cause them ro drop our of school Child
wear, human servic, and juvenile
justice professionals recognize that poor
school performance is often an early
warning sign ofa child ac risk for
involvement in juvenile crime, substance
abuse teen pregnancy, of welfare
dependency. School-linked services can be
an important resource for children who
are growing up in families struggling with
povery, language barirs. poor literacy

51

and basic sills; who live in families wich
substance abuse, domestic violence, or
ther social problems; or who live in
communities with limited acess to child
cate, befote- and after-school atwvities,
and recreational opportunites

Improving Orcomes by More Effective Use
‘of Education, Health, and Socal Service
Resources

‘A second factor propelting the
development of schooblinked service
snodels nationwide isthe recognition thar
‘improving outcomes for children requices
more effective integration of existing,
resources for health, education, and social
services. The cacegorical funding
approaches of the past rwo decades have
made ie diffcule to provide appropriace
preventive services ro children and
families. Schoot inked services offer an
added value tothe existing network of
services that are often too fragmenced,
categorical, and crsis-oriented 10 offer a
good match with what files need ro
succeed.”

By supporting families before chey get
inco rouble and by connecting families to
existing tesources in the community,
schooblinked Family centers support the
missions of child and family serving
agencies and the wider communicy.
Schools want 10 improve student
achievement. Health and social service
providers want physically and emotionally
healthy children and families sha wil
bbecome productive workers and citizens.
‘Communities want better ourcomes for
children, Citizens wane co be sue chic tax
dollars yo to programs that work, Fundess
and policymakers ate seeking ways co
provide service that are cost<ffectve.
Families want services that respond
flexibly co their needs and priorities.

‘often an earty warning
ign of child a ee for
Invorernent in jurerite
crime, subreance abu,
teen pregnancy. or wellare
dependency.


80

at ages 3 and 4, and offered high quality preschool programs to dis-
advantaged children.

All of these programs, I should emphasize, did target disadvan-
taged children. So, much of what we know about early childhood
intervention is specific to children who face disadvantages early in
childhood. We know much less about the effect of these programs
on children more broadly distributed across the population.

Despite the diversity of these programs in their design and their
features, we did find a consistent result that the programs that
were evaluated do show important gains to both children and their
families. These include gains in emotional and cognitive develop-
ment, substantial improvement in educational processes, increases
in economic self-sufficiency measured by things like reductions in
welfare participation, reduced levels of crime and juvenile delin-
quency, higher levels of employment and income in adulthood, as
well as improvement in health outcomes.

Let me just give you a couple of examples. One study that we
looked at, for example, showed that children who participated in
the intervention experienced a 52 percent reduction in the use of
special education services by age 15; this is compared to a group
of children who did not participate in the program. Likewise, an-
other study evaluating children who participated in a program by
age 15 found a 73 percent reduction in measures of juvenile crime
and delinquency.

One study that we examined which included the longest follow-
up, measuring outcomes for children in adulthood, when they were
age 27, showed that children who had participated in a high qual-
ity preschool program had earnings at age 27 that were 60 percent
higher than nonparticipating individuals.

In another example, some of the benefits accrued to the parents
who participated in the program. In this case, mothers of children
in the intervention experienced a 33 percent reduction in welfare
utilization by age 15 of the child, again compared with mothers
who did not participate.

Let me say just a little bit more about the costs and benefits of
these programs and, in particular, the savings to government. For
some, the types of benefits that I have just mentioned might be
enough to justify these programs. But we could also put them in
economic terms.

In two cases of the nine programs we examined, it is possible to
undertake a cost/savings analysis which we did to compare the pro-
gram costs with the savings generated down the line. In particular,
we took into account the savings to taxpayers as a result of early
intervention programs in the form of higher taxes paid by program
participants, both mothers during the time that their children were
in the programs, or afterwards, as well as the children once they
became adults, savings to taxpayers in terms of reductions in social
welfare spending like welfare programs, and subsidized health
care, reductions in the cost of criminal justice expenditures, as well
as other special savings such as in education.

One example that I will highlight, which you will probably hear
more about from Dr. David Olds, was the Elmira natal/Early
Infancy Project implemented in New York. In this case, children
have been followed through age 15, and we were able to account


142

major urban area. We hypothesized that the effects of the program would be found in the same
‘outcome domains as we observed in Elmira and that the same background variables would
moderate the effect of the program. So, for example, we hypothesized explicitly that the effect of
the program on birthweight and length of gestation would be greater for women who smoked
cigarettes and were young teens (<16 years of age at registration). Even though the program
effect on hypertensive disorders of pregnancy in Elmira was not statistically significant, we
hypothesized that the program would reduce the rates of pregnancy-induced hypertension in
‘Memphis, given high rates of this problem in African-American pregnant women bearing first
children.

In planning this study, we conducted extensive pretest and pilot work in Memphis and
learned, among other things, that the rate of state-verified cases of child abuse and neglect among
low-income first-bom children in Memphis was too low (3-4%) to serve as a viable outcome in
this setting. We therefore chose not to hypothesize program effects on rates of state-verified
cases of child abuse and neglect, but instead hypothesized that the program would produce
effects on children's health-care encounters for injuries that would be like those observed in
Elmira - .c., greater for women with few psychological resources. In Memphis, we hypothesized
that the effects would be greater for women with more mental-health symptoms and limited
intellectual functioning in addition to limited sense of control, as observed in Elmira." Finally,
given that the effects of the Elmira program were greater for women who were unmarried and
from low-income families, we focused recruitment in Memphis on this population.

‘The program was conducted through the Memphis/Shelby County Health Department.
From June 1990 through August 1991, 1290 women were invited to participate and 1,139

enrolled through the obstetrical clinic at the Regional Medical Center in Memphis. Women were

20


185

health problems and to use the health-care system to address those problems, they enhance their
clinical effect through the early detection and treatment of disorders. Each nurse carried a
caseload of 20-25 families and received regular clinical supervision.
C. Program Content

During the home visits, the nurses carry out three major activities. They promote
adaptive change in women’s behavior thought to affect the outcomes of pregnancy, the health
and development of the child, and matemal life course; they help women build supportive

relationships with family members and friends; and they link women and their family members

with other health and human services. The nurses follow detailed visit-by-visit program
protocols. The content of the protocols is organized developmentally to reflect challenges that
‘women are likely to confront at different stages of pregnancy and during the first 2 years of the
child's life. Specific assessments are made of maternal, child, and family functioning, and
specific educational content and psychosocial interventions are prescribed, depending upon the
nature and degree of vulnerability revealed in the assessments.

V. OVERVIEW OF RESEARCH DESIGNS, METHODS AND FINDINGS

In each of the three studies of the program described above, women were randomized to
receive either home visitation services during pregnancy and the first two years of the children's

lives or comparison services. While the nature of the home-.

tation services was essentially
the same in each of the trials, the comparison services were slightly different. The designs and
methods employed in each of the trials are outlined below.
‘A. Elmira Design and Methods

‘The first study was conducted in a small, semi-rural county of approximately 100,000

residents in the Appalachian region of New York State. The program was conducted through

“4


13

SUBCOMMITTEE ON HUMAN RESOURCES
Testimony by Rob Reiner
(to be delivered 9:30 a.m., 7/16/98)

| want to thank Congressman Shays and Congressman Towns
for giving me the opportunity to testify on behalf of our

youngest citizens.

You may have heard the story of the stream of innocent bables
floating down the raging river towards the looming waterfall
and the concerned citizen who feverishly tries to pull those
babies out of the river as they head towards their certain doom.
Another concerned citizen approaches and asks what the first
guy Is doing. He says, "I'm trying to save these bables—please
help me.” At which point the other guy starts running upriver.
The first guy says, "Where are you going? The babies are
passing us by.” The second guy says, "I'm going upriver to stop

whoever's throwing these babies in.”


137

transportation services offered Treatment 2 but in addition were provided a nurse who visited
them at home during pregnancy. Families in Treatment 4 (n=116) were provided the same
services as those in Treatment 3, except that the nurse continued to visit through the child's 2nd
birthday. For assessment of the prenatal phase of the program, Treatments I and 2 were
combined and compared to the combination of Treatments 3 and 4.

Assessments of outcomes were made by interviews, observations of mother-child
interaction, observations of conditions in the home, and reviews of medical and social service
records by individuals who were not aware of the women’s and children’s treatment assignment.
Details of the research design and methods can be found in our earlier reports.'""*

B. Elmira Resatts

At the stage of randomization, the treatment conditions were essentially equivalent on all

‘background characteristics examined. Moreover, at the 15-year follow-up, assessments were

completed on over 90% of the women and children origi

ly randomized who did not die ot
where there was no adoption. Low attrition and no treatment-control differences in background
characteristics on those assessed after enrollment means that the estimates of program effects
‘were not biased by loss of families. All analyses of program effects were based upon an
intention-to-treat approach, that is data were employed for outcome analyses irrespective of the
degree of program participation.

{tis important to note that we hypothesized that the effects of the program would be
‘greater for families who experienced greater stress and had fewer resources to cope. We tested
this hypothesis by focusing the analysis on low-income unmarried women.

1, Caregiving and Child Development Results. With few exceptions, the beneficial

effects of the program on caregiving outcomes were not present for the sample overall. Nurse-

16


Child Opportunity Zone
Family Centers 1993-1998

COZ Family Centers ate operational in
13 Rhode Island communities ss ofthe
1997-1998 school yeat. The Child
‘Opportunity Zone Family Centers were
‘originally funded with planning grants in
1993-1994 and 1994-1995. The range of
funding in the planning years varied from
$3,000 10 $60.000 per communicy
During the planning phase, a community
resource and needs asessment was
completed by all ste to provide
information used to set goals and
priorities for the COZ Family Center. tna
{ew communities, parents have been and
continue to be extensively involved in
‘making decisions about prograrn design
and implemencation, Most COZ Farnly
Censer communities ae just Fishing
thee thied of tourth year of operation.

Funding through the state COZ. Family
Center iniiate sn the 1997-1998 fiscal
year is $35,000 per COZ community
This funding evel requires chat COZ
Family Gencer communities seek other
sources of funds for programs and make
linkages with existing programs in order 10
address local needs and priors, Each
‘COZ community has developed 3
working partnership that involves the
school. human service agencies.
community members. and parents. There
isa deliberate focus on doing whatever i
rakes co break down the fragmentation of
the existing service delivery model,
facthiate access wo services, and connect
parencs co each other and co informal
support necworks in he communi.

‘Of the thirteen communities involved in
the COZ Family Center i
are working in more than one school in
the district. Eight have school-based
Jocations for their Family Ceacers, one has
«community-based location, and four
have both school and community-based

55

locations. COZ Family Centers ate
connected with 32 elementary schools. 2
middle schools, and 2 high schools in che
13 participating communities

COZ Family Center
Core Areas

While che COZ Family Center Initiative
does not requite a core se of program.
components all sites are expected 10
develop programs and services that help
childten experience success in school by
focusing on one or more outcomes in four
Childrens Learning Environments
Allchildten will ave access o high
qualigy and developmentally appropriate
catly childhood experiences and
opportunites to lesen in school, in before-
and afterschool programs. and during the
summer - in environments fee of drugs
«time, and environmental hazards
Plyscal and Mental Health

All children and families will be provided
with health informacion and education
and will have acess to primary care
services, including prenatal cae. well child
«ate speciale care, mencal health care.

Economie Opportunity
All amiles will have access 0
opportunites information seviees and
education that enable them co be
economically self-sufficiene including
aide education, job shall aiming lecacy
training, and carer development

Family Support

All parents will have access to information,
‘opportunites, services and education co
support their tole as parene. A
continuum of opporcunicies will be
available for parents to be involved in thei
children’s education. All fais will have
access to food. clothing, and housing,
among other basic needs

Wile te choot ete
are actively volved io
forging partnerships with
‘ce -memunity agences ant
(amen school are
meant tobe apartner
among equals. COZ
Family Centers are chen
“the schoo! but nt
soley ot” the schoo.

‘The COZ Family Center



2

And how can those successes be measured and replicated as States
implement welfare reforms and demand for quality child care
grows?

We focus on public-private partnerships in the development of
early childhood programs because one fundamental premise is al-
ready clear: affecting the lives of pregnant women and their chil-
dren requires a comprehensive, intense and integrated approach,
involving government, health care providers, employers and others.
Charting a healthy, productive course for a mother and her baby
serves human service, public health and economic development
goals. Both public and private sectors have an undeniable stake in
the outcome, and each has an indispensable role to play in achiev-
ing it.

At our hearing on Early Head Start programs, my friend and col-
league Senator Chris Dodd put these issues in the right perspective
when he observed that children represent only 27 percent of our
population, but 100 percent of our future. In well-designed, science-
based early childhood development efforts, we have the power to
shape that future for the better.

Our witnesses today bring diverse experiences, deep commitment.
and impressive expertise to the discussion of early childhood devel-
opment issues. We sincerely look forward to their testimony.

At this time, I would recognize the ranking member of this sub-
committee and an equal partner in all of our hearings, Mr. Towns.

[The prepared statement of Hon. Christopher Shays follows:]


174

Today, the concept of early childhood intervention, once reserved
for families at risk, has been extended to all children and parents
as a means of providing the best possible start. When you consider
all the learning and development that takes place during the first
3 years of life—cognitive and motor skills, language, learning, emo-
tional control, social interaction—it’s no wonder that we want more
than ever before to ensure that our children get the care they need
to flourish.

Toward this end, both private and public sectors are acting in
their own enlightened self-interest by Providing their employees
with the types of services that DCC and other companies provide.
By helping parents find the resources they need to raise a health:
child, organizations like Chesebrough Ponds, American Home Prod-
ucts, American Electric Power, the Coca-Cola Co., the Department
of Justice, the Centers for Disease Control, Hughes Electronics,
TRW, the Home Depot and other corporations and governmental
organizations have reaped measurable benefits. Workplace stress,
turnover and absenteeism has decreased. Recruitment, retention
and productivity have soared. These organizations have discovered
helping employees provide for their loved ones helps the bottom
ine.

Private and public organizations must continue to work together
to ensure that working parents get the resources they need to en-
courage their children’s growth during these critical years. Early
intervention that focuses on improving the lives of parents and
children will help today’s work force be more productive and tomor-
row’s work force better prepared for the challenges that lie ahead.

In closing, I would like to thank you, Mr. Chairman, and mem-
bers of this committee; and I would be pleased to answer any ques-
tions you may have.

[The prepared statement of Mr. Burki follows:]


198

‘Overview for COMPANY

‘On a weekly basis, counselors’ cases are evaluated by department managers to ensure that the
needs of the clients are being met. The research process. quality and number of referrals, personal
‘notes and internal procedures are monitored for compliance

(On a monthly basis, counselors undergo evaluations where their intake and needs assessments
with clients are monitored. Intakes must combine professionalism and attention to detail along
with strong empathetic skills. Managers also evaluate counselors qualifying providers to judge
their ability to professionally screen providers to meet clients” specific needs.

‘On a quarterly basis, professionals from various fields perform in-servicing for our counselors to
keep them current with the trends and knowledgeable in their discipline. Recent examples include
prenatal and Medicare seminars, handling grief and loss and adult care legal issues.

UL. Provider Reviews

DCC will only refer COMPANY employees to providers who comply with their respective state
regulations. If a complaint is todged against a provider, our counseling staff will refer the
COMPANY employee to the appropriate governmental authority. DCC will also personally
investigate the complaint. DCC. at its discretion, reserves the right to suspend or terminate
providers from our database. If we receive a complaint. DCC will suspend referrals to the
provider until a thorough investigation by the appropriate governmental authority and a
satisfactory resolution of the complaint warrants reinstatement to referral status. DCC does not
‘monitor providers as a licensing or registering authority.

IV. Client Review

Your DCC account manager will meet with you semi-annually or quarterly to feview
COMPANY utilization and the results of the quality assurance questionnaires. Any issues or
concerns that have been raised by your staff and employees will be reviewed during this
‘meeting and plans for future quality reviews will be established, DCC utilizes the feedback from
‘our quality assurance program in the following ways:

To continually monitor and improve DCC’s counseling. education and referral services
To measure, review, and evaluate the effectiveness of DCC counselors

To measure client employees” overall satisfaction with DCC services

To measure and monitor the overall quality of the DCC-referred service providers

DCC’s quality assurance department reviews every returned client quality assurance
questionnaire. In the event of a problem or grievance. although rare, the quality assurance
department instantly addresses the situation with the appropriate department manager. The
department manager and the case counselor then immediately review the entire case. Every
‘effort is made to rectify the situation and to prevent its Furure occurrence.

V. Quality Assurance Guarantee

To back its quality claims, DCC introduced quality assurance guarantees which are unparalleled
in the industry. DCC guarantees in writing that the average rating for its “overall service” will be
at least 90 percent “good.” “very good” or “excellent.” If it is not, DCC will discount the otal
annual fees by one percent for each percentage point below 90. For example. if 85 percent of the
returned quality assurance questionnaires rated DCC services “excellent” to “good.” DCC would
refund COMPANY five percent (90-85 =5) of its total annual fee.

DCG--— °



163

45. Olds, D.L., Henderson, C.1

Kitzman, H. (1994). Does prenatal and infancy nurse home
visitation have enduring effects on qualities of parental caregiving and child health at 25 to
50 months of life? Pediatrics, 98, 89-98.

46. Olds, D.L., Henderson, C.R., Kitzman, H., Cole, R. (1995). Effects of prenatal and infancy
taurse home visitation on surveillance of child maltreatment. Pediatrics, 95, 365-372.

47. Karoly, L.A., Greenwood, P.W., Everingham, S.S., Hoube, J., Kilbum, M.R., Rydell, CP.,
Sanders, M., & Chiesa, J. (1998). Investing in our Children: What We Know and Don't
Know About the Costs and Benefits of Barly Childhood Interventions. Santa Monica, CA.:
The RAND Corporation.

48. Kitzman, H., Olds, D.L., Henderson, Jr., C.R., Hanks, C,, Cole, R., Tatelbaum, R.,
MeConnochie, K.M., Sidora, K., Luckey, D.W., Shaver, D., Engelhardt, K., James, D., &
Bamard, K. (1997). Effect of prenatal and infancy home visitation by nurses on pregnancy
outcomes, childhood injuries, and repeated childbearing: A randomized controlled trial. The
Joumal of the American Medical Association, 278, 644-652.

49, Goldenberg, R. (1996). Editorial: Intrauterine infection and why preterm prevention
programs have failed. American Journal of Public Health, 86, 781-783.

50. Ainsworth, M. D. S., Blehar, M., Waters, E., & Wall, S. (1978). Pattems of
attachment Hillsdale, NJ: Erlbaum.

51. Sroufe A., & Carlson, E.A. (1995). Contribution of attachment theory to developmental
psychopathology. In: D. Cicchetti & D. Cohen (Eds.). Developmental psychopathology, Vol
L Theory and methods (pp. 581-617). New York: Wiley.


%6

12

Endnotes

"Shore, R.(197) Redhiking the Brin. New York:
Famites and Work Insane.

2 Storing Poets: Meeting the Needs of OurYoungest
(Charen (1994) New York: Carnegee
Corporation of New York

+ Year of Promise A Comprehensive Learning
Sey for Amer Chron (1998) New or
Carnegie Corporation of New York

SSharerand AM. Weiss HB. Krevder HIM,
mere
Cara aed ay Rah

188 Deyloos.|G. (1994) FulSernce Schoo San
Franesco, CA Jossey-Bass ne

* Bet Prices Prmang Proxies (1998),
Quartery publication of Georga Academy (Vol
V.No.3 Winer, 1998) Auanea.GA'Georga
‘Academy Journal

"39 Dryloos. |G. (1994).FuSernce Schoo. San
Ean, CA or tn ane at of
(Chidrer SchebLinked Sences (1992)

School eked incegrated Servet (1 2 No
1) LosAteas.CA: Center forthe Future of|
[Chidren,The David and Luce Packard
Foundation.

"Shaw. KM Replogle. (1996) Cholenger 0
Serer

Comprenerave
MA Harvard Farty Research Project.


27

family of three, The subsidy program would also be extended to provide age-appropriate
activities for children 13 through 16. Starting Right will also partner with communities to
develop pilot projects linking the state, business community, schools, child care, Head Start,
preschool, and other similar programe. The number of eligible children enrolled in Head Start
programs would also be increased by approximately 700 slots. Included in this is the
‘enhancement of services to low-income children inchiding: social services, health, nutrition
services, mental health, pareatal involvement, and transitional services for children entering
kindergarten.

Health insurance coverage will be offered to child care center employers, The state will offer
partially subsidized health care coverage to licensed child care centers participating in the state's
child care program. While the state leads the nation in providing similar coverage to home based
providers, this plan would also result in an increase in child care placement in centers across the
state. Under Starting Right, tho state will work to increase training resources for child care
providers. Enhanced training in the aress of childhood health and safety will be provided.
‘Special training for care of newborns and infants will also be developed. And, one of the best
‘ways to make sure our children make a successful step from child care to school is to coordinate
links between the schools, pre-schools and child care providers allowing for a smooth transition.

In addition, since Rhode Island is primarily a small business state, come of these funds will be
used to help small businesses join together in public-private partnerships to help create or offer
carly care opportunities for their employees’ families. Another focus will be upon areas of
‘geographic shortages, infant/oddler care, and care during non-traditional hours and for parents
with alternating work schedules, including before and after school care. Once again, this will
result in a workforce that is prepared to meet the dernands of the new millennium and create
greater economic growth.

Conclusion- A brighter vision for tomorrow
My administration has adopted a short and simple yet essential goal: All children will enter
school ready to learn and leave school ready to work. What happens to a child between the aycy


(401) $96-2109
Saft
| Coordinator (paresine)
| Program Assineane (4
‘ime)

In sehoal.
(Chtdren and een are

‘emoconaly healthy.

70

‘WESTERLY
‘CHILD OPPORTUNITY ZONE FAMILY CENTER
coz Grade Total Percent
‘Schools Levels Enrollment Low-Income
Westarly High School 312 1.004 TM
Advisory Board

‘Tae Westerly Inceqrated Socal Services Program has an Adwtary Counel of 17 members repreenting
the school human service agencies. town government. community members and famihet.The advisory
counel meet 6:8 umes a year to set the sratege drecion ofthe WISSP Program and co

prone mput on programs and sernces.A Teen Commie of 1S students meets bimonthly to plan
programs and to provi feedback on exiting services

Schoo! Location
WISSP i located na suite offices on the ist Noor of Westerly High Sehood adjacent to the
Guidance Oxpariment and School-co:Carees program WASP has a reception aea that tfled
Goring the schoo! day. 4 ace spaces anda median size conference room Programs ae oflered it
the WISSP offices. Cvoughout the school and in the community.

Funding 1997-1

(does pa nde kind appr fm shal det kind supper frm hel nd hun ere a oF
onrbons f pore nd omy ete)

3% Ourer ubsane Abas Ta Force Town, Donstions)

Seo! Duvet 60% COZ Family Coen Orpariven of
Edceaton Oeprmar of Heath Unites
wm

Program Components Jvente hearing board elerals for services

{Children's Learning and Enrichment Subtrance suse svesimert and raleral

Peer Tutoring Program (ttaratbon Sympatico)

‘Nawal Helpers Program - Peer Mediation Famiy meeongs and counseling (OCYF)

‘Teen Helphine student volunteer taining Individual counseling (South County Chid and

WISP Teen Commitee Famiy Constance)

Emergency cris intervention (South Shore

SchooHtnked health and social services Hen Hes)

Informavon referral. and follow-up for india! Join ta development for schools, human

students service agencies
Teen Hebpine 2pm 10 poe

‘Adule Education
“Teen parenang group (Ving Nurse Serwces)

sng volence eduction and support ‘GED Program ane Tatorng (Washington County
(Women's Resource Center) ‘Adit Lezrng Center)

“Anger management groups (DAPAC)

Natrivoncourieng (Were Hoxpt)

Berenement coursing (YNS Hopes)

ALA Teen


146

number of days hospitalized with injuries and ingestions were greater for children born to women
with few psychological resources (indicated by a combination of low intellectual functioning,
high levels of mental-health symptoms, and limited sense of mastery/self efficacy), Figures 6
and 7 illustrate the concentration of positive program effects in women with few psychological
resources. Note the similarity in pattern of results shown in these figures with the child-abuse-

and-neglect and emergency-department visits findings in the Elmira study displayed in Figures 2

and 3.

‘An explanation for the difference in number of days children were hospitalized with
injuries can be found in the nature of their problems. As can be seen in Table 1, nurse-visited
children were hospitalized at older ages and for substantially less serious reasons. The three
nurse-visited children who were hospitalized with injuries and ingestions were admitted when
they were 12 months of age or older (and thus mobile), while six (43%) of the 14 comparison
children were hospitalized when they were younger than 6 months of age (and thus immobile).
Eight (57%) of the 14 comparison-group hospitalizations involved either fractures and/or head
trauma, while none of the nurse-visited hospitalizations did. Two of the three nurse-visited
children were hospitalized with ingestions. These profiles suggest that many of the comparison-
‘group children were hospitalized for longer durations because of seriously deficient care. These
differences in injuries were corroborated by matemal reports of breast-feeding and beliefs about
caregiving, observations of the home environments, and the two-year olds’ behavior towards
their mothers.

Nurse-visited mothers reported that they attempted breast-feeding more frequently than

did women in the comparison group (p = .006), although there were no differences in duration of


63

CUMBERLAND
CHILD OPPORTUNITY ZONE FAMILY CENTER
coz Grade Total Percent
Schools Levels Enrollment Low-Income
BENorton Schoo! KS cod aK
Advisory Board

‘The BF Norton Family Center Governing Board it comprived of 6 parents, 6 agency representatives,
and th school principal. The Governing Board meets quarterly to plan. evaluate progress and ensure
shat meet family priorities a inthe anual needs

‘School Location

“The BE Norton Family Center ia targe room inthe school building The Family Center coordinator
‘salto the Tide | and Language Arts Coordinator for the school. facltating cose connections with

‘teachers and sft Parens are frequent volitaers and resources to Family Center programs. The

‘school primarily serves children and failes rom the surrounding neighborhood There are many

Portuguese and Spaith speaking fares in the aren and che Norton Schoo! has che ESL classrooms

for the district. Materals from the Family Center are provided in both Englsh and Portuguese.

Funding 1997-1998: $73,448

(dees ot cee rind tppert fram schol dae nd prt fom heath end human sec pecan
hoe

‘anton of pore nd coma

‘Seho0! Dame

48% COZ Famiy Center Deparuranc of
Edcesdon Deparomene

teak Une Wn)

IOC (avout Nocthem RI Meal Hes)

‘Children's Learning and Enrichment
‘Aterschool homewormantoring program
(Subscance Abuse Prevention Tat Force)
‘Atterschoo! mim-coures for K-S sudenes

‘Scholarships wo the Boys and Gris Cab
(Subsance Abute Prevention Tak Force)
Famfy ieeracy program -hteray book bags
Mach games nigh for parents and chikren
"Workshops for parents on education issues and
homelichool ivohment

SchoobLinked Health and Social Services
CChid Outreach screening at che Farmly Cencer
(Sehoo! Dares)

‘Workshops for teachers and parencs on
hildrers mental health (Northern RI Mena
Heath Ceneee)

Fesings Aker Dvorce Support support group
(Substance Abuse Task Force)

‘Adult Education

GED classes (RURAL)

Englah a Second Language classes (Schoo!
Distt)

Family and Community Development
Family fun actvies

Kathryn Dashing Te
WseeracyFariy

Famiy Center
LF Norton lementary
School

164 Broad Serest
‘Cumbertand, RI €2864

(401) 26.2030 t
Salt

Family Conese
‘Coordinator (paresine)
Parent Chit Preschool
Coordinator (par-ene)
‘Program Assistant (par-
‘ime

‘Children reach
Aindergarten ready to

Parents have resources
‘hat support their roe as

‘Parents are imolved ln
‘hele children's edveation,
Fay membaritare
econo a ebvetion


20

Mr. SHAYS. Governor, you are a leader in this area, and you
honor this committee with your presence. It is nice to have you
here.

Governor ALMOND. Thank you very much, Mr. Chairman and
members of the committee. It’s a privilege for me to represent the
people of Rhode Island and be before the subcommittee today, and
it’s also a privilege to be on this distinguished panel.

I look forward to hearing what I am sure is a compelling story
from Ms. Pearson. And, Rob Reiner, I just want to say from all the
people in Rhode Island, we thank him for what he has done for the
children of this Nation, and I speak for, I know, for all of the Na-
tion’s Governors when I thank him for the tremendous commitment
he has made. He joined me in Rhode Island yesterday to speak to
our community about the importance of early childhood programs.

We all know, the evidence is irrefutable, that from birth to age
3 are the critical years in a child’s life. We know that today. Ninety
percent of the brain is formed during that period of time. And, of
course, historically, we have put our money in other areas.

We all are working very, very hard, this Congress, all of the Na-
tion’s Governors, on education reform. Elementary and secondary
education reform is extremely important. It’s long-term. It’s going
to take a decade or more before we are going to see the real bene-
fits of the work being done by the States in this Nation.

There is one thing we can do to help education reform, and it will
work, and it will work quickly, and that is to provide good child
care programs for the youngsters in the Nation. We have a chang-
ing economy. Times have changed since my children were born in
the sixties. We have many single parents, unfortunately, in the
United States. A lot of them have been on welfare. We need this
help to transition them off of welfare, but we also have to help the
working poor. There is no question about that.

We view every child in Rhode Island as sitting on a three-legged
stool. One of those legs is the parent in a strong family and to have
parents who know how to nurture their children and bring them
up properly.

We also look at health care. And I am very, very proud as Gov-
ernor to say that we have addressed the health care issues in the
State of Rhode Island. We have a program of managed care for
Medicaid where we insure all children to the age of 18 to 250 per-
cent of the poverty level. We also ensure prenatal to 350 percent
of the poverty level.

Rob was with me yesterday when Christine Ferguson, who used
to be a staffer for Senator Chafee and is currently my Director of
Human Resources, gave some preliminary figures, and some of
them are very startling. She just completed the study of the two
poorest census tracks in the city of Providence with respect to

ealth care, and low weight births have decreased 50 percent in
the last 3 years by providing good health care to children. Just
think of what that means with respect to the health care industry
and the savings.

You know, we know today that good preventive medicine can
save us an awful lot of money in the future. We are seeing the
spacing between births, which is so important to the health of a
woman, the same for subsidized insurance as it is for private insur-


37

Ms. PEARSON. I don’t know. There are many days I go and I see
different children each day.

Mr. REINER. They are all infants and toddlers?

Ms. PEaRSON. No. I think there are only two—well, my son is the
youngest, and he is 8 months.

Mr. REINER. See, that’s critical. When we talk about child care,
we really have to talk about quality child care. Because you should
have no more than three infants or toddlers for one caregiver. Oth-
erwise, there is no way that those children can form attachments.
The only way you are going to stimulate brain growth and develop-
ment is through a secure attachment, and it has to be consistent
over a couple years. So there has to be a relationship with the care-
giver, and that caregiver works in conjunction with the parent so
it’s a team. It’s a supportive team.

We don’t live in groups anymore. If we lived in rural agrarian so-
ciety like we did 150 years ago, we wouldn’t have these issues in
front of us. We had grandmas and grandpas and aunts and uncles
all around to help out. Now we are living very separate lives, and
we need to rebuild that support system so that we can work to-
gether. She needs to know that there is a consistent, responsible,
loving caregiver that she can work with on a personal basis that
is her sister, her aunt. And if it isn’t, in fact, her sister or her aunt,
it’s somebody who is like that.

Mr. Towns. Let me say to this committee——

Mr. SHays. You have the floor, but I just wanted to comment
that this is the first time in my 11 years that I have seen a witness
ask another witness another question.

Mr. REINER. I was totally aware that that probably has never
happened.

Mr. Suays. I am even more impressed. I continue to learn as well
every day.

Mr. Towns. It was a good question.

Well, a few months ago, just talking about this committee and
where we are and what we are trying to do, we tried to pass a bill
which would have placed health and safety standards on all feder-
ally owned and operated day care centers. And, of course, I intro-
duced several amendments to that bill. Unfortunately, after the bill
passed the subcommittee, it never was placed before the full com-
mittee for a vote. So should Congress demonstrate its concerns
about child care by requiring health and safety regulations in Fed-
eral child care centers? I mean, should we do that here, recognizing
the fact that some people say that is the right of the State? But
the point is, we do have Federal dollars going in; and if we put
Federal dollars in, I am willing to think we should monitor the dol-
lars.

Mr. REINER. Well, I think if there are Federal dollars assigned
to child care, they should be assigned to what constitutes quality
child care, and we know what that is. I mean, that’s very easy to
identify, and I think you wouldn’t want to, you know, send loosely
block granted money to the States and say, OK, you can use it on
whatever kind of child care you want. I think it would have to be
incumbent on the States to make sure the money was being used.
for quality child care and those standards we know.


157

Acknowledgments

‘The work reported here was made possible by support from many different sources.
‘These include the Administration for Children and Families (90PD0215/01 and 900003),
Biomedical Research Support (PHS $7RR0S403-25), Bureau of Community Health Services,
Maternal and Child Health Research Grants Division (MCR-360403-07-0), Camegie Corporation
(B-5492), Colorado Trust (93059), Commonwealth Fund (10443), David and Lucille Packard
Foundation (95-1842), Ford Foundation (840-0545, 845-0031, and 875-0559), Matemal and
Child Health, Department of Health and Human Services (MCJ-363378-01-0), National Center
for Nursing Research (NRO1-01691-05), National Institute of Mental Health (1-K0S-MH01382-
01 and 1-RO1-MH49381-01A1), Pew Charitable Trusts (88-021 1-000), Robert Wood Johnson
Foundation (179-34, 5263, 6729, and 9677), US Department of Justice (95-DD-BX-0181), and
the W. T. Grant Foundation (80072380, 84072380, 86108086, and 88124688)

‘We thank John Shannon for his support of the program and data gathering through
‘Comprehensive Interdisciplinary Developmental Services, Elmira, New York; Robert
Chamberlin for his contributions to the early phases of this research; Jackie Roberts, Liz Chilson,
Lyn Scazafabo, Georgie McGrady, and Diane Farr for their home-visitation work with the Elmira
families; Geraldine Smith, for her supervision of the nurses in Memphis; Jann Belton and Carol
Ballard, for integrating the program into the Memphis/Shelby County Health Department; Jon
Korfmacher, Ruth O’Brien, JoAnn Robinson, Lisa Pettitt, Dennis Luckey, Peggy Hill, Pilar
Baca, and Susan Hiatt for work on the Denver trial, and their the many home visiting nurses in
Elmira, Memphis, and Denver, and the participating families who have made this program of

research possible.


Program and Policy
Implications

The COZ Family Center Initiative,
planned and implemented in 13 Rhode
Island comnnunities over the pas five
years, shows promise as a mechanism for
improving child and family wellbeing.
‘The COZ Family Centers in each
community are innovative, yer Fagile,
cffors to provide supports to families
befote they ae in trouble co build parent
leadership, and to leverage resources across
the education, health, and human service
systems in order 10 improve outcomes,
‘The fll potential of school-linked family
centered services in Rhode Island can nor
be cealized without deliberate atention to
‘program and policy issues tha affect the
‘quality and scope of the COZ. Farmly
Centers in each community.

Financing

“The level of funding and mechanism for
Financing childrens programs have
significancrmpacts on the quale and
scope of the programs. Icis sill rue char
financing often drives the priors and
goals ofthe programs to be offered.
making it difficult for local efforts 10 say
focused on achieving outcomes. The COZ
Family Center inisative attempts ro
reverse this dynamic by providing a small
amount of flexible funding co local
communities in order 10 move toward the
Family Centers desired outcomes, Most
local COZ sites have been effective in
creating strong linkages with existing
resources, developing partnerships cil
gaps in services, and seeking funding co
rmcet identified needs The median budget
for the 13 COZ Farnily Centers is
{583,000 and che range is from $52,000 10
$268,000. Ten communities have more
than doubled the stae investment of
{535,000 per community and four COZ

57

Family Centers have program budgets
ling over $100,000. These figures do
not include the significan resources
invested by partnership organizations chae
provide staff, space. and in-kind resources
to meet Family Center goals and priorities.
Dowie he eRe COZ Family
Centers have been able ro make with
extremely limiced resources he fragile
financing of the iiviative mits the
potential to make lasing change and
achieve long-term goals. Several barnes 10
progress include the overwhelmingl
categorical, cris oriented nature of sate
funding. The purpose of linking services
wich a childs educational development i
to ensure that supports ate there when the
child and family need them. COZ Family
Centets will continue co be limited in
scope and impact until mote flexible.
preventive funding is available across the
health and human service svstems,

Evaluation

Tvestments ia ongoing documentation
and evaluation of school-linked famils
centers is ctiical fo meeting long-term
{goals and making ecal change for children
snd families. The demand for
accountability requires the identification
and measurement of atleast some

indicators of child well-being related to
schoo! readiness and school success. The
process of deciding on appropriate
indicators must take into acount not only
those indicators that are most meaningful
to the sate and local agencies but aso
those with whieh parents and community
-members are most concerned." Evaluation
measures need co be eealisic and not
‘overpromise results chat are nor in line
‘wich the level of resources committed t0
the local communities. Investments in
‘valuation can confirm success and can
reveal where programs need to be refined
and improved.

Flexble,non-cateporicl,

“The fact that COZ Fait
Centers span a number of
school in a singe trict
and acrom thireeen



23

for the mont critical years of development, ages 0-6. We have recognized the broad economic
implications of child care and early childhood policies, and we are taking « leadarchip role in
developing programs for our children. . 7

Quality carly childhood care and intervention programs perform a dual function in the economy.
In the abort rum, such services moet the needs of the existing work force by assisting working
parents in meeting their child care needs. Research suggeats that employers benefit from lower
absenteciam and tumover, higher employee morale and reduced recruitment costs by providing
‘child care assistance, [n the long term, quality exrly childhood programs are also critical in
‘Preparing children to enter the workplace of the future. Research demonstrates that quality early
childhood education programs all children contribute to higher levels of success in school,
‘greater achievernent motivation, higher vocational expirations and higher employment retes.

‘Such strong outcomes, coupled with « changing economic environment, are sparking
considerable interest across Rhode Island in expanding quality earty education and childcare
programs as an economic development strategy. Leading experts in Rhode Island indicate that
economic growth over the past 20 years has been the result of an influx of poople entering the
workforce, a trend that is not expected to continue, With fewer people entering the labor force,
each worker's productivity is critical to achieving a competitive edge in an increasingly global
and information based economy. While educational achievement was less important in a largely
manufecturing-based economy, the work place of the future will demand more critical thinking
and learning capacities, Morcover without tapping the potential of more disadvantaged children,
critical labor shortages are expected to stymic economic perforraance.

However, despite all of the progress in Rhode Island, we still face vexing issues that are similar

to other states, And, for many poor and low-income families, child care and intervention

problems can be severe:

» Studies like the Cost, Quality, and Child Outcomes Study have confirmed that low to
middle income fails still face great struggles in finding affordable, good-quality
childcare — and that most care now retained by pareats is mediocre, at best.


144

and 4 (nurse-visitation during pregnancy). For the postnatal phase of the study, Treatment 2 was
contrasted with Treatment 4.

As in Elmira, outcome assessments were conducted by individuals who did not know the
treatment assignment of the participating women and children. Data were derived from
interviews, observations of mother-infant interaction, observations of conditions in the home,
and reviews of mothers’ and children’s medical and social-service records.

In interpreting the findings from this trial, it is important to note that it was conducted
during a nursing shortage, which led to fairly high rates of staff turn-over because nurses left
their jobs with the health department to earn more in competing hospitals. Given that these kinds
of factors are likely to buffet the program as it is administered in other community settings, the
Memphis findings may provide a good estimate of what the program might be able to achieve if
it were replicated on a large scale.

D. Memphis Results

At the stage of randomization, the nurse-visited and control groups were essentially
‘equivalent on all background characteristics examined. For those individuals on whom
subsequent assessments were conducted, these groups remained equivalent on background
characteristics. Moreover, postnatal assessments were conducted on a large portion of the
‘women originally assigned to Treatments 2 and 4. Office-based assessments were completed at
24 months postpartum, for example, on 96% of the cases for which there was no fetal or child
death. Low attrition and no nurse-visited-control differences in background characteristics on
those assessed after enrollment means that the analyses of program effects are not likely to have
been biased by loss of participating families. All analyses of program effects were based upon an

intention-to-treat approach, that is data were employed for outcome analyses irrespective of the

2B


‘Written Testimony of Lynn A. Karoly 9

‘The research required represents a substantial commitment of funds—most likely in the millions
or even the tens of millions of dollars. However, the early intervention programs that may prove
warranted (and that some people are already advocating) will represent a national investment in
the hundreds of millions or billions of dollars. A modest if substantial expenditure initiated now
could thus ensure that maximum benefits are achieved from a much larger expenditure over the
Jong term.


172

Mr. Towns. Mr. Burki.

Mr. BurkI. Thank you, Mr. Towns. I am Peter Burki, chief exec-
utive officer of DCC, Inc., a leading global provider of critical work-
place services that increase productivity and efficiency and reduce
absenteeism, turnover and stress. I am pleased to have been in-
vited to appear before you today to discuss what we believe to be
one of the day’s most important issues.

The subject of this hearing corresponds with DCC’s ongoing ef-
forts to provide early childhood intervention services to working
parents, to raise awareness of the connection between these re-
sources and a child’s cognitive, emotional and physical develop-
ment, and to demonstrate how children, parents and all organiza-
tions can profit from these services.

In the past several years, businesses have had to adjust to a rap-
idly changing social landscape which will continue to change as we
approach and prepare for the 21st century.

Mr. Burki. Consider the facts, and I know you have heard some
of these already, 78 percent of working parents live in dual-income
households, compared to 64 percent 20 years ago. In 1994, 10.3 mil-
lion preschoolers had mothers who worked. Almost 30 percent of
preschoolers and over 18 percent of children under the age of 1 are
in organized care. Today, one out of every five parents is single.
That’s 20 percent. Since 1970, the number of single families has in-
creased by 133 percent, from 5.5 million to 12.8 million. Single
male families have grown by 213 percent, from 1.2 million to 3.8
million.

These trends highlight the critical issues that we in the public
and private sectors must address in order to promote a healthier,
better prepared and more productive work force for today and for
the future.

The daily challenges for employers and employees are becoming
all too familiar: A young mother needs to find affordable child care
and transportation so she can make the transition from welfare to
work. A single dad needs critical early intervention services to ad-
dress his daughter’s developmental needs. A young family needs to
find the best child care options for their 6-month-old son. They
need information to help them understand and evaluate those
choices and how they impact on their child’s future development.

To make matters more complicated, as we all know, employees
are working more hours, workloads are increasing, leaving depend-
ent care responsibilities hanging in the balance.

Companies like DCC address these issues by providing critical
tools to working parents that they need to balance work and family
and provide their children with a healthy start. These services offer
counseling on issues like identifying high-quality child care; edu-
cation on topics such as prenatal care, child development and par-
enting; and referrals to community and nationwide resources that
can help with any work/life need. As a result, expectant parents ob-
tain proper prenatal care to ensure fewer complications at birth.
New mothers can breast-feed when they return to work so their in-
fants are healthier; and, in turn, health care costs are reduced.
Welfare recipients can successfully transition from welfare to work,
and parents can find quality care for their young children and re-


44

when you add up all the other programs that you are now using
to try to provide a safety net for those people? Have you made any
comparisons?

Governor ALMOND. I couldn’t answer that, but I will get that in-
formation for you and have it transmitted to you.

[The information referred to follows:]


85

Written Testimony of Lynn A. Karoly

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176

‘© A-young family needs to find the best child care options for their six-month-old son, They need
information to help them understand and evaluate those choices and bow they impact their child's
fumre development.

‘To make maners more complicated, employee hours and workloads are increasing, leaving dependent
care responsibilities hanging in the balance.

‘Companies like DCC address these issues by providing the critical tools working parents need to
balance work and family and provide their chikiren with a healthy star.

‘These services offer counseling on issues like identifying high-quality child care, education on topics

such as prenatal care, child development, and parenting, and referrals to community and nationwide

resources that can help with any work/life need. As a result.

‘+ Expectant parents obtain proper prenatal care to ensure fewer complications at birth.

‘+ New mothers can continue breastfeeding when they return to work, so their infams are healthier
‘and in turn, heaith care costs are reduced.

© Welfare recipients can successfully transition to work.

‘© Parents can find quality care for their young children and receive the educational materials they
need to understand their child's developmental needs during the critical early years.

‘These types of services are a necessity, not a luxury, for parents today. Without such services, parents
cannot effectively work.

Research continues to provide clear evidence that what happens in the first few years of a child's life
does matter, and has an enormous effect on a child's ability to learn, relate to others, and function in
the world, for the rest of his ot her life.

‘We have learned that young children are far from passive vessels, that they actively interact with their
environments and in fact influence the behavior of those around them. We now know that what young

children see, hear, smell, touch, and do shapes not only what they know, but how they lear. For good
‘for ill, what happens to young children in the first years of life is critical to their—and our—furures.

‘The human brain achieves 90% of its total growth before the age of three. The brain of a newborn
‘baby has about 100 billion nerve cells—more, actually. than an adult! The difference is, babies’ nerve
cells aren't wired up yet. They're kind of like a new stereo or computer system without its cables—you


212

in those particular communities, so I] fully endorse the 4pproach
that you have just outlined.

Mr. Towns. Thank you.

Ms. KNITZER. I would concur with what Dr. Olds said about the
community and focusing on that, and short of—I don’t know what
they are doing in France, but we do have enterprise zones and em-
powerment zones here, as well as some other community initia-
tives, and we are, in fact, hoping to do a study of this. It is our
sense that, except for defining the need for child care, there has
been very little attention to what community assets and resources
are or should be in those empowerment zones, and there is an op-
portunity to make a connection there that I think hasn’t yet been
made.

Mr. TOWNS. One more question, Mr. Chairman.

You know, you indicated, and I just want to get clarification, you
said it would take 20 years, Dr. Olds. Why 20 years?

Mr. SHays. Do you know how old we will be in 20 years?

Mr. Towns. That’s the point I was trying to make. Mr. Shays
will no longer be in Congress.

Dr. OLDS. Would you like me to talk in the middle of the bells?
T will wait.

Mr. Towns. OK.

Dr. OLps. It has taken us 20 years to get to the point where we
have what we think is a program that has thoroughly developed
science and thoroughly developed clinical methods. And what we
have seen in many instances is programs have been put together
and rushed into service before they have had adequate infrastruc-
ture built to provide—to recruit qualified people to service people,
to provide adequate training and supervision. We think that one
has to build from the strong clinical and scientific base, and in
order to do that—our calculations show that, in order to do it and
to have confidence that we can reproduce the kinds of effects we
have seen in the research, it will take us, unfortunately, 20 years.

But, you know, for a long time, I was going to invoke the Japa-
nese experience and their economic—in their solving economic
problems, and that is probably the wrong analogy today, but I
think we need to take the long view. These are not problems that
we as a society can solve overnight. It will require very careful
linkage between science, clinical work and program design. We
need to build capacity.

If we are going to build a business, for example, you can’t do it
overnight. And we have actually run numbers to look at the num-
bers of low-income women bearing children in our society, the num-
bers of available nurses, the numbers of places where this kind of
clinical capacity is currently operating. And we have chosen not—
for example, many programs choose to use a model to train the
trainers, where people go out and train others to do the program
model, even if they themselves have not had sufficient clinical ex-
perience in conducting the program themselves. We don’t support
that. Because we think, without the level of deep clinical experi-
ence in conducting the program, the essential elements of how you
can bring about—successfully bring about change on the part of
parents during pregnancy and during the care of their children, it


Overview for COMPANY

Locate Resources

COMPANY employees can use LifeCare Net to request referrals for providers in the areas of
prenatal care. child care, adoption, colleges and universities, special needs. and adult care.
‘Options include conducting a quick search of providers, locating associations and networks in 2
Subject area, ordering educational resources germane to the employee's LifeCare needs,
specifying a provider for DCC to research, ot submitting information for a complete
‘assessment by a DCC counselor.

With access to DCC’s provider database. the largest and most comprehensive of its kind,

LifeCare Net users can:

‘© Access over 2.5 million service and care providers.

‘© Obtain real-time listings of local dependent care providers via the Internet. or receive pre-
qualified, pre-screened referrals via first-class mail

© Retrieve tailored directions from the user's home (o service providers.

DCC’s innovative mapping software allows LifeCare Net users to access detailed computerized
‘maps of any local community: our database of nearly 2.5 million providers is overlaid to this
‘mapping software. This cutting-edge technology matches each LifeCare Net client with the
‘most appropriate care providers in his or her specified location, presents a geographic overview
of providers in a particular area. and gives turn-by-turn directions from the employee's home
oF office to the provider's location.

LifeCare Net Quality Assurance

DCC monitors the quality of the LifeCare Net service via a voluntary system called
“Feedback.” Employees may use the Feedback feature to send DCC quick comments about the
LifeCare Net service. There are also two online quality assurance surveys: a short version
(seven questions) and a iong version (21 questions). Each comment and survey is reviewed by
our quality assurance team. and client feedback will be taken into consideration when designing
future versions of LifeCare Net

LifeCare Net Is Easy To Use!

LifeCare Net offers a search feature as well as an area for feedback and comments, and a
complete online help function makes navigating the site trouble-free. From book-marking to
printing. users have total online support with the click of a button. And DCC’s LifeCare Net
help desk is always available toll-free at 888-604-9563 or via e-mail (Ien_help@life-care.nev).

Technical Support

LifeCare Net technical support is avaitable (0 subscribers at all times. {n addition to an online
quick help feature. users can call our toll-free number for technical support 24 hours a day at
(888) 604-9565 or contact suppor staff via e-mail at len_help@life-care.net

DC Geter 8


62

CRANSTON
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Written Testimony of Lynn A. Karoly 5

Development Project (IHDP) found IQ differences between treatment participants and controls at
the end of program implementation that approached or exceeded 10 points, a large effect by most
standards, The difference in rates of special education and grade retention at age 15 in the
Abecedarian project participants exceeded 20 percentage points. In the Elmira, New York,
PrenatalEarly Infancy Project (PEEP), participating children experienced 33 percent fewer
emergency room visits through age 4 than the controls, and their mothers were on welfare 33
percent less of the time. In the Perry Preschool program, children’s earnings when they reached
age 27 were 60 percent higher among program participants. ‘Thus, we conclude that there is
strong evidence to support the proposition that at least some early interventions can benefit
participating children and their mothers.

It is also apparent from Figure 1, however, that for most programs, most indicators are not
measured. This is even truer of the maternal analysis, where five of the nine evaluations paid no
attention to possible effects on the mother other than parental development. Our analyses thus
represent only a partial accounting of program benefits. Furthermore, most evaluations did not
involve long-term follow-ups, and some benefits could take a number of years to accrue (some
could also erode with the passage of time).

What Are the Savings?

‘Some people may think that the benefits of targeted early intervention programs for participating
families are enough to justify public expenditures on them. Others may appreciate the benefits to
disadvantaged children bot may be reluctant to raise tax burdens to accomplish such goals or
may wish, at Jeast, for broader favorable ramifications from an investment of public funds. One
source of broader benefit is the potential savings the government (and thus taxpayers) realize
‘when families participating in early interventions require lower public expenditures later in life.
Participating children may spend less time in special-education programs. Parents and, as they
become adults, children may spend less time on welfare or under the jurisdiction of the criminal
justice system. They may also eam more income and thus pay more taxes.

In Figure 2, we compare program costs with eventual government savings for two of the nine
proj Preschool and the Elmira PEIP. The Perry Preschool program enrolled 123
disadvantaged African American children in Ypsilanti, Michigan, in the mid-1960s. The
rogram was a part-time preschool that included weekly home visits by the teacher and lasted for
‘one or two school years. For the Elmira PEIP, 400 disadvantaged, primarily nonminority
families received home visits by nurses trained in parent education, establishment of support
networks for the mother, and linkage of the family to other health and human services. Mothers
received an average of 32 visits from the fourth month of pregnancy through the child’s second
year. We chose these two interventions for three reasons:

+ They were random trials that satisfied sample size and attrition criteria.

+ They measured progress on developmental, educational, economic, criminal justice, and
health measures that could be expressed in monetary terms.

+ They followed the children long enough for benefits to accrue. The latest Elmira PEIP
follow-up was at age 15 and Perry Preschool at age 27.


121

References

Karoly, L.A., Greenwood, P.W., Everingham, S.S., Hoube, J., Kilburn, M.R., Rydell.

C.P., Sanders, M., & Chiesa, J. (1998). Investing in our Children; What We
Know and Don’t Know About the Costs and Benefits of Early Childhood
Interventions. Santa Monica, CA.: The RAND Corporation.

Kitzman, H., Olds. D.L., Henderson, Jr., C.R., Hanks, C., Cole, R., Tatelbaum, R..
McConnochie, K.M., Sidora, K., Luckey, D.W., Shaver, D., Engelhardt, K.,
James, D., & Barnard, K. (1997). Effect of prenatal and infancy home visitation
by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing:
A randomized controlied trial. The Journal of the American Medical Association
218, 644-652.

Olds, D., Henderson, C.R. Jr., Cole, R., Eckenrode. J.. Kitzman, H.. Luckey, D., Pettitt,
L.. Sidora, K., Morris, P. & Powers, J. (1998). Long-term effects of nurse home
visitation on children’s criminal antisocial behavior: 15-year follow-up of a
randomized trial. The Journal of the American Medical Association, 1998: (In
press).

Olds, D.L., Henderson, C.R.Jr., Kitzman, H., Eckenrode, J., Cole, R., & Tatelbaum, R.
Prenatal and infancy home visitation by nurses:Recent findings. The Future of
Children, 198: (In press)

Olds, D.L., & Kitzman, H, Review of research on home visiting for pregnant women and
parents of young children. The Future of Children. 1993;3(3):53-92.

Olds, D.L., Eckenrode, J., Henderson, Jr., C.R., Kitzman, H., Powers, J., Cole, R., Sidora,
K., Morris, P., Pettit, L.M., Luckey, D. (1997). Long-term effects of home
Visitation on maternal life course and child abuse and neglect: 15-year follow-up
of a randomized trial. The Journal of the American Medical Association, 278,
637-643.

Olds, D.L., Henderson, C., Phelps, C., Kitzman, H., & Hanks, C. (1993). Effects of
prenatal and infancy nurse home visitation on government spending. Medical
Care, 31, 155-174.

St. Pierre, R.G., Layzer, J.1., Goodson, B.D., & Bernstein, L-S. (1997). National impact
evaluation of the comprehensive child development program. Final Report to
ACYF, Contract No. 105-90-1900. Abt Associates, Inc., Cambridge, MA.



195

Overview for COMPANY

Legal Services

For clients in need of legal advice or services, DCC can provide local referrals to specialized
atvorneys. DCC offers COMPANY employees a nationwide network of attorneys who average
15 years of experience. Attorneys provide expertise and assistance in any number of areas,
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'* Automobile accident law © Immigration and naturalization
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© Consumer claims and protection © Negligence law

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© Education law © Wills, estate planning and probate

Clients are entitled to free telephone advice and/or office consultations by 2 local attorney on
any personal legal matter that does not pertain to employment or business-related issues. In
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Discount Health Club Memberships

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Personal Services

Even employees without caregiving responsibilities need help managing their work and personal
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variety of personal issues. including:

DCG *


124

identified as smokers were 75% less likely to be born prematurely, that is, before 37 weeks of
gestation.”

From birth through the child’s second birthday, nurse-visited children born to women
with all three risk characteristics used for sample recruitment (poor, unmarried, or teen-aged)
were 80% less likely to have been identified through state Child Protective Service Records as a
victim of child abuse or neglect than were their counterparts in the comparison group. Moreover.
nurse-visited children were seen in the emergency department 56% fewer times than were
children in the comparison condition during the second year of their lives ~ that is, when children
are more likely to be injured because of their increased mobility but immature motor
development. These findings were corroborated by observations of the children's homes and
parents" reports of their care of their children.""

During the first four years after delivery of the first child, nurse-visited women who were
low-income and unmarried at registration were found to have 42% fewer subsequent pregnancies
and 84% greater participation in the work force." An economic evaluation of the program from
the standpoint of savings to goverment showed that for low-income women the discounted cost,
savings to government exceeded the cost of the program before the children were four years of
age.!*

Given these encouraging results, beginning in the late 1980's many groups urged us to
develop the program in new communities on a much wider scale. They reasoned that the
program worked and that at-risk families in our society deserved the program. We chose not to
replicate the program outside of research contexts, however, for three reasons.

First, we did not know whether the findings produced early in the life of the child would

endure. Other preventive interventions had produced effects that washed out after the program


31

ilies that aren’t involved, and mainly because I have some friends
that could use the program, just having that support there behind
you. And sometimes family is just not enough because sometimes
family could be very critical and not telling you sometimes that you
are doing a good job, whereas someone who is on the outside can,
and their eyes are more open.

I do agree with what Mr. Reiner said, that giving information to
our caregivers is very important as well, because we—teaching our
children is still not enough when you send them to your baby sitter
or your caregiver. What are they teaching them, once that door
closes?

You are always constantly thinking, are they being nice to them,
are they talking to them, are they singing to them, things I did
when I was with him for the 4 months. I don’t want that to stop.
I don’t want that to come to an end, because it does stimulate the
mind, and I have seen the product, and it works.

And if we don’t do something about it now, I mean, just like I
said, what do we expect in the future for our children? They are
just going to deteriorate and go down and down and down.

That’s it. Thank you.

Mr. SHAys. Thank you very much. If people would like to ap-
plaud, I would welcome that. "Congratulations.

[The prepared statement of Ms. Pearson follows:]


156

required to develop the program in new communities with fidelity to its essential elements.
Under the Justice Department initiative we are establishing the program in six communities in
the country, including Los Angeles, Fresno, and Oakland California; Oklahoma City, Oklahoma;
St. Louis, Missouri; and Clearwater, Florida

{n this program-replication phase (which will soon expand to include 15-20 additional
sites beyond the Justice Department initiative), state and local governments are securing financial
support for the program out of existing sources of funds, such as TANF (Temporary Assistance
to Needy Families), Medicaid, Maternal and Child Health Block-Grant, child-abuse, and crime-
prevention dollars. They are making this investment in part because the evidence indicates that
the program will reduce future expenditures. This means that the cost of this program, which in
1998 dollars is about $7,000 per family for 2% years of service, can be shared by a variety of
government agencies. This, in tum, reduces the strain on any one agency's budget.

‘We wish to emphasize that we do not believe we can replicate this program on a large
scale in a short period of time without compromising its effectiveness. We believe that it makes
sense to develop a larger number of demonstration sites only after we have learned from our first
group of sites how to develop the program successfully in a variety of new contexts. In the next
phase of this work, we are building in provisions for learning about new implementation efforts
so that we can develop the program in an even larger number of sites as quickly as is possible

without losing program effectiveness.


179

Overview for
COMPANY

DCC'/The Dependent Care Connection” Inc.

‘This LifeCare® Overview is to be treated by COMPANY in the same manner as it treats its own highly
confidential information. COMPANY shall not disclose the existence of any such information to any third
party without the prior written consent of DCC.


that will help families succeed. According to the Inspector General at the Department of Health
and Human Services, so far child care under welfare reform has only produced a voucher system
that requires parental co-payments. Most of the care is given through informal arrangements.

Mr. Chairman, in Denmark, France and Italy, preschool teachers are public employees,
who receive salaries, pensions, leave and health benefits. These countries have decided that the
care and education of preschool chikiren are important priorities. In America, we call children
our greatest nanural resource, but we do not act accordingly. Therefore, while we discuss these
wonderful state and private programs here today, let us not forget that most of America’s poor
children-- the children who need these programs the most-- will not participate in any kind of
enrichment activity and will receive second class care. Mr. Chairman, again, { thank you for
holding today's hearing and I look forward to hearing the testimony of the witnesses.

EE


Overview for COMPANY

I. Case Management Analysis

Total number and average number per case of providers qualified

Total number, average number per case and annual utilization percentage of referrals

© Total number. average number per case and annual utilization percentage of counseling and
education sessions

© Total number and annual utilization percentage of cases

.

Case management analysis is also illustrated in bar-graph form.

III, Case Type Analysis

Total number and percentage of adoption cases

Total number and percentage of prenatal cases

Total number and percentage of child care cases

Total number and percentage of special needs cases

Total number and percentage of college and university cases
Total number and percentage of adult care cases

eeeoee

Case type analysis is also illustrated in pie-chart form.

IV. Calling Clients
© Total number and percentage of female ctients
© Total number and percentage of male clients

Calling clients is also illustrated in pie-chart form.

V. Geographical Breakout
© Total number of calling clients by state

© Percentage of calling clients by state

© Requested area of assistance (total number by state)

VI. Department, Diversity Code and Division Totals

According to COMPANY’s request and the information it provides to DCC, DCC can provide
utilization data based on, for example. a division. department or subsidiary of the company
DCC can customize this aspect and any other of management reporting to best suit COMPANY
needs

DCC °
mw oncoren


189

and physician visits in which injuries were detected. We have interpreted these differences as a
reflection of greater surveillance for child abuse and neglect, leading to more frequent
identification of less serious forms of maltreatment in the nurse-visited condition.

‘This interpretation has been reinforced with results from a 15-year follow-up of the
Elmira sample” in that the program-control differences in rates of state-verified reports of child
abuse and neglect grew between the children’s fourth and fifteenth birthdays. Overall, during the
15-year period after delivery of their first child, in contrast to women in the comparison group,
those visited by nurses during pregnancy and infancy were identified as perpetrators of child
abuse and neglect in 0.21 versus 0.46 verified reports (p <.001). This effect was greater for
‘women who were unmarried and from low-SES households at registration (p <.001).”

2. Prenatal Tobacco Exposure, Prenatal Home Visitation, and Development in the
First 4 Years of the Child’s Life, While there were no overall program effects on children’s
mental development, children born to women who smoked a moderate to heavy amount when

they registered in the program during pregnancy and who received prenatal home visitation had

significantly higher IQ scores at 3 and 4 years of age than did their counterparts in the
comparison group."*"" As shown in Figure 4, control-group children born to women who
smoked 10 or more cigarettes per day during pregnancy had mental development scores that
declined over the first 4 years of the child’s life, in contrast to their counterparts in the
comparison group whose mothers did not smoke during pregnancy." In the murse-visited
condition, children born to women who smoked 10 or more cigarettes at registration during
pregnancy had mental development scores in infancy, toddlerhood, and the preschool period that
were the same as those who did not smoke at all or who smoked only a few cigarettes per day."”

‘These beneficial effects of prenatal home visitation held for the group visited only during


7

breast-feeding. By the 24th month of the child’s life, in contrast to their comparison-group
counterparts, nurse-visited women held fewer beliefs about child-rearing associated with child
abuse and neglect-lack of empathy, belief in physical punishment, unrealistic expectations for
infants (p = .003). Moreover, the homes of nurse-visited women were rated on the HOME scale
as more conducive to children's development (p = .003). There was no program effect on
observed maternal teaching behavior, but children born to nurse-visited mothers with low levels
of psychological resources were observed to be more communicative and responsive toward
their mothers than were their comparison-group counterparts (17.9 versus 17.2; p =.03). There
‘were no program effects on the children's use of well-child care, immunization status, mental
development, or reported behavioral problems.

3. Maternal Life Course. At the 24th month of the first child’s life, nurse-visited
‘women reported 23% fewer second pregnancies and 32% fewer subsequent live births than did
‘women in the comparison group (p=.006 and .01, respectively). Nurse-visited women and their
first-born children relied upon welfare for slightly fewer months (.7) during the 2nd year of the
child’s life than did comparison-group women and their children (p=.07). There were no
rogram effects on reported educational achievement or length of employment.“*

E. Comment on Elmira and Memphis Results

Many of the beneficial effects of the program found in the Elmira trial that were
concentrated in higher risk groups, have been reproduced in the Memphis replication. Overall,
these two trials indicate that the program has achieved two of its most important goals -- the
reduction in dysfunctional care of children and the improvement of maternal life course. Its

impact on the third goal -- the improvement of pregnancy outcomes (in particular, the reduction

26


153

1:5 ratio).

Although outcome data on the mothers and children are not yet available, differences
between nurses and paraprofessionals in the nature and quantity of program implementation
have been reported. Data on program implementation were derived from encounter forms
that the nurses and paraprofessionals completed after every home visit, and from
administrative records.

Differences between Nurses and Paraprofessionals in Program implementation

Nurses and paraprofessionals completed essentially the same number of visits during.
pregnancy (approximately 6.5 visits), but the nurses completed an average of 5 more visits
from birth to the child’s second birthday (22 versus 17). This may be accounted for by a
higher rate of staff tum over among the paraprofessionals (17 paraprofessional visitors hired
‘over the life of the study), compared to no staff turn-over among the 10 nurses. The average
visit by the paraprofessionals was about 7 minutes longer (81 minutes compared 10 74
minutes, p <.001). ‘The nurses spent a slightly larger portion of their time during the visits
addressing the mothers’ and children’s physical health (23% versus 20%, p<.001) while the
paraprofessionals spent more time on the mothers’ life course development (18% versus,

16%, p<.001), their friend and family relationships (19% versus 15%, p<.001), and on the
health and safety of the environment (15% versus 8%, p<001). We did not expect to find
that the nurses would spend more time on promoting parents’ care of their children, but they
did (39% versus 28%, p<.001). *

We expect that these differences in program implementation will affect the visitors’
influence on maternal and child functioning, which will be the subject of additional reports in

the near future.

2


46

Mr. Kucinicu. I would be interested in that.

Do you have any comment on the methodology that the Federal
Government has required the States to follow with respect to keep-
ing your obligations as outlined in the Welfare Reform Act?

Governor ALMOND. We are currently evaluating our entire case-
load and doing case studies for each family with a transition off the
welfare program for each family. We are spending a lot of time and
money on that particular issue, on an individual basis.

Mr. KUCINICH. That is good to hear. I salute you for that.

Governor ALMOND. And it took time because, keep in mind, the
whole welfare system was geared toward receiving a check. Now
we have had to retrain our entire work force.

Mr. KucINicH. Mr. Reiner, thank you for your involvement in
this. Do you have any other ideas on how the private sector can
be more active? Certainly you have pointed the way to what an in-
dividual who is not involved in government directly can do. Have
you communicated your concerns to the private sector in trying to
enlarge the Scope of involvement such as Healthy Families?

Mr. REINER. Yes. Yesterday we had a meeting in Rhode Island.
The Governor convened leaders of the government, the business
community, all the leaders of the State, brought them together in
one meeting to talk specifically about how State government and
private money and foundation money can all partner together and
make this investment. That was the main purpose of the meeting
and was a wonderful meeting and very energized.

The day before, I hosted a conference in New York City with Kai-
ser Permanente, where we brought business leaders from around
the country to talk specifically about how they could get involved.
Now, there are a couple of things they can do. One is within their
companies: family friendly work practices, providing child care, flex
time for parents to do the best for their children. Those practices
are being promoted amongst the companies.

But there is another clement to all this. That is, the fact that
this is all for the common good. We're all part of—children are our
future. We’ve been hearing that our whole lives. We all have to

lay a part in that. We have to find ways of partnering up Federal

overnment, State government, local governments, the business
community, the foundation community, all together to play a part
and create this integrated system.

Mr. Kucinicu. I think it is significant that Ms. Pearson received
information and a referral. That was a critical moment, I take it,
in your life when you received that referral to Healthy Families.
Have you considered the role that social disorganization plays in
trying to communicate?

Mr. REINER. Yes. Advertising. You have a problem, you have to
advertise it. No question about it; it plays a big part.

Mr. KUCINICH. I am very interested in this.

Mr. REINER. Outreach.

Mr. Kucinicu. Let’s talk about outreach a moment, because I
think this is critical. Either you or the Governor might be helpful
in commenting on this since Ms. Pearson has already given us tes-
timony about the effect of someone who reached out, in this case
a medical professional. Because I—and Mr. Towns, I think, we rep-
resent constituents that in some parts have some similarities. The


Overview for COMPANY

Client References:

Barbara Roos
Work/Life Manager
Fleet Financial Services
(401) 278-3165

‘Tom Roberts

Director. Personnel & Administration
Chesebrough-Pond’s

(860)664-2494

Mary Lackides
Health Services Manager

TRW Space and Electronics Group
(310) 813-1791

Denise Allen

Employee Relations Coordinator
Colgate-Palmolive Company
(212) 310-2839

‘Anne Serra
Work & Life Strategies
Hughes Electronics
(520) 794-4541

Additional client references will be gladly furuished upon request.

DCG--—=


(OME rNORED FIFTH CONGRESS

Congress of the United States
Bouse of Representatives

COMMITTEE ON GOVERNMENT REFORM AND OVERSIGHT
2187 Ravaurn House Orrice BULONG
‘Wastenigton, DC 20515-6143

OPENING STATEMENT OF

REP. EDOLPHUS “ED” TOWNS:
RANKING MINORITY MEMBER

BEFORE THE
SUBCOMMITTEE ON HUMAN RESOURCES
JULY 16, 1998

Mr. Chairman, thank you for holding today’s hearing on early childhood intervention
programs. The future of our nation depends on the education of our children. Eatly intervention
assures that each child begins school with an understanding of basic concepts, can leam in a
‘group setting, cooperate with others and follow instructions. These concepts are key in school,
society and life.

Yet, we in Congress fund these programs as if they are not important. A total of $4
billion has been appropriated for Head Start for FY1998 and $279 million for Early Head Start.
These programs provide a comprehensive preschool experience for low income children.
However, Head Star only meets for part of the day, for part of the year. Welfare reform
‘mandates that parents of preschool children work for 20 hours per week. Most of these parents
will only find work in service occupations. Hotels, restaurants and retail stores do not run on a
nine to five schedule. They are open almost 24 hours a day, seven days a week. Finding decent
affordable child care for this kind of non-standard work schedule is difficult. Finding an
‘enrichment preschool program that fits this kind of schedule is almost impossible, Therefore,
the child care promised by many during the welfare reform debates will not be the kind of care


40

your own productive life-style? Was that a factor in the whole
issue?

Ms. PEARSON. I’m sorry, can you repeat that again?

Mr. Suays. Yes. Something that a man doesn’t have to weigh as
a general rule is that giving birth does not take that man from his
employment, where giving birth, for a woman, takes her from her
employment. In your early time, and even maybe now, did you see
your child as interfering with your own opportunities?

Ms. PEARSON. There were selfish thoughts that I quickly got
over.

Mr. Suays. I don’t think those are selfish thoughts.

Ms. PEARSON. They were crazy thoughts. I was like, OK, so I
have this baby, now I can’t sleep like I want to anymore; and I
quickly got over that. Now I don’t even care about sleep. All I know
is that my son comes first.

Mr. SHays. I had someone say to my wife when our child was
born that she wouldn’t have a good night’s sleep until our child
went off to college. That was not a very nice thought for my wife.
The bottom line is that you are dealing with all the things that a
woman has to deal with, and you received wonderful help.

You have provided tremendous insights to us, but it almost
seems too good to be true. You are a very happy, beautiful young
woman, who seems to be almost like a super mom, and I have to
believe that you still have some challenges as well. But I really
welcome your testimony.

Governor Almond, I would like to know how you got into this
issue. I would like to know why you, as a public official—what trig-
gered you? You have all these opportunities as Governor, as you
pointed out. You chose to make this an issue. And you viewed it
as being central to the future prosperity of your State and to your
citizens. What triggered it?

Governor ALMOND. I think several things. I was a U.S. attorney
for 21 years, but I also worked as a volunteer, as chairman of a
very, very successful nonprofit group for economic development. I
know the link of the economy and these types of programs.

I think second it was programs with Mr. Reiner and others at
the National Governors Conference and compelling testimony on
the importance of these particular issues.

None of us take a position in a vacuum. I have two children of
my own. Both of my children my wife put in preschool, even though
she was home with them and took care of them; and I could see
the benefits to my own children of not only having good parenting,
but having a good preschool program. And by the way, that was a
preschool program run by the YMCA.

Now I have five grandchildren. I have a daughter-in-law with
three boys who has decided to stay at home, but all of her children
have 2 years of preschool before they’re going to get to kinder-
garten.

And I have a daughter who works for the U.S. Government and
is very, very fortunate to have day care within her Federal agency,
so she takes her two children to work with her in the morning and
they are right in the building. It is a very, very good quality pro-
gram. I have been there and I see the benefits to my grand-
daughters, and I can tell you that being the grandfather and seeing


120

We have recently been invited by a major philanthropy to develop a system of regional
replication centers based in schools of nursing and public health to develop this program
ona national scale. We have estimated that it will take 20 additional years to develop
this program for all low-income women in our society, if we wish to preserve those
elements of program quality necessary to reproduce the results I have just summarized on
a national scale. This is because quality programming requires recruiting qualified staff,
intensive training, and excellent supervisors ~ capacities that require development over
time.

In general, we believe that policies and practices for assisting young children and their
families ought to be based upon the best scientific evidence available. Given the recent
emphasis on brain development in the first three years of life, there is a lot of enthusiasm
these days about the promise of early preventive intervention.

We know that brain development is rapid during the first three years of life and that many
neuronal pathways are established during this time. There are very few programs that
have been scientifically proven to improve parents’ care of their children, however, and I
see almost no evidence that programs have been able to improve children’s neurological
development. At this point, we have lots of theory but not much proven to work.

‘The few well conducted studies of programs designed to promote early parental care
should give us pause, given that almost all of those tested have failed to achieve the kinds.
of results we so desperately need.

I am particularly concerned about the expansion of Early Head Start before research on
its effectiveness is completed. I am deeply concerned that the programs in place have not
been sufficiently well developed clinically to produce meaningful results. I have similar
concerns about the federal Healthy Start program.

To fund such programs before they have been developed clinically and carefully tested is
likely to put in place a system of services for young families that is deficient and not
reflective of what our evidence indicates that we, as a society, could achieve

Public hope and confidence in the promise of such programs is a scarce commodity that
we dare not squander on approaches that are not likely to succeed. As health and social
welfare policy is redesigned in the near future, I believe that it makes sense to begin with
programs that have been tested, replicated, and found to work.

In the next century, we have a unique opportunity to guide policies for children and
families with solid scientific evidence. I hope we do not miss the opportunity.


214

Ms. KNITZER. Or that we at least evaluate what States are doing,
because States are not going to stop and wait for the 20 years. So
we need to build in, I think, a two-track strategy.

Mr. Suays. Fair enough. We are going to write a report on this,
my hope and intention is, before we adjourn. And we haven't writ-
ten many reports this year, but this would be one we would like
to, so it’s going to be a close involvement.

Mr. Burki, | am going to get up to Westport, given it’s only 20
minutes away, to see your program, and I will bring one of my staff
members with me so we can incorporate that. But given that I
missed your testimony, one of your points, when I was reading your
testimony was, I focused on welfare reform, the need to make that
work, and I think what you are saying to us is we need to make
sure that business—that we don’t just think of this as a welfare re-
form kind of program, that it’s got to involve a lot more than that.

Mr. BurKi. Exactly. It’s a change in society and a change in the
work force and its corporations and organizations and govern-
mental agencies all being proactive in addressing these changes
and realizing that, with the change in the social fabric and the
work force and the families in this society of ours, that we have to
take different approaches. And that is what I think is so important
about this meeting today, is the private and the public sectors com-
ing together and coming up with creative solutions for these types
of issues.

Mr. Towns. Mr. Chairman, I know we don’t have time for an an-
swer——

Mr. SHAys. You have 3 minutes.

Mr. Towns. I don’t want an answer now, but if you would be
kind enough to send us material on things we might say to people
who argue the point in terms of fade out as a result, I would appre-
ciate it.

Thank you very much. Your testimony has been helpful.

Mr. Suays. I am sorry. We are adjourning about 20 minutes be-
fore we should, but we have a series of votes, and we are not going
to keep you waiting. Thank you very much.

(Whereupon, at 12 noon, the subcommittee was adjourned.]

ie)


19

childhood development which will link health care, quality
child care, intervention programs for families at risk, and parent
education from the prenatal period through age five. And if it

Passes, It will be another great model from which to work.

But as successful as these programs have been—and,
hopefully, the one in California will be—we as a nation have
approached early childhood development in an ad hoc,
plecemeal way. We have yet to recognize early childhood
Investment as an effective social problem solver. And until we
do, until we recognize that the way to change outcomes Is to
attack social problems at the roots, we will continue to stand
by the river, futilely trying to grab babies before they go over
the falls.

Again, thank you for letting me be part of what I hope will lead
to a significant investment In our nation's most precious

tesource, our children.


14

| feel that's what this hearing’s about: stopping the loss of our
children to failure in school, drugs, teen pregnancy, welfare

dependency, and violent crime before it starts.

We now know in no uncertain terms that the human brain grows
to 90 percent of Its adult size in the first three years of life. And
the emotionai, physical, and intellectual environment a child Is
exposed to In those critical first three years vis-G-vis parents
and primary caregivers has a profound physiological effect on
how that child's brain will develop. Whether he or she will be
healthy and enter school ready to learn and subsequently
succeed In life or become a toxic and costly burden to society
is in a very large part determined by his or her earliest

experiences.

After almost 15 years of thinking about how a child's early
development could affect social outcomes, four years ago my
wife Michele Singer Reiner, Ellen Gilbert of the international

Creative Management talent agency, and | began the | Am


coer. vekengsmaart

‘oh HUNDRED FIED CONGRESS

Congress of the United States

Bouse of Representatives
‘COMMITTEE ON GOVERNMENT REFORM AND OVERSIGHT
2157 Ravaunw House Orrick Buona
Wassanaron. OC 20515-6149

‘SUBCOMMITTEE ON HUMAN RESOURCES
‘Cuistophes Shaye. Connecticut

EMail groc@mai rouse gov

Statement of Rep. Christopher Shays
July 16, 1998

Good moming and welcome.
In calculating the trajectory of an object in space, a course correction of one degree at

launch can change the destination by millions of miles, Today, we discuss human trajectories,
and changing the course of children’s lives.

Both physical and social science support the critical role of prenatal care and effective
parenting in each child's emotional and cognitive development. A growing body of research
concludes an infant's earliest encounters play a decisive role in “wiring” the brain for learning,
for love, for life, Missed opportunities to program the human navigational computer cannot be
regained, and the costs of later course corrections for children, and their mothers, increase
‘exponentially as they go farther down the path of low self esteem, poor school performance,
neglect, abuse and dependence.

This is our third hearing on early childhood development programs. Previous oversight
of the Healthy Start and Early Head Start programs offered optimistic, even moving, testimony
that well designed efforts can have positive and lasting effects on infants and families. Those at
risk due to poverty, poor health, teen pregnancy and substance abuse can be put on the road to
better health, better parenting and self-sufficiency. But rigorous evaluation of these programs is
still in progress, and important questions remain about the effectiveness, efficiency and
sustainability of various prenatal and early childhood intervention strategies.

We address some of those questions today. Specifically, we ask: How are public and
private investments in early childhood programs contributing to successful outcomes for infants
and mothers? And, how can those successes be measured, and replicated, as states implement
welfare reforms and demand for quality child care grows?


182

their confidence for behavioral change. Much of the educational content of the program was
focused on helping women understand what is known (or thought about) the influence of
particular behaviors on the health and growth of the fetus, on women's own health, and on the
subsequent health and devetopment of the child. This represented an effort to bring women's
‘outcome expectations into alignment with the best evidence available. Improvements in
individuals’ behavior depends upon their confidence in their ability to change. Because
individuals gain confidence if they actually observe their accomplishments, the home visitors
emphasize methods of enhancing self-efficacy that rely on women actually carrying out parts of
the desired behavior. The visitors help parents establish realistic goals and small achievable
objectives that, once accomplished, will increase parents’ reservoir of successful experiences,
and in turn will increase their confidence in taking on larger challenges.

While self-efficacy theory provides powerful insights into human motivation and
behavior, it is limited in several respects. First, itis primarily a cognitive-behavioral theory. It
attends to the emotional life of the mother and other family members only through the impact of
behavior on women's beliefs or expectations, which, in turn, affect emotions. It also attends to
environmental influences in only a cursory way. These shortcomings of self-efficacy theory
have been addressed in the program with attachment and human ecology theories.

C. Attachment Theory

‘Attachment theory posits that infants are biologically predisposed to seek proximity to
specific caregivers in times of stress, illness, or fatigue in order to promote survival."” This
organization of behavior direcied toward the caregiver is called “attachment.” Stated simply,
«a growing body of evidence indicates that children’s trust in the world and their later capacity for

‘empathy and responsiveness to their own children once they become parents can be traced to the

n


110

some instances, the public-private partnership involves foundations and government
either within the states or across multiple states. In other instances, such as
Colorado Bright Beginnings, the business community is deeply engaged in the
partnerships. In still other instances, the aim is to engage a broad variety of
stakeholders at the community level — making sure that early childhood is
everybody's business. For example, this is the strategy of the North Carolina Smart
Start Partnership for North Carolina's Children. Smart Start, now in 55 of the state's
counties, and soon to be statewide, joins local partners from the public sector,
private sector, and families to improve access to health care and the quality of early
childhood services for its young children. A statewide public-private partnership
provides leadership, technical assistance, and resource development. In Florida,
there has been a major effort to “partner” in a different way with key policy makers,
providing them with information about early brain development.

The states providing the most leadership are using many different pathways to
build a sustained commitment to young children and families over time. (See
Appendix C for description of the initiatives in the eight states with the most
comprehensive efforts..). For example, Colorado’s First Impressions has four goals:
(1) universal health care for children; (2) universal volunteer home visits and
support for new parents; (3) improved quality, affordability, accessibility of child
care; (4) and “child-oriented” communities. Colorado has used its Carnegie
Corporation Starting Points grant to create the Warm Welcome program, and is
involving the business community in paying for home visits as a benefit. Prior to
that, Colorado invested in a prekindergarten program and developed a state-level
management strategy to build a system of supports to young children and families,
through a Children’s Cabinet and a state-level management team. To strengthen the
local infrastructure for early care and education the state has begun a pilot effort in
12 counties. It bas also established a pilot mental health project for young children.

In West Virginia the approach is different. Starting Points Centers have been
feseblibed par of West Virginia's pre-existing community mobilization strategy,

known as the Family Resource Network. These Centers in turn, are becoming the
hubs for the delivery of a variety of services, including those related to welfare
reform. The state has also funded a prekindergarten program. Leadership for the
overall initiative is provided by the Early Childhood Implementation Commission
which is a part of the Cabinet on Children and Families.

In Ohio, three basic goals drive the community mobilization and program
development effort: ensuring access to early care and education for every family that
wishes it, improving child health, and increasing family stability. The state began

6


69

PROVIDENCE
‘CHILD OPPORTUNITY ZONE FAMILY CENTERS.
coz Grade Total Percent
‘Schools Levels Enrollment Low-Income
‘Witiarn D’Abate Elementary Sehool KS Ect 36% Contact
Gibert Swart Elementary School KS m ‘00% ‘Thomas DiPipp,
Fogarty Elemenary School Ks 37 100% Director of Federal
CCumden Avenue Elementary School KS oe 7% Programe
"Of ee four schools with COZ Family Cancers, ony the Wiliam O’Abate Furl Center submis eh Schools
aoplcations 1 and cers funding through the sate COZ Fay Genter nine described i chis__ 4 Eemeneay Schoni
publican. The remaning three COZ Famiy Centers are pat of The Providence Pan’ Encerpse spies Province
‘Community COZ Fanly Centers.The Gilbert Stuart COZ # operated by Dorcas Pace Famiy ‘School Department
Lceracy Center. the Fogaery Elementary School COZ by the Salation Army.and the Camden Avenue Aflations
‘School COZ by che Smith Mill Centec The fllowing information refers ony to Willa D'Abate COZ Providence Enterprise
Communicy,
Advisory Board The Providence Plan
‘The D’Abate COZ Fumly Center does not hive a oficial governing board A numberof agencies -
tering tu One egirhond et nx mony be tre inomation nd pond ee
puton prog Crerenes Schon
‘Community Location THT Weseminnter Street
‘The D'Abace COZ i located in large ste of oficesictssrooms adjacent to the school bung, Providence, R02903
(401) 86.9020

‘Cassroom space in the ener is used bya varies of agencies and community groups
Funding (997-1998 for D’Abate COZ Family Center: $159,569

(fer nt ce perf be an hae cece ent 2 Fr cory ear

one Dep

Seren Pos (earner

Departmen a ea Td an ex 22K COZ Fay Cate (Depron of eaion
Sepermentof esth Ute

Shoal Daw

Program Components at the health counseling for seuden and fries
D'Abate COZ Family Center (TIDES, RIYouth Gudance): Child outreach

screening (Providence School Deparerent)
Parent Support and

Education
DiAbate COZ Family Center-Parents Making Adult Education

Dtlerence Fay Cencer (Americorps)
Resource counssor for parents of dabled
<td (RI Parent Information Network:
Parenting skis workshops: Information and
‘referral Housing information and workshops
Children’s Learning and Enrichment
Support wanton to middle school: Peer
‘mentoring fr fifth graders (TIDES): Summer
lending Worary After-school computer cub
‘School-Linked Health and Social Services
Immunization cnc (Travelers Ad), Mental

‘Community access computer nb (TechCorps):
Chid care worker ob ening (Starting Pome:
Job traning (Youtbuild); GED and ESL classes
(RURAL, Adu Acadery): College, career.job
skis counteing scholarship information (URI
‘CCRLEEOC)

Family and Community Development
Community projects in Oneyil: Community
police ofice at Family Center (Providence Police
Deparment): Environmental outreach and
‘education (Olney Housing): Greenway
Project (Providence Pan)

1 Coordinator (fl-ime)
1 Char (aise)


Overview for COMPANY

VII, Dependent Care Referrals

This section includes:

© Total number of referrals by LifeCare service (adult care, child care. etc.)

‘© Total number of referrals by care type within each LifeCare service category (i.e, nursing
home, home care)

© Percentages of referrals for each care type based on the total number of each service
category

© Total number of educational referrals

© Total number of referrals

VIII. Total Client Employee Quality Assurance Results

This information is based on the total number of client employees who have returned their
quality assurance questionnaires to DCC.

DCG==—=


24

> Despite recent state initistives to increase child care assistance to low and middle income
famnitios, long waiting lists and rising demands for child care help among both working
and welfare families pove tough challenges for tates. If wdditional underfunded work
requirements are imposed on states by Washington challenges will become even more
vexing.

+ Welfare moms are finding it dificult to move from welfare to work while maintaining a
bealthy home, Middle income families are scrambling to survive financially aad ensure
tht their children bave the best possible environment in which to develop and grow,

‘The Bhoda Island Experience - 4 Solution That Works Right

‘Although Rhode Island posscases perhaps the most equitable, balanced and positive child care
policies in the nation, we are now faced with the challenges of making rure that they can bo
‘ovifily and fully enacted and maintained. Rhode Island will drew down all ita child care block
gant, 1 million, inchiding matching dollars, and another 1.5 million from Title XX. In
addition, RI will spend 13 million dollar in state funds to support working families, Curreatly,
43% of all families receiving child care subsidy are on cash assistance and $7% are not receiving
cash. Even with statistics auch as these, RI hus not gotten to the care of beneficiaries on welfare.
Of the families on assistance, only 18% are presently using child care, and we have only reached
the tip of the welfare demand.

a Rhode Island, my administration has worked together with the State Legislature to
dynamically re-engineer socio-economic programs much 2a health and welfare and their impact
‘on economic development. In Rhode Island, 95% of all businesses have less than 50 employees.
‘Small businesses struggle to provide good wages and are often unsble to fiznd quality bealth and
child care benefits. My administration is making it possible for Rhode Island small businesses to
thrive and prosper by providing them with quality benefits to aid workers. [tis our belief thet
this is helping small businesses in Rhode Island retain their best and brightest employees.

Rhode Island has adopted a simple goal: All children will enter schoo! ready to leam and leave
school ready to work. I believe that the ages of 0-6 are the most critical if our future stands a
chance. We have made Rhode Island the only state in country in whieh child care and health


148

recruited if they were less than 29 weeks of gestation, had no previous live births, no specific
chronic illnesses thought to contribute to fetal growth retardation or preterm delivery, and at
least two of the following sociodemographic risk conditions: (i) unmarried, (ii) less than 12
years of education, (iii) unemployed. There were no differences in the sociodemographic
characteristics of those who enrolled and those who declined, except that African Americans
were more likely to participate than were whites. At registration, 92% of the 1139 women
registered were African-American, 98% were unmarried, 65% were aged 18 or younger, 85%
came from households with incomes at or below the federal poverty guidelines, and 9% smoked
cigarettes. The details of the research design and methods are described in greater detail in our
original report,"

1. Treatment Conditions. After completion of informed consent and baseline
interviews, identifying information on the participants was entered into a computer program that
randomized women to one of four groups. Women in Treatment | (n= 166) were provided free
transportation for scheduled prenatal care appointments; they did not receive any postpartum
services or child development screenings. Women in Treatment 2 (n = 515) were provided the
free transportation plus developmental screening and referral services for the child at 6, 12, and
24 months of age. Women in Treatment 3 (a = 230) were provided the free transportation and
screening offered Treatment 2 plus intensive nurse home-visitation services during pregnancy,
‘one postpartum visit in the hospital before discharge, and one postpartum visit in the home.
‘Women in Treatment 4 (n = 228) were provided the same services as those in Treatment 3; in
addition, they continued to be visited by nurses through the child's 2nd birthday.

For the evaluation of the prenatal phase of the program, Treatments | and 2 were

combined to form a single comparison group, which was contrasted with combined Treatments 3

2


10

I also asked ABC to give me an hour of television time to bring
this to the American public, and that show has been aired now
twice, and it has been seen by 15 million people. I had a very short
period of time to get some messages across, but we got two ideas
across, and I want to share them.

One was we now, through the new imagining techniques, we
have—we presented two brains. One was a perfectly formed brain
with all the gray matter filled in. The second was a brain about
two-thirds the size with a lot of black crevices where gray matter
should be but wasn’t. We asked neuroscientists and neurobiologists
what to make of these images, and they said this is clearly the
scan of a normal person, and this is the scan of a person who has
Alzheimer’s disease. When we explained that these were both
brains of 3-year-olds and that one of them was the product of a
healthy, nurturing, loving situation at home in those first 3 years
and the other one was a product of extreme neglect like we see in
Romanian orphanages and other places in the country where chil-
dren are deprived of stimulation and love and contact, this brain
did not grow. It wasn’t a question of the brain growing and then
shrinking, as it would in Alzheimer’s. It was a question of the brain
not growing, and it will never grow. It is stunted.

These are creating attachment disorders, which is the single
most important thing in terms of the effectiveness of how we func-
tion as a society. If we do not make these secure attachments early
on in life with parents and primary caregivers, we will not be able
to attach to teachers in school, to workers in the workplace and to
other members of society as we become adults. This is what we
tried to do.

The second thing we got across, and this was with help from the
RAND Corp., was we did a graph that showed the curve of the
brain growth and development over the course of a lifetime. And
what we saw, no surprise, was that the brain grew from—to 90

ercent, from zero to 3, from 3 to 10, another 10 percent, and then
From then on it was a flat line, a little dip at the end, unfortu-
nately.

And what we did was the inverse curve, was with public spend-
ing, and we found, again, no surprise, during the first 3 years, vir-
tually no money was spent, and then as people got older, more
money was spent. So we had the time of greatest risk, the time of
greatest opportunity, no public resources spent, that was first.

The second thing we tried to do with the campaign was present
materials to parents and caregivers. We have videos, we have bro-
chures on child care, on parenting, we have a web site in Yahoo,
and we got a lot of information out to millions of Americans.

The third thing was to get policymakers like yourselves to pay
attention to this and what were the implications in terms of public
policy.

Now it’s becoming very clear that to make a real impact on crime
and teen pregnancy and drug abuse and child abuse, welfare de-
pendency, and homelessness, we must make a real investment in
our children in the earliest years. We also know that in order to
affect public policy we not only have to have the scientific evidence
in Place but we have to have the economic evidence in place as
well.


141 ’

cigarettes smoked per day (2.50 vs. 1.50, p=.10), and fewer days having consumed alcohol in the
last six months (2.49 vs. 1.09, p=.03). Parents of nurse-visited children reported that their
children had fewer behavioral problems related to use of drugs and alcohol (0.34 vs. 0.15.
p=.08). There were no program effects on other behavioral problems.

5. Cost Analysis, The Rand Corporation has recently conducted an economic evaluation of
the program that extends the estimate of cost savings beyond those reported in our earlier
report.” While there were no net savings to government or society for serving families in which
mothers were married and of higher social class, as indicated in Figure 5, the savings to
government and society for serving families in which the mother was low-income and unmarried
at registration exceeded the cost of the program by a factor of 4 over the life of the child. This
figure shows, moreover, that the return on the investment was realized well before the child’s
fourth birthday. The primary cost savings were found in reduced welfare and criminal-justice
expenditures, and increases in tax revenues.

6. Conclusion. In general, as expected, the beneficial effects of the program were greater
for families at greater risk as defined by women’s being unmarried or from lower-SES
households. These findings were encouraging, but by themselves insufficient to form a
foundation for policy and practice. In order for scientific findings to serve as a guide in this
regard, they must first be replicated. The scientific credibility of such findings increases if they
can be reproduced with different populations living in different contexts and in different times.
C. Memphis Design and Methods

‘The Memphis trial was designed to determine if the effects of the Elmira program could
be replicated when it was conducted through an existing health department and when it served a

large sample of low-income African-American women, children, and their families living in a

20


184

Overview for COMPANY

Anote on referrals

DCC only refers providers who comply with their states” respective licensing and registration
Fequirements. All DCC referrals are accurate and up-to-date, and our counselors pre-screen
and pre-qualify each and every one by phone for every client. At 2 client's request, DCC will
also provide referrals to Internet Web sites that would be helpful to his or her care needs. DCC
‘monitors all referred sites for quality and appropriateness of information.

Step Five:
After pre-screening and pre-qualifying local providers. the DCC counselor calls the employee
with the information on those providers who meet the employee's specific LifeCare needs.
‘Counselors will also fax referrals and send additional information directly from the provider ar
the employee's request.

Step Six:
‘The same day that we relay the referrals by phone. we also send hard copies of our referrals
via First Class mail. Each referral packet consists of:

© A personal letter from the DCC counselor describing the enclosures
‘© At least six referrals whenever possible

‘© Printed educational materials relating to the type of care requested

© A quality assurance questionnaire which asks the employee to rate DC's services

‘The COMPANY employee will receive 2 customized information and referral package within
three to five business days after his/her initial call to DCC. In emergency situations, an
employee can receive his/her packet on the next business day.

Step Seven:
‘The DCC counselor fotlows-up with the employee at a pre-arranged date and time to check on
his/her progress and to offer any additional assistance. COMPANY employees are encouraged
to call DCC counselors as often as needed throughout the entire case process. (The average
‘number of interactions between a DCC counselor and calling employee is six.)

Step Eight: .

COMPANY management will receive quarterly utilization reports that track the program usage
for the reporting period. These reports include a tabulation of all quality assurance
questionnaires returned by COMPANY employees during the reporting period and copies of
the actual questionnaires coded to ensure confidentiality

DCG


29

Mr. Suays. Before calling on you, Ms. Pearson, I will be happy,
and I am sure my colleagues on the full committee will be happy,
to work with you to determine how many other States are like
yours.

Governor ALMOND. Vermont, Washington and Hawaii.

Mr. REINER. Minnesota as well.

Mr. Suays. It seems to me like that is a solvable problem.

Mr. REINER. Minnesota and Tennessee.

Governor ALMOND. Yes, they varied. We were the highest at 250

rcent.

Petr. Suays. We will come back to it, but I just say that this is
something we need to put on the record, and I am sure we can be
helpful.

Governor ALMOND. Very good. Thank you very much.

Mr. SHays. Ms. Pearson, it’s lovely to have you here, wonderful
to have you here. You have the floor, and I look forward to hearing
your testimony, and then we will be proceeding to ask all of you
some questions.

I am just going to ask you to pull the mic a little closer. 1 am
going to ask you to lower it down just a speck because I want to
make sure we hear you. OK. Thank you.

Ms. PEARSON. I just want to start off by saying my name is
Felicia Pearson. I am 31 years old, a single mother, and I would
like to start off with a quote that I made once that wasn’t really
brought out, so this is my opportunity now.

That we, as adults, we have to eat. When we are hungry, we eat.
And we have to think about our newborn babies, that this is a new
life, a new world to them, and everything in front of them is over-
whelming and exciting, and they want to know what is this for,
what is that, how do I do that.

Well, as parents, we have to feed them, and this is their food,
to learn. So that’s something I just want everybody to think about.
That in the first year a child’s brain grows 70 percent, and it is
very important that we try to push as much as we can with them
in stimulating their minds, so that one day they will grow up and
be healthy adults like us.

I got pregnant in the year of 1997, and by my 6th week, I got
very, very sick, and I went into depression. I also attempted sui-
cide, because I was sick morning, noon and night, and it never
stopped. So I want everybody to imagine if you had the flu 24
hours a day, and it just never stoppe . And all you feel like you
want to do, you want to end your life. It’s like when am I going
to get relief, and that’s all I kept saying to myself. And, of course,
the cowardly thing to do is to take your life, and then I knew I
would have to get help because I knew I wanted this baby, but, at
the same time, I was hating the baby, and I would call it “the
thing.

So I went to the doctor, and I told her what had happened and
of course, she wanted to admit me. She was very upset in hearing
that I wanted to do such an act, and I felt as though I could get
through it, and I told her no, I would wait, and it just got worse.
I completely stopped eating, I stopped drinking, and I would just
wake up in the morning hoping there was blood in the bed, hoping
that the baby was gone. So I knew that I had to get help.


166

‘Simuttaneous
50  Fiion of Treatment

Figure 2. Estimated nurse-comparison differences in the rates of child abuse and neglect
as a function of maternal sense of control - Elmira. (Reprinted with
from Olds, D.L., Henderson, C.R., Chamberiin, R., Tatelbaum, R. Preventing
child abuse and neglect: 2 randomized trial of nurse home visitation. Pediatrics,
1986;78(1):65-78.)



186

Overview for COMPANY

‘The LifeCare prenatal kit contains the following:

Educational Resources

© “What to Expect..." book series by Workman Publishing
—What to Expect when You're Expecting
What 10 Expect the First Year

—What to Expect the Toddler Years

© “What to Expect...” Pregnancy Organizer
© =Lamaze Parent Magazine

© DCC LifeCare Digests

—Birthing Method

—Breast-Feeding and Formula Feeding
—Child Care Options

Nursery Safery information

Fire Safety information

SIDS educational materials

CPRichoking poster

E

© Diaper bag

© Bib screened w/DCC icon and logo

© One-piece undergarment screened w/DCC icon and logo
© Magnet with newborn’s immunization schedule

‘Adoption
CC's specially-trained adoption counselors offer prospective parents counseling, education and
‘support and can walk them through the legal. financial and customary guidelines of domestic.
jimernational. public and private adoptions. DCC counselors furnish clients with educational
materials which cover a variety of adoption topics and up-to-the-minute issues. DCC directly links
clients to the appropriate resources and referrals. such as:

‘© Adoption medical issues © Public adoption
© State adoption specialiss ‘© Private adoption

‘© Adoption agency overviews ‘© International adoption

© Adoption support groups © Post-adoption information
© National adoption organizations Issues in adoption

DCG--— ’


98

Lynn A. Karoly Page 8

February 1995, Portland, OR. “Demographics, Sectoral Change, and Changing Relative
Wages: A Regional Approach,” presented at the Urban Economics and Policy
Seminar, Portland State University (with Jacob A. Klerman)

January 1995, Washington, DC. “Money for Nothing? Remittances by Migrants in the
Malaysia Family Life Surveys,” presented at the annual meetings of the American
Economics Association.

November 1994, Orlando, FL. “Health Care Reform: Labor Market Perspectives,”
roundtable discussion at the annual meetings of the Southern Economics Association.

‘October 1994, Chicago, IL. “Retirement Behavior and Health Care Reform,” presented
at the annual meetings of the Association for Public Policy Analysis and Management
(with Jeannette Rogowski).

June 1994, Vancouver, BC. “Long Jobs and Lots of Jobs?,” presented at annual
meetings of the Western Economics Association (with Jacob Alex Klerman).

January 1994, Los Angeles, CA. “Demographics, Sectoral Change, and Changing
Relative Wages: A Regional Approach,” RAND conference on “Reshaping the
Family: Social and Economic Changes and Public Policy” (with Jacob Alex
Klerman).

January 1994, Berkeley, CA. “The Effects of Rising Earnings Inequality on the
Distribution of U.S. Income,” Demography Seminar Series, University of California,
Berkeley (with Gary Burtless).

December 1993, Washington, DC. “The Effects of Rising Earnings Inequality on the
Distribution of U.S. Income,” Brookings Economics Seminar (with Gary Burtless).

December 1993, Washington, DC. “The Effects of Rising Earnings Inequality on the
Distribution of U.S. Income,” U.S. Bureau of the Census (with Gary Burtless).

October 1993, Washington, DC. “The Effect of Health Insurance on the Decision to
Retire,” presented at annual meetings of the Association of Public Policy and
Management (with Jeannette A. Rogowski).

October 1993, Washington, DC. “Demographics, Sectoral Change and Changing
Relative Wages: A Regional Approach,” presented at U.S. Department of Labor
(with Jacob A. Klerman).

September 1993, Washington, DC. “Demographics, Sectoral Change and Changing
Relative Wages: A Regional Approach,” presented at Labor Economics Seminar,
University of Maryland (with Jacob A. Klerman).

June 1993, Lake Tahoe, CA. “The Effect of Health Insurance on the Decision to Retire,”
presented at annual meetings of the Western Economics Association (with Jeannette
‘A. Rogowski).


140

pregnancy and were not explained by differences in measured aspects of the postnatal
environment.

In light of this, itis important to note that we reported earlier that control-group mothers
reported that their six-month old infants were more irritable than did those visited by nurses.""
We have now conducted analyses that show that these effects were concentrated exclusively in
infants born to women who smoked during pregnancy and that the positive program effects held
for children whose mothers were visited only during pregnancy, as well as those visited in
pregnancy and infancy. These findings have led us to focus greater attention on the role that an
improvement in prenatal health can play in reducing subtle neurodevelopmental impairment in
children,

3. Maternal Life Course 15 Years after Delivery of First Child. During the 15-year
period after delivery of their first child, unmarried women from low socioeconomic (SES)
households showed a number of enduring benefits. In contrast to their counterparts in the
comparison condition, those visited by nurses during pregnancy and infancy had 1.1 versus 1.6
subsequent births (p = 02), 65 versus 37 months between the birth of their first and 2nd children
{p= .001), 60 versus 90 months on welfare (p = .005), 0.41 versus 0.73 behavioral problems due
to substance abuse (p =.03), and 0.18 versus 0.58 arrests by self-report (p <.001). New York
State records revealed that they had 0.16 versus 0.90 arrests (p <.001).*

4. Antisocial Behavior Among the Fifteen-Year-Old Adolescents. In contrast to
adolescents born to poor, unmarried women in the comparison group, those visited by nurses
uring pregnancy and the first two years of the child's life reported fewer instances of running
away (0.60 vs. 0.24, p=.003), fewer arrests (0.45 vs. 0.20, p=.03), fewer convictions/violations of

probation (0.47 vs. 0.09, p<.001), fewer life-time sex partners (2.48 vs. 0.92, p=.003), fewer

19


91

LYNN A. KAROLY

RAND Internet: Lynn_Karoly @rand.org
1700 Main Street 310-393-0411, x7359
Santa Monica, CA 90407 310-393-4818 (fax)

EDUCATION

Ph.D., Economics, 1988, Yale University

M.A., M.Phil., Economics, 1986, Yale University

B.A., summa cum laude, Economics and Mathematics, 1983, Claremont McKenna
(Men's) College

PROFESSIONAL EXPERIENCE,

1995 - present -- Senior Economist, RAND, Santa Monica, California

1995 - present -- Director, Labor and Population Program, RAND, Santa Monica,
California

1991 - present -- Associate Director, Population Research Ceniter, RAND, Santa Monica,
California

1991 - present -- Training Director, RAND Postdoctoral Research Programs in
Population Studies and the Study of Aging

1989 - present -- Faculty, RAND Graduate School of Policy Studies, Santa Monica,
California

1993 (fall) -- Visiting Fellow, Economic Studies Program, The Brookings Institution,
Washington, D.C.

1992 - 1995 -- Economist, RAND, Santa Monica, California

1988 - 1992 -- Associate Economist, RAND, Santa Monica, California

PROFESSIONAL SERVICE, HONORS AND AWARDS

Co-Editor, The Journal of Human Resources, 1997-present

Member, Board of Trustees, Claremont McKenna College, 1996-present

‘Associate Editor, Cambridge University Press “RAND Studies in Policy Analysis” Book
Series, 1996-

Research Associate, Institute for Research on Poverty, 1995 - present

Member (Chair), Dorothy S. Thomas Award Committee, 1994 - 1997

‘Ad Hoc Member, NIH Social Sciences and Population Study Section,
June 1994, February 1995

National Science Foundation Graduate Fellowship, 1984-1987

Yale University Graduate Fellowship, 1983-1984

Phi Beta Kappa, 1983


193

Overview for COMPANY

Adult Care Kit

‘Asa valuable supplement to DCC’s adult care counseling, education and referral services,
DCC can provide COMPANY employees with an adult care kit. This kit of educational
‘materials and products, with instruction sheet, is tailored to benefit both the caregiver and care
recipient by including:

Educational Resources

How To Care for Aging Parents book by Workman Publishing
DCC Eldercare Education Series

DCC's LifeCare Digest On Home Safety

Health Insurance for People with Medicare

Social Security Information

Disaster Preparedness

Emergency Preparedness Checklist

Using Your Medicines Wisely

eoecccce

I

Daily record keeper
Wipe-off emergency board
Bookmark magnifier
Flashlight

‘Sensor night light

Pill organizer

Jarfooule gripper

eoeccce

DCG *


11

Now, as I said, the scientific evidence has been in place for quite
a while, but the economic evidence is starting to become known
through the RAND Corp., investing in our children, and we can see
the cost benefits of investing in intervention programs.

Because, historically, there have been so few resources devoted
to early childhood development programs, measurable outcomes
were limited. However, the RAND study has shown there are sig-
nificant findings with respect to early interventions for families at
risk. The bottom line is, with the right kinds of interventions, we
can make dramatic reductions in these social ills. And this, simply
stated, means a sizable saving to not only the government but the
taxpayer.

Early childhood development experts and people in law enforce-
ment have long known the wisdom of investing in our youngest
children. Recently, there was a State-wide conference in Ohio of all
the attorneys general, the chiefs of police, the judges, and one dis-
trict attorney said that justice doesn’t start in the electric chair, it
starts in the high chair. And I think this is very well understood
now in the law enforcement community, and there are wonderful
programs all over of the country going on.

Vermont, under Governor Dean, has Success By Six, which pro-
vides families with quality child care, nutrition and literacy pro-
grams, as well as extensive parent education.

North Carolina Governor Jim Hunt has initiated the Smart Start
Program, a public-private partnership, which helps all children of
families throughout the State obtain quality, affordable child care,
health care and family support services.

Missouri Governor, at that time, Governor Bond, started the Par-
ents As Teachers program, which is internationally recognized as
one of the great early childhood education programs in Rhode Is-
land.

You will hear from Governor Almond in a minute. He helped cre-
ate Right Care and Starting Right, an expansive effort to make
quality child care more accessible and affordable.

And the National Governors Association, under Governor Miller
and Governor Voinovich, has made early childhood development a
top priority.

And I, myself, I have taken what I have learned in the last 4
years and have crafted and am chairing a California initiative
which is officially qualified for the November ballot called the Cali-
fornia Children and Families Initiative, and if it passes—it pro-
poses the creation of a comprehensive, integrated approach to early
childhood development which will link up health care, quality child
care, intervention programs for families at risk, and parent edu-
cation from the prenatal period through age 5. And if it passes, it
will be another great model from which to work.

But as successful as some of these programs have been, and,
hopefully, the one in California will be, we as a Nation have ap-
proached early childhood development in a very ad hoc, piecemeal
way. We have yet to recognize early childhood investment as an ef-
fective social problem solver, and until we recognize that the way
to change outcomes is to attack social problems at the roots, we
will continue to stand by the river futilely trying to grab babies be-
fore they go over the waterfall.


Lynn A. Karoly Page 7

‘Seminar and Conference Presentations

April 1998, Chicago, IL. “Health Insurance and Labor Market Transitions of Older
Workers,” presented at the annual meetings of the Population Association of America
(with Jeannette A. Rogowski).

March 1998, Santa Monica, CA. “The Costs and Benefits of Early Childhood
Interventions,” RAND/UCLA Child and Adolescent Health Policy Seminar (with Jill
Houbé).

February 1997, New York, NY. “Money for Nothing? Remittances by Migrants in the
Malaysia Family Life Surveys,” Columbia University Conference on Migration in
Developing Countries and Transition Economies.

October 1996, Washington, D.C. “Retiree Health Benefits and the Decision to Retire
Early: Evidence from the Health and Retirement Survey,” American Association of
Retired Persons Policy Seminar (with Jeannette A. Rogowski).

May 1996, Seattle, WA. “Explaining Racial and Ethnic Differences in Adolescent
‘Employment Outcomes,” presented at the University of Washington Demography
Seminar (with Robert F. Schoeni).

May 1996, New Orleans, LA. “Explaining Racial and Ethnic Differences in Adolescent
Employment Outcomes,” presented at the annual meetings of the Population
Association of America (with Robert F. Schoeni).

May 1996, New Orleans, LA. “Retiree Health Benefits and the Decision to Retire Early:
Evidence from the Health and Retirement Survey.” presented at the annual meetings
of the Population Association of America (with Jeannette A. Rogowski).

April 1996, Los Angeles, CA. “Anatomy of the U.S. Income Distribution: Two
Decades of Change,” presented at the University of Southern California Population
Research Laboratory Seminar.

January 1996, San Francisco, CA. “Anatomy of the U.S. Income Distribution: Two
Decades of Change,” presented at the annual meetings of the American Economic
Association.

June 1995, Madison, WI. “Demographic Change, Rising Earnings Inequality, and the
Distribution of Personal Well-Being, 1959-1989,” Institute for Research on Poverty
‘Summer Workshop.

April 1995, San Francisco, CA. “The Indonesian Family Life Survey: Household
‘Survey,” presented at the annual meetings of the Population Association of America.

April 1995, San Francisco, CA. “A General Equilibrium Approach to Changing Relative
‘Wages,” presented at the annual meetings of the Population Association of America
(with Jacob Alex Klerman).


187

Overview for COMPANY

Child Care

DCC offers an extensive program to help working parents find care for their children. DCC child
‘care counselors explain the range of options available to parents and can locate the following.
programs:

© Child care centers © Preschools/nursery schools

© Family child care © Before and after-school programs
© In-home care © Summer programs
—Baby-sining agencies and options © Emergency/temporary care
—Nanny agencies and opti © Special needs programs

—Au Pair agencies and options

Parenting

DCC can provide clients with resources that address a wide range of parenting issues.
including:

© Child development © Child safety

© Parenting education classes © Discipline

© Sibting rivairy © Raising adolescents

‘© Separation anxiety ‘© Parental guilt and jealously
Summer Care

‘Summertime can pose a difficult problem for working parents whose care arrangements only
apply during the school year. DCC counselors can help parents find the following types of
programs:

‘© Sleepaway options © Academic
‘© Daytime options © Computer literacy

‘© Traditionat programs © Travel, outdoor and nature
© Specialized programs © Fine arts

© Sports

ShareCare®

Flexible scheduling and telecommuting are’a part of today’s workplace. However. finding part-
time care can be a challenge. ShareCare matches parents who live near each other and have
similae child care needs. By sharing a provider. many care options become affordable and feasible
for parents. ShareCare offers solutions for parents who need:

© Inhome care © Emergency/temporary care
© Baby-siters ‘© Family child care providers
© Child care centers © Before and after-school care

DCG--—=


102

Lynn A. Karoly Page 12

July 1998


201

Overview for COMPANY

Users of LifeCare Net can pose these and any other caregiving questions to professional DCC
LifeCare counselors, who will respond quickly and privately via e-mail. Users may also browse
archives of answers to frequently-asked LifeCare questions.

LifeCare Forums
COMPANY employees will enjoy access to forums addressing a wide range of LifeCare issues.
Forums provide a true sense of “community” as LifeCare Net subscribers nationwide and
‘worldwide interact with each other about the work/life topics most important to them.

Message Boards

‘The forum has message boards in which users can post or peruse messages with tips, advice,
support, and experiences.
LifeCare Net offers clients the flexibility to customize message boards:

© Create unlimited message boards on topics appropriate for COMPANY

© Develop private message boards exclusive to employees and/or public message boards
linking users to other LifeCare Net clients

© Link directly to pre-existing message boards on COMPANY intranet

Chat Rooms

LifeCare Net users can also engage in real-time chat sessions within each LifeCare community.
Noted experts will periodically be invited to host a real-time discussion on a particular topic
within a community.

My Benefits

LifeCare Net integrates your company's complete benefits information online. While visting a
LifeCare Net community, employees can click on “My Benefits” to quickly access information
about COMPANY programs and policies that pertain to that community: insurance. Employee
Assistance Programs. tuition reimbursement, etc. This feature allows employees to understand
the range of benefits available for their immediate needs. and provides them with the contact
names and numbers of benefits administrators co facilitate program use and awareness. For
‘example, the Prenatal Community's “My Benefits” area might outline information on your
company's family leave policies. New Baby Gift program. seminars. and hospital and other
health-related coverage.

COMPANY benefits administrator(s) will have special access rights to LifeCare Net. enabling
them to add, delete or edit benefits at any time

Events

LifeCare Net can save employees valuable time by providing the key information they need
when encountering a significant life event. LifeCare Net features executive summaries on life's
major milestones: birth. beginning school. graduation, marciage. retirement. etc, Links take
users directly to applicable educational materials. This section of LifeCare Net also encourages
employees to explore “My Benefits” to find COMPANY benefits relevant to the event

DCG--—= °


192

Overview for COMPANY

Grandparents As Parents
DCC’s Grandparents As Parents program provides grandparents with the information and

resources to help them take on the challenges of parenting a second time around. The program
provides education and referrals on:

.

Establishing or finding support groups
Child care

‘School issues

‘The child welfare system

The Department of Social Services

Adult Care
Today itis not uncommon for working people to care for their parents or elderly loved ones.

DCC can assist with:

ee ry

‘Nursing homes
Assisted living facilities
Continuing care retirement communities
Home health care

Long distance caregiving
Emergency care

Respite care

Hospice

Discharge planning

‘Adult care assessments
Independent housing

Senior centers

er i ee ey

Legislation
Legal issues

‘Court-appointed special advocates
Financial assistance/Medicaid
Health and nutrition

Resident care
Adult day care

Transportation services
Home-delivered meal programs
Medicare and Medicaid
Long-term care insurance
Supplemental insurance
Financial issues

Legal issues

Volunteer programs

‘Suppor groups

DCG


118

Over the years, we have been encouraged to disseminate the program model, but we have
waited to do so until now because we wanted to have sound scientific evidence of its
effectiveness and thoroughly developed program protocols. In this way, we can now
provide greater assurance to communities that replicate this program will reproduce the
results achieved in the research.

We have examined the program in three separate, large scale randomized trials.
Randomized trials are the most scientifically credible method of determining the
effectiveness of health, social service, and medical interventions.

The first study was carried out in Elmira, New York with Caucasian families.

The second was conducted in Memphis Tennessee, with African American families.

The third is being completed in Denver with a large portion of Mexican-American
families.

We have found that the program can reduce some of the most intractable health and social
problems facing at-risk families in our society and a recent report by the Rand
Corporation shows that the program can more than pay for itself in reduced government
expenditures, when it is focused on unmarried, low-income parents.

A recent report on the Elmira study shows that by the first child’s 15th birthday, nurse-
visited low-income unmarried mothers had:

© 33% fewer subsequent births;

+ 30 months greater spacing between first and second births;
‘+ 30 fewer months on welfare;

‘¢ 81% fewer arrests and convictions; and

* 79% fewer verified reports of child abuse and neglect;

Compared to their counterparts who had been assigned to comparison services, the 15-
year old children born to nurse-visited, low-income, unmarried mothers had:

© 60% fewer instances of running away;
* 56% fewer arrests;

* 81% fewer convictions and violations of probation; and


65

MIDDLETOWN
CHILD OPPORTUNITY ZONE FAMILY CENTERS

coz Grade Enrolimene Low-Income
Schools Levels Total Percent
Forest Avenue Elemenary School Kt 35 0x
‘Aquidnack Elementary Schoo! ca We

Kennedy Elementary Schoo! 309 mx

LUnden Elementary School preK and K 13 20%

Advisory Board
‘The Middietows COZ hat» Steering Commatee comprised of agency represenatves, teachers
{uidince counselors and parents Approwimately 15 members parucipate exch mone co pian acumies
and evahate progress.

‘School Location

The Middletown COZ has a family rexource cancer in each of the four participating elementary
schools The COZ raf who have offices a the Schoo! Adminstration Buiding, re frequently on-see
In the schools connecting with teachers, school staf parents. and children An aterschool cid care
rogram for chidren inthe Midélecown school system i offered on-site atthe Linden. Aguldneck and
Forest Avenue Schools by the Newport County HCA.A belore-schoo chi care program is offered
athe Linden Sehook

Funding 1997-1998: $61,907

(tee na cde mk! npr fom che tend supper fm heath an human sera EEC oF ne
Crees

by err nd cere hee
7% UnuesWay
‘el
‘Schoo! Drret 57% COZ Famay Center (Deparent af Everton.
[Beparement of Meath Uneed Wi
Program Components ‘Childrens Learning and Enrichment
Parent Parent newtlerer on how to support cdeens
beemwees earning

Parenting workshops (New Visions, Newport
‘County Child and Family Services, Famiy ‘fecachoo| since cb
Networks)

Parent Resource Libary 2¢ each schoo!
Learning Lending Library of tops. games, books,
sofware Famnlly and Community Development
Ioan and Preschool Progame Prenat ean che
Parents ax Teachers ply groups - bth o age 3

Parents as Teachers (Schoo! District)

Psy groups for 3-and 4 year olds

‘Child Care

Belore-school childcare (Newport County

YMCA)

‘Aker school chid eae (Newport Counry

YricAy

Book swaps
‘Book group for childcen with arention deficit
Sinorder

Chsdeen ranch
ladergartenceady to

‘Cnhdren experience
accent in sehook.
Parents are involved in
tale chitdren’s education.



71

‘WOONSOCKET

‘CHILD OPPORTUNITY ZONE FAMILY CENTER:
coz Grade Total Percent
‘Schools Levels Enrollment Low-Income,
‘Second Avenue Schock Ka o 100%
Fey Avenue Schoo! Ka 204 0%
‘Coleman Elementary School 3.5 cal om,
CGruzens Memorial School KS me 2
Advisory Board

“The Board of Connecong for Children and Famies act a8 the governing council forthe Child
‘Opportunity Zone. Ths 15-member Coordinating Counc has ffy-one percent parents and forty
rine percent human service, education, busines. and cv leaders. The Coordinating Counc ses the
stratepe direction and gves advice on programs to be ofered that meet paren provites.

‘School and Community Locations
‘The Fairmount Far Center operated by Connecting for Chidren and Faris iste primary ste
for he Woonsocket COZ Acris ofthe Fairmount Fuly Center are inked with thee shoo n
{the Farrmount neighborhood all within a thee-biock area Stal work wih children and fate atthe
Family Center. in the neighborhood. andi the schools There family resource room inthe
Goleman school and activites are ofered onsite a Coleman akerschoolA schoo bsed health
“ence is beng planned for Coleman School anda Family Room is planed for Cruze Memoral

Funding 1997-1998: $183,700

The Rhode tnd Fondation *

{COZ Famiy Cerer

(Deparemen of
19% Esveavon Beparement of Heath Uneed Wap)

12K sarang Poms (Deparment of Edeavon
‘Bepartnen ot Henn Onced Way Carne)

Program Componencs
‘Parent Support and Education

Farmount Family Cencer:Farly resource room
at Coleman Schoo Information referral and
fetlow-up:Parent support group: Resource
‘Counselor for parent of chiren who are
<iabled (RI arene Information Cente)
‘Neighbor-o-neihbor prenatal support: Parent-
‘o-parent mentoring: Outreach home vss:
“Transation seraces: Child ere for event: fant
toddler car set datributon: Ca fey
‘education

Infant and Pre-School Programs

Camp forages 4-11:Summer Teen Employment
(Famty Retources) Neighborhood teen action
_roup.Parencteacher coffee hours: Trasliion
support forthe school evens and IPS

‘Adult Education
ESL and computer classes (RIRAL, Literacy
Volunteers) Incernahips for adults enrolled
Pachways Program: Family home child care

Fam Uceracy Program (Even Sart) prowder tring
cS Learning and: amity and Der

‘Akerachool dubs and min-courses,Se-eteem Neighborhood safety committee: Lending ibrary
program {URI} Spore and ar lattes (Northern atthe schook Safe Stes dass Neighborhood

I Meal Heath Cente) 6-Week Summer

‘eet: Mukicuurlfexuval: Family actwoes

Fairmount Fury Center
28 Fire Avenue
Woonsocket, Au 62895,
(wonyree-3384

Seat



Overview for COMPANY

Employees using LifeCare Net can personalize the service by completing a confidential and
optional online profile. By entering information about themselves and their loved ones who
may require care, LifeCare Net can detiver timely information and news that address their
specific situation. For example, the parent of a newborn baby would receive different news
than the caregiver of a parent with Alzheimer’s Disease. Because LifeCare Net automatically
tracks the development of the user's child(ren), users do not have to update their profiles unless
there are family changes, such as a new addition!

LifeCare Net Communities

LifeCare Net is comprised of eleven communities. As this service continues to expand, DCC
will add new communities to LifeCare Net. COMPANY will receive each new community
upgrade automatically and at no extra charge.

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16

We also know that, In order to affect public policy, we must
have not only scientific evidence of the wisdom of this kind of
investment, but the economic evidence as well. As I've sald,
the scientific evidence with respect to brain development has
been in place for quite some time, but now for the first time,
with the release of the Rand Corporation's book entitled
Investing In Our Children, we can also see the cost benefits.
Because historically there have been so few resources devoted
to early childhood development, programs with measurable
outcomes are limited. However, the Rand study has shown
significant findings with respect to early interventions for
families at risk. The bottom line is that, with the right kinds of
Interventions, there can be dramatic reductions in crime, teen
pregnancy, drug abuse, child abuse, and welfare
dependency. Simply stated, this means sizable savings for the

government and the taxpayer.

Early childhood development experts and people in law

enforcement have long known the wisdom of Investing In our


160

18, Milberger, S., Biederman, J., Faraone, S., Chen, L., Jones, J. (1996). Is maternal smoking
during pregnancy a risk factor for attention deficit hyperactivity disorder in children?
American Journal of Psychiatry, 153, 1138-1142.

19, Wakschlag, L-S., Lahey, B.B., Loeber, R., Green, S.M., Gordon, R.A., & Leventhal, B.L.
(1997). Maternal smoking during pregnancy and the risk of conduct disorder in boys.
Archives of General Psychiatry, 54, 670-680.

20. Fried, P.A., Watkinson, B.W., & Dillon, R.F. (1987). Neonatal neurological status in a low-
risk population after prenatal exposure to cigarettes, marijuana, and alcohol. Developmental
& Behavioral Pediatrics, 8, 318-326.

21. Mayes, L.C. (1994). Neurobiology of prenatal cocaine exposure: Effect on developing
monoamine systems. Infant Mental Health Joumal, 15, 121-133.

22. Institute of Medicine, (1990). Nutrition during pregnancy. Washington, D.C.: National
‘Academy Press.

23. Klein, L., & Goldenberg, R-L., (1990). Prenatal care and its effect on preterm birth and low

birthweight. In 11

Merkatz, & J.

‘Thompson, (Eds). New perspectives on prenatal care

(pp. 501-529). New York:Elsevier.

24, Newberger, C.M., & White, K.M. (1990). Cognitive foundations for parental care. In D,
Cicchetti, & V. Carlson (Eds). Child Maltreatment: Theory and research on the causes and
consequences of child abuse and neglect (pp. 302-316). Cambridge, England: Cambridge
University Press.

25. Sameroff, A.J. (1983). Parental views of child development, In R, A. Hoekelman, (Ed.).

Minimizing high-risk parenting (pp. 31-45). Media, PA: Harwal Publishing Co.


Lynn A. Karoly Page 9

June 1993, Ithaca, NY. “The Effect of Health Insurance on the Decision to Ret
presented at Conference on Health Insurance and the Labor Market, Cornell
University (with Jeannette A. Rogowski).

April 1993, Cincinnati, OH. “Remittances by Migrants: Evidence from the Malaysia
Family Life Survey,” presented at annual meetings of the Population Association of
‘America (with Nga Vuong).

Apri 1993, Cincinnati, OH. “Demographics, Sectoral Change and Changing Relative
Wages: A Regional Approach,” presented at annual meetings of the Population
Association of America (with Jacob A. Klerman).

February 1993, Santa Monica, CA. “Demographics, Sectoral Change, and Changing
Relative Wages: A Regional Approach," presented at RAND Population, Aging and
Development Seminar (with Jacob A. Klerman).

January 1993, Anaheim, CA. “Demographics, Sectoral Change, and Changing Relative
Wages: A Regional Approach,” presented at annual meetings of the American
Economics Association (with Jacob A. Klerman).

REFEREEING

American Journal of Sociology, Contemporary Policy Issues, Demography, Eastern
Economics Journal, Economic Inquiry, Industrial and Labor Relations Review, Journal
of the American Statistical Association, Journal of Economic Literature, Journal of
Human Resources, Journal of Political Economy, National Science Foundation, National
Tax Journal, RAND Journal of Economics, The Review of Economics and Statistics, The
Review of Income and Wealth.

July 1998


21

ance. We are seeing mothers and pregnant women who smoke or
drink alcohol or abuse drugs declining as we get them the proper
medical attention.

So if we can get children healthy, the next step is to make sure
the children are developing, so that we can meet our goal in Rhode
Island, which is a very, very simple one, to make sure every child
enters school ready to learn. That alone can make a huge impact
with respect to education reform.

Let’s understand this. We do today, even with the problems in
public education, graduate a significant number of extremely good
students who go on to higher education. The problem is we have
some who lag behind. What we can do is give them an early start,
which is going to be a big boost to education and education reform
for the future. It’s similar to the medical issues with respect to put-
ting money into preventive medicine as to what you save and what.
your product is in the future.

I am also very, very proud to say that, in the past couple weeks,
the legislature at my request in Rhode Island passed the Starting
Right program. Over the next 3 years, we will have, and we are
the only State in the Nation that has, child care as an entitlement
for the working poor and for our individuals on welfare. We are
going to go to 250 percent of poverty with respect to a child care
incentive. That is going to be our entitlement. That is going to be
extremely important. And we are in the process of building a child
care system that has to be, it has to be, affordable, it has to be
quality. And this is not about baby-sitting, this is about the devel-
opment of children, and we have to invest in those particular areas.

I will close by just saying to the Congress, I applaud you for
what you did with respect to children’s health care. You passed leg-
islation last year that took us to 150 percent of poverty to the
States. We have talked about devolution, how it would be a race
to the bottom by the States and I know that hurt a lot of my fellow
Governors and hurt me. Devolution has turned out to a race to the
top, and we are doing what is right for the people of the State of
Rhode Island and for the Nation.

One thing that bothers me is, when you passed that health legis-
lation, Rhode Island was already well above what you passed, and
there is about $8 million sitting there that I cannot use that I need
because we insure up to 250 percent of the poverty level. And when
you have an individual who is leading the race to the top, and you
say to me, we are going to penalize you because you were there be-
fore we said may I, or I asked may I, that is wrong. And I have
a waiver in to HHS now to allow me to use that $11 million, about
$8 of which I don’t think I can use on health programs, to expand
the RIte Care program for poor families.

But I could also use that. I need the flexibility to put that money
to early childhood programs which can help children and help par-
ents, build the work force, and help the economy of the State of
Rhode Island.

Thank you very much.

Mr. SHays. Governor, thank you very much.

[The prepared statement of Governor Almond follows:]


50

Attributes of Effective
Programs for
Children and Families

Successful programs are comprehensive,
flexible, responsive and persevering
‘Programs take responsibilty for providing
‘asy and coherent access to services thar
ae sufficiently extensive and intensive to
meet the major needs of the families they
work with, Efective programs recognize
that no matter where the point of entry
into services takes place, families may need
access to a range of prevention and
intervention services. Services and
supports are provided either directly or
through formalized linkages to other
agencies and community partners.

Succes programs see children in the
content oftheir families. Successul
programs are two-generational. Programs
work to meet the needs ofthe parent as
well asthe child. Ac the same time, parents
are helped to meet the health and
developmental needs oftheir children.

Succesfal programs deal with families as
part of neighborhoods and communities.
Programs have deep roots in the
community and respond to the needs
perceived and identified by the
community. To assure their relevance to
the community they wish to serve,
programs recognize cultural values in cheir
design and offerings. Staff reflect the
cechnicity of the community and the
community takes part in planning the

Successful programs operate in sting that
encourage practitioner 0 build song
relationships based on mutual rust and
‘ropec. Progeams ae based in
‘organizations which are widely accepred
by the community (eg. schools,
‘community organizations, community-
based family support programs) and that

cam be kept open year-round and during
‘non-traditional hours. Staff have the time,
training, skills, and institutional support
necessary to create an accepting
enyironment and co development
‘meaningful one-to-one relationships. They
establish a climate that is welcoming,
continuous, and reliable.

Successful programs have a long-term
preventive orientation, a clear mision. and
continue te evolve overtime. Programs do
‘not wait until families are in trouble to
provide services and to reinforce the
screngths of the child, che family, and the
neighborhood. Programs that are
successful with the most disadvantaged
populations persevere in cheir efforts co
reach the hatdest-to-reach and tailor their
services to respond co the distinctive needs
of those at greatest risk. Programs have a
clearly arcculated mission, yet managers
ae allow their programs to continually
evolve to respond to changing individual,
family and community needs. They
‘operate in a culeure that is outcomes-
oriented, rather than rule-bound.

Successful programs are well-managed by
competent and committed individuals with
clearly idenifable skill. Staff are trained
sand supported to provide high quali,
rponsive services. Staff are versatile and
flexible and actively collaborate across
bureaucratic and profesional boundaries.
Staff do “whatever it takes” - they have the
Aexibilty to respond to concrete needs for
help with food or housing or a violent
family member, as well as ro subtler needs
fora listening er.

Adapted from Scher, LB. (1987). Common

‘Commiomens New York Columbia Univeiy
‘Navonel Comer fr Children on Poor. 1994


95

Lynn A. Karoly Page $

Feigenbaum, Susan, Lynn A. Karoly, and David Levy, “When Votes are Words Not
Deeds: Some Evidence from the Nuclear Freeze Referendum,” Public Choice, Vol.
58, 1988, pp. 201-216.

Karoly, Lynn A., “A Study of the Distribution of Individual Earnings in the United
States from 1967 to 1986,” unpublished Ph.D. dissertation, Yale University, 1988.

BOOK REVIEWS

How Rich is Too Rich? Income and Wealth in America by Herbert Huber and Sidney
Carroll, in The Journal of Economic Literature, Vol. XXXII, No. 1, March 1994, pp.
130-131.

‘WORKING PAPERS

Karoly, Lynn A. and Rogowski, Jeannette A., “Health Insurance and Labor Market
Transitions of Older Workers,” prepared for presentation at the annual meetings of
the Population Association of America, September 1997.

Karoly, Lynn A., “Money for Nothing? Remittances by Migrants in the Malaysia Family
Life Surveys,” paper prepared for presentation at the Columbia University
Conference on Migration in Developing Countries and Transition Economies,
February 1997.

Rogowski, Jeannette A. and Lynn A. Karoly, “Retiree Health Benefits and the Decision
to Retire Early: Evidence from the Health and Retirement Survey,” prepared for
presentation at the annual meetings of the American Public Health Association,
December 1996.

Karoly, Lynn A. and Robert F. Schoeni “Explaining Racial and Ethnic Differences in
Adolescent Employment Outcomes.” prepared for presentation at the annual meetings
of the Population Association of America, May 1996,

Karoly, Lynn A., and Jacob Alex Klerman, “Demographics, Sectoral Change, and
Changing Relative Wages: A Regional Approach,” prepared for presentation at the
RAND conference on "Reshaping the Family: Social and Economic Changes and
Public Policy,” June 1994.

Dertouzos, James N., and Lynn A. Karoly, “The Impact of Wrongful Termination
Doctrines on U.S. Employment,” September 1993.

Dertouzos, James N., and Lynn A. Karoly, “Wrongful Termination Litigation in the
Post-Foley Era,” June 1993.


33

Mr. Suays. Ms. Pearson, an individual who has been helping you
is here with you. She doesn’t need to be up there, so we are not
going to invite her, but we would welcome you introducing her, if
you would like to.

Ms. PEARSON. This is my support worker, Lynn Kosanovich, and
I love her very much.

Mr. Suays. Well, you feel rich and you have enriched us, as have
the other two witnesses.

First, let me just acknowledge the presence of our other members
on the subcommittee, Mr. Kucinich and Mr. Barrett and Mr. Scott,
who is here as well, and we also have Connie Morella, who is here
from the full committee, and we welcome all of them, and all can
participate.

I would call on the ranking member to start the questions.

Mr. Towns. Thank you, Mr. Chairman.

Let me begin by thanking all of you, all three of you for your tes-
timony, and let me begin with you, Governor. I commend you on
the job that you are doing in your State. As you know, some States
are requiring co-payments from welfare recipients who seek to
place their children in day care. Do you have any thoughts on the
desirability of co-payments?

Governor ALMOND. I think it depends, of course, on how far your
program goes. If you are at 100 to 150 percent of the poverty level,
of course you can’t have co-payments. But I think as you go higher
up, you can have some co-payments with respect to day care until
you can get the State resources to supplement those. You certainly
want to cover as much as you can of the population. It’s a question
of resources.

As I mentioned earlier, we certainly could use the $8 million that
is sitting there allocated to Rhode Island for health care that I
can’t use over on child care, but I would prefer to see a fair pro-

am with respect to the sliding scale and no co-pay, just as we

ave no co-pay for the health care programs.

It is an expensive proposition. One of the biggest issues facing
mothers in child care is the cost. Even for individuals who are
doing very, very well, it’s a disincentive to go into the work force.
If mothers can stay home with children, that’s fine. We have a lot
of single mothers who can’t stay home with their children, so they
have to have child care.

Then we have the two-parent families. A lot of them have to
have two parents working in order to provide for their children and
provide for the future and provide for higher education at some

int and use the savings account in order to be able to afford

igher education for their children.

My wife is here with me today, because we are going to go over
to Maryland to see my daughter who is over there with two chil-
dren in day care. And I can tell you, she is a professional, she is
an engineer, but it’s expensive to have two children in full-time day
care. No question about it.

So from a standpoint of co-pay with child care, if we can do it
without, let’s do it without, but it’s going to take some resources.

Mr. Towns. OK. But, you know, when you say take some re-
sources, I sort of hear two things. When you talk to people, you
hear people saying it’s just so important if we want to be able to


168

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183

degree to which their needs were responded to sensitively and competently as they were growing
wp"

‘Attachment theory has affected the design of the home-visitation programs in three
fundamental ways. The first has to do with its emphasis on the visitors’ developing an empathic
relationship with the mother and other family members. The establishment of a relationship
based on empathy and respect was expected to help women eventually trust others and to
promote more sensitive, empathic care of their children. The second has to do with an emphasis
in the program on helping mothers and other caregivers review their own childrearing histories
and make decisions about how they wish to care for their children in light of the way they were
cared for as children. And third, attachment theory has led to the explicit promotion of sensitive,
responsive, and engaged caregiving in the early years of the child’s life.“

While attachment theory provides a rich set of insights into the origins of dysfunctional
caregiving and possible preventive interventions focused on parent-visitor and parent-child
relationships, it gives scant attention to the role of infants’ constitutional differences as
independent influences on parental behavior, and it provides inadequate attention to issues of
parental motivation for change in caregiving. It also minimizes the importance of the current
social and material environment in which the family is functioning as influences on parents!
capacities to care for their children. For more systematic treatments of these issues, we tuned to
self-efficacy and human ecology theories.

‘The nurses thus have been equipped with a set of theory-driven program protocols that
guide their efforts to help women improve their health-related behaviors, their care of their
children, their planning of subsequent pregnancies, the completion of their education, and

participation in the work force.


17

youngest children. Recently in a statewide law enforcement
conference in Ohio, one district attorney said that justice
doesn't start In the electric chair; it starts in the high chair. The
fact Is there are wonderful, effective programs throughout the

country:

. Vermont, under Governor Dean, has instituted
Success by Six, which provides families with quality
child care, nutrition and literacy programs, as well as

extensive parent education;

. North Carolina Governor Jim Hunt has Initiated Smart
Start, a public/private initiative which helps all
children and families throughout the state obtain
quality, affordable child care, health care, and

family support services;


61

COVENTRY

CHILD OPPORTUNITY ZONE FAMILY CENTERS.
coz Total Percent
Schools Enrollment Low-Income
Blackrock Schoo! 453 Bs
Hopkins Hil Sehoot 367 2%
Oak Haven Schoo! 301 3K
Toque Schoo! 480 (ex
Washington Oak School wl 20%
Western Coventry Schoo! 387 uy
Coveney Middle Schoo! ese 20%
‘West Bay Area Career & Tech encolimene whigh School =
‘Coventry High Schoo! Las 10%
Advisory Board

‘The Covenary COZ has a Stering Commitce comprised of agency eepresencaives, eachers,
<ommunicy members. business leaders and parents

Schoo! Locations

“The Coventry COZ considers al of the schooks tobe part ofthe COZ inwative Washington Oak and
(Oak Haven Elementary Schooks havea family resource cancer on sce each safe by five hour per
week parent coordinator The remaining four elementary school, the middle school and he high
Shoo! do ot have phyical space but parents students, and schoo! staf ae iovolved in actues
sponsored by the COZ There ia small office atthe high choo! for use by the COZ Coordinator,
whote main ofe sat the Coventry school admsnistation bulléng,

Funding 1997-1998: $36,127
(doe ence rd spp fom choo dan min port frm beat ond human erie oper. me

ead ped nua ney men fon Na

seo Dare 8% coctana coe Orr
oct Bape os See

te rtp ec fn abe 7A 8

Program Components SchoobLinked Heath and Socal Services

Parent Education Perle cog (ie Fart Secs

Fareong hoe vane (She der) vcion

Fa Resource Ceres a eh

Commune recur loro a choo

Faron voter ndbook Saadent source noemevon te i shoo

Infant and Pre-School Program arty and Communiey Development

Preschel nor ours fat fre

Reading chen tamed cde Cem fy

mo fed Ron Wek parade Subuance Abie Tak

Force)

Coneace
‘Sue Conde, Coordinator
Pardcpating Schoote:
6 elemeneary schoole

| middie shoot

Thigh scoot

Aspe
Coventry Puli Senools

Aone:
Coventry COZ

Coventry Pulte Schools
122 MacArthur Bid
Coveney, AV @2816

(401) 222-9400

Sate

1 Coordinator (partie)
2 Parent Coordinators
(parttime)



130

the areas of education and work,’ as well as a limited sense of control over their life
circumstances and over contraceptive practices in particular.»
D. Modifiable Risks for Early-Onset Antisocial Behavior

More recently, we have analyzed risks for early-onset antisocial behavior’ and
determined that the impact of the program on maternal and child health early in the life cycle
reduces risks for these problems. Children who exhibit early-onset antisocial behavior are more
likely to develop violent behavior during adolescence and are hypothesized to become chronic
offenders.’ Figure 1 provides a framework for integrating our thinking about how these diverse
influences converge in producing childhood-onset conduct disorder and how this program of
prenatal and early childhood home visitation by nurses reduces its risks. Children who develop
early-onset disorder are more likely to have subtle neurodevelopmental deficits (such as.
‘compromised intellectual or language functioning and attention deficit disorder) combined with
harsh, punitive, and rejecting parenting” Maternal life-course factors also predict the
development of antisocial behavior, in that children with these behaviors are more likely to come
from large families, with closely spaced children, where parents themselves are involved in
substance abuse and criminal behavior.”

Il, THEORETICAL FOUNDATIONS

‘The program has been grounded in theories of human ecology,*” self-efficacy,” and
human attachment." The earliest formulations of the program gave greatest emphasis to human
ecology, but as the program has evolved, it has been grounded more explicitly in theories of self-
efficacy and attachment."

A. Human Ecology Theory


114

Mr. Towns. Dr. Olds.

Dr. Oxps. Thank you for the opportunity to testify on this impor-
tant topic. My name is David Olds. I am a professor of pediatrics
and director of the prevention research center for family and child
health at the University of Colorado Health Sciences Center. For
over 20 years, my colleagues and I have been developing and study-
ing a program of prenatal and early childhood home visitation by
nurses that reduces child abuse and neglect, use of welfare, and
crime in low-income families. The program serves low-income
mothers who had no previous live births, many of whom are un-
married adolescents.

The nurses visit pregnant women in their homes during preg-
nancy and the first 2 years of children’s lives. In those visits, they
help women reduce prenatal cigarette smoking, the use of alcohol
and drugs; they help women improve their diets and identify
emerging complications of pregnancy that can be treated before
they compromise the health of the mother and the fetus. They help
parents provide more responsible care for their children, and they
help parents develop a vision for their future and plan subsequent
pregnancies, complete their educations and eventually find work.

The program has been developed, refined and tested over a 20-
year period, so that today the nurses have structured, written pro-
tocols and intensive training to guide them in working with fami-
lies who live in highly challenging and often dangerous situations.

Over the years we have been encouraged to disseminate this pro-
gram, but we have waited to do so until now because we wanted
to have sound scientific evidence of its effectiveness and thoroughly
developed program protocols. In this way, we can now provide
greater assurance to communities that programs replicating this
model will reproduce the results achieved in the research.

We have examined the program in three separate, large-scale
randomized trials. Randomized trials are the most scientifically
credible method of determining the effectiveness of health, social
service and medical interventions. The first study was carried out
in Elmira, NY, with Caucasian families. The second was conducted
in Memphis, TN, with African-American families. The third is
being completed now in Denver with a large portion of Mexican-
American families.

We have found that the program can reduce some of the most in-
tractable health and social problems facing at-risk families in our
society, and as you heard from Dr. Karoly, a recent report by the
RAND Corp., shows that the program can more than pay for itself
in reduced government expenditures, when it is focused on unmar-
ried, low-income parents.

A recent report on the Elmira study shows that by the time the
child reached 15, nurse-visited, low-income, unmarried mothers
had 33 percent fewer subsequent births, 30 months greater spacing
between the first and second births, 30 fewer months on welfare,
81 percent fewer arrests and convictions, and 79 percent fewer
verified reports of child abuse and neglect.

Compared to their counterparts who have been assigned to com-
parison services, the 15-year-old children born to nurse-visited,
low-income, unmarried mothers had 60 percent fewer instances of
running away, 56 percent fewer arrests, 81 percent fewer convic-


116

pacities that require development over time. To do it well will even-
tually require Federal support of this system of replication centers.

In general, we believe that policies and practices for assisting
young children and their families ought to be based on the best sci-
entific evidence available. Public hope and confidence in the prom-
ise of such programs are scarce commodities that we dare not
squander on approaches that are not likely to succeed. As health
and social welfare policy is redesigned in the near future, I believe
it makes sense to begin with programs that have been tested, rep-
licated and found to work.

Thank you.

Mr. Towns. Thank you very much, Dr. Olds.

(The prepared statement of Dr. Olds follows:]


Statement of Rep. Christopher Shays
Suly 16, 1998
Page 2

We focus on public-private partnerships in the development of early childhood programs
because one fundamental premise is already clear: affecting the lives of pregnant women and
their children requires a comprehensive, intensive and integrated approach, involving
governments, health care providers, employers, and others. Charting a healthy, productive
course for a mother and her baby serves human service, public health and economic development
goals, Both public and private sectors have an undeniable stake in the outcome, and each has an
indispensable role to play in achieving it

At our hearing on the Early Head Start program, my friend and colleague Senator Chris,
Dodd put these issues in the right perspective when he observed that children represent only 27
percent of our population, but 100 percent of our future. In well designed, science-based early
childhood development efforts, we have the power to shape that future for the better.

‘Our witnesses today bring diverse experiences, deep commitment and impressive
expertise to the discussion of early childhood development issues. We look forward to their
testimony.


93

Lynn A. Karoly Page 3

Klerman, Jacob Alex, and Lynn A. Karoly, “Young Men and the Transition to Stable
Employment,” Monthly Labor Review, 117(8), August 1994, pp. 31-48 (also
available as RAND Reprint RP-338).


38

I mean, there could be Federal guidelines; but, quite frankly,
each State knows what those standards are; and there are accred-
ited, you know, child care facilities. We know what those standards
are.

Mr. Towns. Governor, do you want to comment on that?

Governor ALMOND. We have licensing requirements. We want the
best possible child care that we can have. We want safe child care,
and we are able to do that.

Let me say this. If you want to, you know, set some broad stand-
ards, minimal standards, we will exceed them. I can assure you of
that.

Mr. REINER. I can agree with that. All the Governors I have
talked to are more than happy—you know, they will exceed those
standards.

Mr. Towns. OK. Well, you know, when I think about standards
and regulations and all that, and I just listened to Ms. Pearson,
who talked about the fact that—being able to communicate with it,
and you have to set a number. Because if you have too many chil-
dren, then it makes it very difficult for her to be able to commu-
nicate or to be able to share her concerns. So I think there are a
lot of things that have to go into this, because she raises a very
interesting point. The fact that if this person is now responsible for
the care, you know, during the time that she is out working or
whatever, and then if she doesn’t have the opportunity to commu-
nicate with her views and feelings and concerns and if she has a
lot of kids, I mean, I am not sure you can do that effectively.

Mr. REINER. That’s why we know there is a ratio of 1 to 3 for
infants and toddlers, a ratio of 1 to 6 with 3- and 4-year-olds. I
mean, there are certain standards that are put forth by people like
Patti Siegel in California who is, you know, one of the major child
care proponents in this country. And there are child care people
you know, you can go to Children’s Defense Fund and talk about
what standards. I mean, it’s pretty clear, you know, the ratios that
you need in order to maximize, you know, brain growth and devel-
opment. That is not rocket science.

Mr. Towns. I have no time to yield back, but I yield back.

Mr. SHays. Ms. Pearson, you went to the hospital with a very se-
rious challenge, and you were told then about the northern Vir-
ginia Healthy Families program; is that correct?

Ms. PEARSON. Yes.

Mr. SHays. So you weren’t sure at first you wanted to go into
that program, and then decided you did; is that accurate as well?
Just try to walk me through what your reluctance was. I mean, it
seems normal but I would like to hear it from you.

Ms. PEARSON. I was very reluctant due to the fact that I was still
going through the morning sickness. Then once they put me on the
Zoloft that was for my emotional upset, and then they had me on
the Compazine to help my nausea, I started feeling a little better.
Then I was like, maybe I don’t need this program; I can get
through this, I can do it.

Once the assessment worker came to interview me, and my
roommate at the time was with me, she explained everything to me
and what would happen. I was like, well, I didn’t think that I
qualified for it. So I was like, well, I don’t think I need it. My room-


158

References

1. Kramer, M.S. (1987). Intrauterine growth and gestational duration determinants. Pediatrics,
80, 502-511.

2. Olds, D.L. (1997). Tobacco exposure and impaired development: A review of the evidence.
Mental Retardation and Developmental Disabilities Research Reviews, 3, 1-13.

3. Sureissguth, A.P., Sampson, P.D., Barr, H.M., Bookstein, F.L., & Olson, H.C. (1994). The
effects of prenatal exposure to alcohol and tobacco: Contributions from the Seattle
longitudinal prospective study and implications for public policy. In H.L.Needleman, & D.
Bellinger (Eds), Prenatal exposure to toxicants (pp. 148-183). The Johns Hopkins
University Press.

4. Rutter, M. Intergenerational conti

ies and discontinuities in serious parenting difficulties.
In. D. Cicchetti & V. Carlson (Eds), Child maltreatment - Theory and research on the causes
and consequences of child abuse and neglect (pp. 315-348). Cambridge, MA:Cambridge
University Press.

5. Moffitt, T-E. (1993a). Adolescence-limited and life-course-persistent antisocial behavior: A
developmental taxonomy. Psychological Review, 100, 674-701.

6. Moffitt, T-E. (1993b). The neuropsychology of conduct disorder. Development and
Psychopathology, 5, 135-151.

7. Raine, A., Brennan, P., & Mednick, S.A. (1994). Birth complications combined with early
maternal rejection at age 1 year predispose to violent crime at age 18 years. Archives of

General Psychiatry,51, 984-988.

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125

ended. We needed to see enduring benefit before we could justify a public investment in this
service.

‘Second, we did not know whether the findings from the Elmira program were limited to
the population studied (primarily whites living in a Central New York county) or whether they
might apply to a wider range of communities and populations. In particular, we needed to be
sure that this was a program that would work with minorities living in urban areas.

Third, we needed to develop the program protocols and methods of training nurse home
visitors to the point that new programs based upon this model would reliably reproduce the
essential elements of the program tested in the randomized trials. Many programs examined in
research settings are subsequently altered or watered down in the process of being scaled up,
often leading to reduced effectiveness. We wanted to avoid that fate for the current program and
needed to be able to provide clear guidance for new communities about what, exactly, they
should do to replicate the program.

In the meantime, several national groups used the findings from the Elmira trial to
promote a variety of home-visitation models in spite of the fact that the promoted programs bore
little resemblance to the program tested in Elmira. Some programs employed paraprofessional
visitors who began during pregnancy but had little follow-up during infancy, Others began after
delivery and employed paraprofessionals as home visitors. Rarely were such programs designed
explicitly to promote matemal life course (plan future pregnancies, stay in school, find work,
etc). We did not discourage -organizations using data from the Elmira trial to promote such a
wide variety of program types because, for all we knew at the time, the Elmira findings might be
reasonably applied to a many types of programs. We chose, instead, to focus our efforts on

conducting a follow-up of the Elmira study to examine the durability of the early effects,


100

LYNN A. KAROLY

LYNN A. KAROLY is a RAND senior economist and director of the RAND Labor and
Population Program. Dr. Karoly recently lead an interdisciplinary team of RAND
researchers who investigated the costs and benefits of early childhood intervention
programs. Other areas of Dr. Karoly's expertise include economic inequality in the U.S.,
youth labor markets, and retirement behavior. In addition to her research, Dr. Karoly is the
taining director for the RAND Postdoctoral Research Programs in the Study of Aging and
in Population Research. She has been on the faculty of the RAND Graduate School of
Policy Studies since 1989. In 1993, she was a visiting fellow in the Economics Studies
Program at the Brookings Institution in Washington, D.C. She is currently a research
associate with the Institute for Research on Poverty at the University of Wisconsin,
Madison and is a co-editor of the Journal of Human Resources.

Dr. Karoly received a B.A. (summa cum laude, 1983) in Economics and Mathematics from

Claremont McKenna College and an M.A. (1986) and Ph.D. (1988) in Economics from
Yale University.

July 1998


4l

your first granddaughter born and finding out that your daughter
is going to go back to work is a little unsettling. You wonder what’s
going to happen. Keep in mind, we’re separated by several hundred
miles. But to see the quality of the program that she is in is ter-
rific.

It is all of those things, I think, combined that give you the feel-
ing, this is the right thing to do.

Mr. Suays. Mr. Reiner, I am tempted to see if you have ques-
tions for the witnesses. I would like to ask you—when we talked
earlier, you shared with me how you got involved in this issue, but
there is not a person in this room who doesn’t feel they know you.
I just think for legislative history, it would be helpful to know why
a famous movie actor and producer and businessman decides that
he is going to champion this issue.

Mr. REINER. This is something I’ve been thinking about for al-
most 20 years. I went through a very difficult time in my life. I was
going through a divorce, I went into therapy as people do when
they’re struggling. During that period, it became very clear to me
that the earliest influences I had had a direct and profound effect
on how I was functioning as an adult. I could see the direct correla-
tion between the two. Being somebody who has been civic minded
my whole life, I thought, there’s something in this in terms of af-
fecting social outcomes. I certainly didn’t have any scientific evi-
dence to back that up. It was just an instinct.

Then, as I got a little bit more successful and had a little bit of
a power base from which to reach out, I started doing that. I start-
ed finding out what was going on around the country in terms of
early childhood development. I convened a meeting at my house
with policymakers and early childhood development experts, people
from the Carnegie Corp., the Families and Work Institute; and dur-
ing the course of putting together this group, the first person actu-
ally that I called, I called out of the blue, was Tipper Gore. I really
was a babe in this. I really didn’t know who to reach out to, but
I heard she was interested in mental health issues; I figured I’d
give her a call.

She took my call, we talked on the phone; she said, come to
Washington, we'll sit around and talk. I went with my wife, met
with her.

Then some of the members of the Department of Education, and
they brought out—this was about 4 years ago; they brought Clin-
ton’s Goals 2000 out, the first goal of which was, every child must
enter school with a readiness to learn, and then all these other
goals. I said, it seems to me that if you can reach that first goal,
all the rest of these goals would kind of fall into place. She said,
yes, you’re talking about zero to 3. I didn’t even know the term at
that time. I said, yeah, I guess I’m talking about early childhood
experience and so on.

I then went and researched this, convened this group of people.
During the course of that research, I came across the Carnegie
Corp.’s Starting Points report, which came out in 1994 and very
clearly, in no uncertain terms, said that there was hard scientific
brain research to back up eve! ing that I had been instinctively
feeling for all those years up till that point.